30568 (2) APPLIOANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL . PERMIT NO, 3 0 5 6 8
WILDING DIVISION APPLICA'IION/IaI?RM1'P. PLUMBING.MECHANICAL J J o
BUILDING PROJECT IDENTIF'ICAT'ION
HIIILDINGADDRESS:t - SANITARY NO, APP'LICAT'ION SUBMITTAL DATE
ZL560 7-v; iEst,S} C 1
OWNER' NAME: (� \F.1F�j� PHONE: & CONTRACTOR'SNAME: LIC NO:
O Ie G ' U1% NIC CONTROL#
\RCHITECf?ENGINE R. LIC NO: ADDRESS: El..�o r G . L632
CONT. - ofQ{oMNE: _ •' - h — - BUILDINGPHRMITINFO
f"LRdtart p p a: 7 eI& ` ❑ Consultant Fees Peid 6 A Ilcenl(InI11Bl IPL F.l.ECf PLUMB MECII
bWIcK 'IR6S B7J60 y ,PP ) ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 herehy nftinn then 1 am license.)under provisions of Chapter Y(commencing JOB DESCRIPTION
{t�{t1100 with See ..7000)of Division 3ofthe Budir,,amd limitation,Cad,andm licensees
h`W� in lull lone and affect. - y PERMIT ISSUANCE - •' RESIDENTIAL:
QFVZUF in fidI haven Lic.p - ❑SFDWU El KITCHEN REMODEL
N6 D C. nr APPLIANCES-R17S IDIENTIAL [-]ADDITION El PLUM BING RE-PIPE
py ARCH CI'S ❑MULTI-UNIT []STRUCTURAL
I uoidcrsmnd t once sh 11 he a. tbli PANELS.
andr ODIPICATION
Oz O UP10200 AMPS - 11 INTERIOR I HIMNF.Y REPAIR
. on a Pmfes:mnn 201-IIgX)AMPS - IMPROVEMENT
ems+ WNF.R NUILDF.R UECIARAT OVER IOCYAMP'S .. [I BATH HHMODF;IJRF.PAIR [I DEMOLITION
0.s W st frab,aRrm Ihnt 1 vm exempt mom the Cornm nr's License Law fur the
3 d V Tonna ng reason.(Section 9031.5.Business and Prnfcsome;Cale:Any city or countySIGNS ELECTRICAL
❑OTHER
_b O which requites a permit m construct,.Iter.improve,demolish,or repair any awclnrc -
#Hullo ins issuance,also requires the.pplicant forsuch gcoahm lileasigncl statement SPECIAL CIRCUITIMISC. 1
1s�s�yy ihm he is licensed purtuannnihe pmvisions of the Cnmmcmirs License Law(Chepmr9 _
000 (commencing with Seaimn7WU)mf Division Sof the Nosiness and Professions CodcTm TEMP.METER OR POLE.INS r. COMMERCIAL:;
mm he is exempt donaftom and the basis for the alleged exemption.Any yiolmom of ❑NEW BLDG/AUDITION• .'O DEMOLITION
til t4 Section 7031.5 by any applicant lou o permit subjects the applicant m a civil Penalty of POWER DEVICES [I NEW NT ,E)DEMOLIFOOD TION y not mVICE
om then fre hundred dollars H5 W).
dQ ❑ Lasnwmrnfthepmpety,or myemployees with wages as their sole cmmpernatimn. SWIMMING POOL ELECTRIC IMPROVEMENT
1.$ wiU do rM1e work.andthemrvcmreis not imm�dW ornffemd for sole lSecA01J.Business ❑OTHER'
F 5b' and Profesions Cora;*Me Comlructofn Liwnse Iatw dace not apply m an owner n( OUTLE'f5-SWI'I'CIIRS
-FIXTURIiS
Property who builds or improves thereon,and who does such work himself or through his n employees;provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELIiCFR SQ PR -
# sale.ILhowever,the building or improvement is sold within an yeurofcompletion,the SQ.FT FLOOR AREA $/SQ.FT.
caner-builder will have the burden of proving that he did not build or improve f stput, t
mfsalcJ.
Las,the p of ct property,nm exclusively commctins with licensed footmen's i. I TOTAL: s -
amvwn the project(Sec.]fF14,Nuslnesv and Professions Ctde:)'Che Camractors Li-
cense taw dons not apply to sur owner of property who builds or improves thereon,end QTY PLUM OP13RMIT FEE Q�sw
�wlmconmmts liusuch projects withterminators)licensed parmanno the CormO av SEP
7 19
Licatse Law. PERMIT ISSUA / f96
0lam exempt amt eS ,B&P C for this reason ,;•.
ALTER-DRA &VENT TER WA) }4a' VAI DATION -
Owner_ Dam ' —. - ' IVALUA
.ter
WORKER'S COMPENSATION DECLARATION HACK PLOW PROTECT U I
1 herehy.(Tion under pcof perjury one of the following declnration.r
•n I have and will maintain a Certificate of Comcm to self-insure for Worma's Cmmpcn DRAINS-FLOOR,ROOF,AREA, STORIES TYPE GGNSIHUCfION
sabot,as provided for by Seen..37M of the Labor Cade,for Of performance of the ,
work for which this permit is issued. - FIXTURES-PERI'RAP
❑I haveand will maintain Workers Compensation Insurance,as required by Section r
3)OO mOhe Labor COJe,fm the perfomimn,eml'Iheworkfnr which this permit is Issued, GAS-IA.SYSTEM-I INC.4 OUTT.1?TS
OCC. ROUP APN
My Worker's Compensation Insurance aarierand Policy number ere:
Currier: Policy NO.: GAS-EA.SYSTEM-OVIiR 4 THAT
CERTIFICATE OI'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCEG R FASIVINDUSTRI,WASTE INTERCEPTOR
(This auction need mol he completed if the permit is far one hundred doll.(S End) BUILDING DIVISION FEES
or less.) GREASETRAP. PLANCHECK FEE.
I cenify that in the Performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STONM EA.200 Pf.
not employ any Person in any manner so as m become subject to the Workers Compen- ENERGY FEE
sation Lows of California.Date
O 2 Applicant WATER HEA'T'ER WiVENTIELECfR GRADING FEE
rA NO'T'ICE TO APPLICANT..IL after making this Certificate of Exemption,you should WATER SYSTP.M/fREATING -
a.� become subjectto the Wcolon's Compensmion pmvisions of the Label Code,you most SOILS FRE
L7J rimadh comply with suchm,isionsor this crmit shall he deemal revoked
P P WATER SERVICE ON N
az CONSTRUCE IONLENUINGAGENCY NHWRISIDENTIALPLMB. " SQ.F. PAID. UV
UO I hereby affirm that hem is a construction lending agency for the permsmance of Data Receipt#
U. F the work for which this permit is isme!(See.3097,Civ.C.) _
O Lend,Is Nome t TOTAL:
WLender's Address 'TOTAL:
1 cenify that 1 have read Nis application and stale that the above information is BUILDING FEE
r
:r h foce".I.,.a to comply with all city and county ordinances and such,Iawv relating n' QTY. MECHANICALPERMIT FEE•U building construction. ad hereby summit,reprawaudvesof this city to cater upon the SEES MIC FEE -
abm emomationed pnsPeny for inspection purpoms. -
-(We)agree to save,indemnify and keep harmless the Cut of Coition.ngaim, PERMIT ISSUANCE ELECTRIC FEE
liabilaies.judgmenis,cash,and expanses which may many m,.ccnm.,afmt said City ALTER OR ADD TO MECH
nwi uenca of the gronfin,of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. Alk HANDLING UNIT(TO 10,003CFM) ' MECHANICAL PPE
I
AIR HANDLING UNIT(OVER TO."CFM) CONSTRIICI'IONTAX
Signature of Applicant/Conracmr Data EXHAUST HOOD OVIDUCT) HOUSING MITIGATION Flip.
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant Or future building occupant some or handle brow rdeus material .HEATING UNIT(TO 100,00)BTU)
as defined by Ne Cupertino Municipal Code,Chapter 9.12,and the IR.Im vad Safety
- Code,Section 25532m)t I ' HEATING UNIT(OVER IIX),000 BTU)
-nyas ❑No
. 1 t VENTILATION FAN(SINGLE BESIDE ' PAID - s
Data Receipt#
Will the air chumm or aurum building by the B use equipment or devices which
emit hazardous ver conluminame as defined by the Bay Area Ail Quality Management BOILL'R-COMP(3HP OR IW,(NIO BTU)
District? TOTAL:
❑Yoe No - BOILER-COMP(OVER IIq,100 BTI.))
1 have recd the hanrdoue mortal mquiremenr under Chapter 6.95 of the Chi- AIR CONDITIONER - ISSUANCE DATE
(omit Health&Safety Gude.Seaiom 25505.25533 and 25534.1 understood That if the NEW RF_SIDENTIAL MECR SQ.FT.
building does not currently have a lenum.that it is my rcrywmsibility un notify die occupant
of Ne requiremenB which most he and prom issuence Of.Ccmificae of Occupeacy. rs
Owner or amboreed agent Date TOTAL: ISSUED BY:
'OFFICE