30586 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. /� O1"'/�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J '5 l8
BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: s SANITARYNO. APPLICATIONSUBMITTALDA'I
OWNER'SNML: �/ PHONE C IiA OR' NAMIi: M LIC NO: rz
W�..7F,Y '. NIC CONTROL#
RCHITECEENGINF:ER: LIC NO: AD FZ; - , ` ❑
CONT CT: PHONE: W BUILDING PERMIT INFO
r67 ❑ Consultant Fees Paid by Applicant(Initial) BLDG PLUMB MECH
Cf
Ir-e. 7a- /,),P5 ® ❑ El IDLICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affrn that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Section 7001Division of Busines,y�ndProfesaigpCa�ad my license is RESIDENTIAL'
Q //_� y PERMIT ISSUANCE NTIA
F W in full force end Apar. o a y Q/
aUV Licenppe Class l/ Lica ❑SFDWL El KITCHEN REMODEL
FZuI Dale J�'F Contrucmr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
n<a WET`�'�—
ARCHITECT'S DECLARATION PANELS F.7H ❑MULTI-UNIT ❑STRUCTURAL
ZO-Z 1underimnd my plans shall he used as public resents MODIFIC TLN
OZ—, UP TO 200 AMPS
Fa t u�i L¢ensed Profcsstonal ❑INTERIOR NEY REPAIR
OWNER-BUILDER DECLARATION 201-INTAMPS IMPROVEMENT
"etz, I hereby affirm thin 1 am esem t from the Convector's Licentt law Rome OVER 1000AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
P
3 L H following reason.(Semina](p L5.13nsincss and I'rofnssimn.Code.Any city or county SIGNS ELECTRICAL ❑OTHER
LLl LL O y which rtqulres a promit to construct.alley,improve.demolish.or repair any structure
1'm�2 6 sm.,,,hs isonarecid-mgmim,thenpplicontfnoebpermit m filfc,loned statement SPECIAL CIRCUIT/MISC.
MN that he is licensed pursmm to the provisions of the Contractor's license Law(Chapter 9
j 1t1 LL O (commencing will Spellnn7(all of Di sills,3nf the Businessand PollC..ar,CMe)ar TEMP ME9ER 11R 1'O LE INST. COMMERCIAL
a X o CC that he is eacmpt therefrom marine basis tar the alleged exemplum.Any violation of [I DEMOLITION
K^LL Section 7031.5 by any applicant for t subjects the applicant to a civil ❑NEW BLDG/ADDITION
#emit ) penalty of POWER DEVICES t
F Z} not more than five hundred dollars(S500). ❑TENANT El FOOD SERVICE
ESG ❑hres owner ofthe Prnpeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMP VEMENT
yF.m will do the wok,and thestrucmre is not inhadedmmifeted forale(Sl 7044,Business EJER
W 3 and Professions Code:The Contractors License Law does not apply m in owner of OUTLETS-SWITCHES-FIXTURES
0. property who builds or improves theredoes on,and who ds such work himself or through
his own employees,provided mat such improvement,are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL howeveqtlm building or improvement is sold within one yearofcompletion,the SQ.FT.FLOOR AREA S/SQ.ET.
er-builder will have the burden of proving that he did not build or improve for par- P A '
ry e.i'do.), A
❑ I.as owner of the pmperty,am exclusively contracting with licensed commcrorsw TOTAL:
conmmct the project(Sec.7044,Business end Pmfiloinns Code:)The Contractor"U. I I
ccnu Low does not apply loan owner ofproperty who builds prlmproves thereon,and QTY PLUMBING PERMIT FEE I ]flee
who contracts for such projects with a contracmgs)licensed pursuant m the Contracmds Is7 J�
License Law. �t
❑1 am exempt under Ser. ,B& PERMIT ISSUANCE PC for this reason Uh M /
Owner Date
ALTER-DRAIN&VENT-WATER(EA) ALUAI'ION
WORKER'SCOMI'ENAT
SIONDECLARATION BACK FLOW PROTECT.DEVICE
�1 -v
• I hereby amrm under penalty of Perjury one of the following dealomtion'l ems(
❑Ihaseand - maintain a Crafficate of Consent to wif-insure for Worker's Compel DRAINS-FLOOR,ROOF.AREA,COND.
scion,v ovided for by Section 37(X1 of me Labor Code,for the pcknnrenee of the STORIES TYPE CUNSTHUC'HO
r which Lis permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Satin,
fPoch�thn Later Cod5eY till
�the
l�ertfloomnanf thhePwlrk ,whihiicch this permit is issue . GAS-G.SYSTEM-I INCA OUTLETS OCC.GROUP APN
it
Camey 'r''F` `fJYr'I(� cmc P,licy No nn;,r7141(
GAS-EA.SYSTEM-OVER 4FA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
(This section need not X completed ifthe permit is Toren hundred dollars pHad) BUILDING DIVISION FEES
or less.) GREASE TRAP
I certify that in the prrfotmvatt of the work for which this Permit is tamest.I shall PLANCHECK FEE t
not employmy person is may manneraron,hecemenupecun the Worker,,Compels- SEWER-SANITARY-STORM EA.200 FT.
Z scion Laws of California.Date ENERGY FEE I
ZO Applicant WATER HEATER WNENT/ tA7CCrR GRADING FEE
.N. NOTICE TO APPLICANT:If,after making this Certificate of Eremitism.,you should
a , became subject to the Warkers Compamaion provisions of the Labor Coda,you must WATER SYSTEM/1'REATING SOILS FEE
[[7
Rallo,ah comply with such provisions or this permit shall bm
Ile deeed revoked.Q WATER SERVICE
CONSTRUCTION LENDING AGENCY
Z NEW RESIDENTIAL PCMB. SQ.FT. PAID
IJ0 lin'by affirm whihthimethereisamn(Section lending agency Tante performance of Dam Rmcei
fiUthe work for which this permit isismeJ(Sec.3097.Civ.CJ
Lenders Name
M
r � Lender',Address TOTAL' TOTAL:
r O. 1 certify that I have read this application and stale that me above information isMUNIT(OVER
BUILDING 12EE
LJ ZZ? const l agree to comply with all city and county ordinances and stale laws relining toECHANICAL PERMIT FEE
building construction,vol hereby aathome representatives of this city to enter upon theSEISMIC FEE
ahove-mentioned prn(wny fill inapeetion purpow'. ANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino againstELECTRIC FE
liabilitics,judgmcnts.costs andexpcscs which may in any wayacerucvgaimm said CityDD TO MECH.
Inco ace of the granting of this permit PLUMBING
A LICAeT UNDERS' NDS AND WILT.COMPLY WITH ALI,NON-POINTNG UNIT 10,0a0CF,N)
5 IRCE erMECHANICAL PE
'6 -31� r NGUNIT(OVER 10,000CFM) CONSTRUCTIONTA
Signature of APlpacam/Con m Date OOD(W/DUCT)US MATERIALS DISCLOSUREHOUSING MITIGATION E
Will the applicant or future building occupant store or handle hazardous material HRATING UNIT(TO 100,000 BTU)
as Defined by the Cupertino Munie al Code.Chapter 9.12,end Le Health old late,,Cody Section 25532(,)'! HEATING UNIT(OVER 1011,000 BTU)
E3 yes
VENTILATION FAN(SINGLE RESIU) PAID
Will the applicant or furore botldin owcupant use equipment tar devices which Dae Receipt#
rout hairdous air contaminants as de by the Bay Arca Air Quality Management BOILER-COME CHP OR 10(1,(X10 BTU)
District? TOTAL:
E]yes Na BOILER-COMP(OVER 100,000 BTU)
1 have real the horallous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
folia H Safety Cwle,Sections 25505.25533 end 25534.1 understand Lat ifthe ISSUANCE DATE
No
g�cutrernlyhu,c�ynant.that it ismyresponsibility to notify Lenccapant NEW RESIDENTIAL.MECH. SR FE
oft r t (�m,,]]ll prion,iwnnea afu Cs
Owme.or authmrieed agent Date TOTAL: ISSUED BY: ■Ld�' LLY
OFFICE