30610 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY {/��
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 30610
/k O V�O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
'��'1/, p L BUILDING PROJECTIDENTIFICATION
BUILDI/��R9 3 aVo r! '� �lr(/''6 r SANITARY NO. APPLICAi'ION SUBMITTAL.DATE
tito q6
OWNER'S NAWP,HONE:y CONTRACTOR'S NAME: LIC NO:
Al Io c �e'
Z jZ� �,�� SL NIC CONTROL#
RCH C`UENGINEER: LIC NO: ADDRESS: ❑
CONTACT; PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm mat I am licensed d ander pro.aaimma ser Chapter 9(commencing
JOB DESCRIPTION
WON with Section 700(hie Division 3 ofthe Business and Professions CWe,and my license is RESIDENTIAL
1 ,= in full force and effect. PERMIT ISSUANCIi
yl— ❑SFT)Wh ❑KITCHEN REMODEL
�U U License Class Lie# APPLIANCT;S-RIiS1UENTIAL ❑ADDITION O PLUMBING RE PIPE.
rei c. Dam Cnnmmwr
ARCHITECT"S DECIARATION ❑MULTI-UN It' ❑STRUCTURAL
p.5 h PANELS
Z n Z I understand my plans shall the uJ as public records MODIFICATIONOZZ—0 UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
[F�FW Licensed Professional 201-I000AMPS IMPROVEMENT
C C 5 Q I M1ercby alarm hen Ir am emmpERnm he Contia�or's License Law for the OVER I"AMPS ❑BATH REMODEUREP IR 0 DEMOLITION
2 O W following U foreason.(Section)031.5,Business and Professions Core:Any ci y t t ❑OTHER -
�d g or century SIGNS IiLECI'R1CA1,
1+13 LL E' which requires a permit to consumer,ober,improve.Demolish,or repair any swmurc
O Fortino il,norarce,ulsoesquirex meapplicam lorsuch permit ,,tilramer al 11emen1 SPECIAL CIRCUIT/MISC.
�;!ly then he is license)pursuant to the provisions ol'the Cnnttacmrs License Law(Chapmr9
W�GCO (commencing with Section i000)of Division3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMC>CA
Q.a p that he is exempt Isenhour and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicantfor a permit mhjectstheappliconun ucivil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
y not mare man five hundred dollars($500).
F Z i OTHERIMPROVEMENT
$ Q �1,as,,thewowner of the pmpeny0r myemployees wimwages as their sole compensation. SWIMMING PUUI.IiLECTRIC
will Jn the work.unit thesmmmrc is not inamJcJ nr nffereJ for sale(Sar. Husina,s ❑OTHER
3� unit Professions Code:The Contractor's Licetne Law thcs nut upply m an owner or OU'TLET'S-SWITCHES-FIXTURES
property who build,or improves thctcon,mad who does such work hinrselt or throush
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENT AL ELECTR SQ PT.
sale.If,however the building or improvement is sold within one yearnfrompletwo.the SQ0.IT.FLOOR AREA $/SQ.IT,
owner-builder will have the burden of proving that he did not build or improve for put- A
psssefsale.). Y f
TOTAL:
1,as owner of the property,am exclusively cnrdcting with licensed contractors to
mJ h
consuuct the project(Sec.90sq Business and Professions Codec)'lbe Contractor's Li. ®�� iJ
crow Law docs nor apply m an owner or lnopeny who bui Ids or improvesre
theon.and Qty.. PLUMBING PERMIT ITE
who contracts for such projects with a connuetor(s)licenced parsuunt to the Contractors `/ n
License Low. PERMIT ISSUANCE
❑lam caturilndc'Scc .B&P C for this mason Vr
6 ALTER-DRAIN&VENT-WATER(EA)
Owner Data
a
\ ORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE /
IhercbYunder Penalty m(perjury one of the following declarations:•Q Ihav and will nmintninu Curti Eeme ofConsemtosclf-iseamba Workers Cmiorn- DRAINS-FLOOR.ROOF.AREA,COND,
unci,as provided far by Section 3](X1 of the Luba Code.far the Performance of the S'li)RIBS "CYTE GDNSTRDGTIDN
work for which this Permit is issued. FIXTURES-PER rRAP
❑I have and will maintain Worker's ComPenution Insurance,as required by Section
3100mfthe LaborGde.for the performance ufthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.CROUP APN
My Workers Compensation Inveranre carrier and Policy number nm:
Cartier. Policy Nm.: GAS-EA.SYSTHM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSAHON INSURANCE GREASEINDUSI RL WASTE INTERCEPTOR
BUILDING DIVISION RiF;S
[Thk,oction recd not hecnmpleed i tthe permit is forms,hundred dollars pt 110) GREASETRAP
ser IessJ PLANCHECK FEE
I rectify mat in the performanceofmc week for which this permit is issued,L,hall SEWER-SANITARY-STORM EA.2001T.
not employ any person my manner so as to become subject to the Worked Compere ENERGY FEE
O Z satiom Laws of California,Data WATER HEATER WNENT/ELECTR GRADING HE
Z O Applicant
NOTICE TO APPLICANT:If.after making this Cenificam of Exemption,you should WATER SYSTII,`TREATING
� E become object the Workers Gempro%abou provisions of the LnMn Code,you sena SOILS FEB
u
Wforthwith comply with such provisions or this Permit.shall he decnmd revoked. WATER SERVICE
Q
A' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.fT. PAID
U O Data RccciptM
I hereby affirm that then is a construction lending agency for the performance of
F
fl the work for which this Permit is issued(,Sec.3097,Cm C.)
LendeA Name BUILDING 171711: TOTAL
L) Lceder'a Address
)+ Lal
[r I cenily mat I hove read this application and state mat the above information is
V�71 rotten.1 agree ceir and with y uth and county ntaiives of and swm hews relating m p'TY. MECHANICAL PERMIT FEIi
1.1 F7
building construction.and hereby authorize representatives of this city mentor apron the SEISMIC FEB
tomme-mentioned proper,for inspection purposes. PERMIT ISSUANCE
(We)agree m save.indemnify and keep besides,the City of Cupertino against ELECTRIC HE
Iiabilities,judgmcnts,costsand eipcnses which may in any way accormirpna said CityALTER OR ADDTO MECH.
in consequence of me grouting of this pemtit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,M)Cl'M)
SOURCE REGULATIONS. MECfiANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCI'ION'I'AX
Signature of AppliaanuCouttactor Dam EXHAUST HOOD W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle humorous material HEATING UNIT(TO 100.000 BN)
os defined by the Cupertino Municipal Colic.Chapter 9.12,and the Health and Safety
Cork,Section 2553Na)P HEATING UNIT(OVER 100.0011 BTU)
❑Yes ❑N0 VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building t use equipment or devices which Uu¢ Receipt#
pp dby the
Amu
BOILER-COMP(3HPOR Io0.tX0B'rU)
nit hvarnos air nmmminants as ddinW by the Hoy Area Air Quality Management
TOTAL:
Dissect? BOILER-COMP(OVER 100,00 BTU)
❑Yea ❑No
I have real the hazmdous seroma),witmoram under Chapter 6.95 of the Cali.. AIR CONDITIONER ISSUANCE DATE
fun in Health&Safety Code,Sections 25505,25533 and 255:4.1 toa ccs4nJ that if the NEW RES I DEN'I']AL MECH. SQ.PT.
building docs not rnmntly have a heriani.that oris my responsihiltry mnmify the mecupom
oI the ragoimmen,which most be met.dormisuuneeru Cenilicuteni Occupancy. / /J
Owner ser amthomeJ engem Data TOTAL: ISSUED BY:
OFFICE