30663 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDINY:-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PF,RMITPLUMB NO-MECHANICAL 30663
BUILDING PROJKCIIDENTIFICATION
BUILDING ADDRESS: SANITARY NU. APPLICATION SUBMITTAL DATE
3700 G® c /
OWNER'S N ME: PHONE:
/E-- CONTRACTOR' N
`GJ N❑IC
CONTROL N C
%RCHITEJC NO: ADDRESS
J
i S 4J' C L CA M /t)0
CONTACT. PHONE m a g,! BUILDING PERMIT INFO
Allc-- , /-) q TE,e, [:] Consultant Fees Paid by Applicant(Initial) B❑ EI❑ PLUMB MECH
14�LICENSED CON'TRACTOR'S DECLARATION QTY ELECTRIC PERM IT FEE ®/
I hereby anion that I am fi.nsed under prsisions of chapter 9(aging eneinIf JOB DESCRIPTION
�aZ with Section 7")of Division 3ofthe Business and Pmfccsions Cede,and my license is
�40p PERMIT ISSUANCE
u Li full force and off, N C/7/s ?J. �j L ❑KITCHEN NEb10DF.1,
lUU Licence Clash T E S ✓G APPLIANCES-RESIDEZNTIAL El ADDITION ❑PLUMBING RE-PIPE
E Q 6 Date Contractor
VI
ARCHITECTSdullbcuw UECIAcAT10N (.(70 R/� PANELS [I MULTI-UNIT ❑STRUCTURAL
Z O Z I underaunJ my plans.hull he uzuJ as public r.ords MODIFICCHIMNEY
TION
REPAIR OZ—O 111"ID 2011AMI'S C1 INTERIOR ❑CHIMNIiY ftEPA1R
(.-SFW Licensed Professional 201.101)(AMPS IMPROVEMENT
a J OWNER-BUILDER DECLARATION
a g�Q 1 hcmhy affirm Ihm 1 um exempt it the Cunvhetors License Law for,he OVER["AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
5:0W U following mason.(Section 7031.5.Business and Profusions Code:Any city or county SIGNS ELECTRICAL TITHER
1+13 LL in which requires a permit to construct,alcor,improve,demnllsh,or repair any swemm G �/
north its issuance.also requires thcappli.nt forsuch Permit o file aligned statement SPECIALCIRCUIT/MISC. i
Ihot he is licensed pursuant la the prove...of the Cnmracmr's License Law(Chapter 9
�G CO (commencing with Section 7")of Division 3 oftbe Businessand Professions Ceac)or TEMPI METER OR POLE INST. COMMERCIAL;
a a catz that he is exempt therefrom and the basis fur the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
' ti y Section 7031.5 by any applicant for a permit subjects the applicantto a civil Penalty of POWER DEVICES ❑TIiNANT ❑FOOD SERVICE
F=0 no,marc than Live hundred dollars($50B. IMPROVEMENT
C] 1.as owner night,property.or my employees with wages as their sole compensation. SWIMMING POOL EL[CTRIC
W$ will do the work,and theswcwrc isnnl intended orolieved finish,(Scc501 Business ❑OTHER
ly 3 w and Professions Come:The Contractor's License Law does not apply m an owner of OUTLETS-SWITCHES-FI%TURES
progeny who builds or improves thereon,and who does such work himself or through
his own employ.,,provided ghat such improvements arc not intended or offered fur NEW RESIDENTIAL ELE SQ Ff.
sale.If.however,are building or improvement is sold within one year ofcomplelion.vthe SQ.FT.FLUOR PA
LSQ.FT.
owoer will have the hurden of proving That he did not build or improve for par P M D
pave ofsule.), TAL:
I,at,owner of the property,am exclusively contracting ulgh licensed contractors to
coinstruct the printer(Sec.0044,Business and Promising Code)The Cnnuacturs Li- DEC 13 199
me Law does not apply to an owner of property who hands or improves thereon.and QTY. PLUMBING FERMI FEE
who contracts for such parjeci with a contractor(%)licensed pursuant o We Conloscu "
License Law, PERMIT ISSUANCE VI I1 Uf VVCCTII IN
C 1 an exempt under Sec. .B&P C for Ni,reason
ALL HR-DILA IN&VIENT-WAI HR(EA) as VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby union under penalty of perjury one t) the follomsmim n Worker's
Co:
❑I haveer,&%provided
for
maintain Section 37M ofCOmcnuo oil i,for the Worker'sC of
DRAINS-FLOOR.k001'.ARFA,CONU. S'1 OkIE5 TYPE CONSTRUCTION
saint.as provided for to Section 3]W of the Inbar Code,for the perfortnanee of the
work have
which this permit is jawed. FIXTURES-PER TRAIT
1 have and will Code.
for
Wmerfor Come(ifthe w rk urance,ho which
h required by Section
3](X1 office laMa CtJe.for the performance of the work lin which lhispemgit is issued. GAS-EA.SYSTEM-I INC.4OUTLETS OCC.GROUP AI'N
My Worker s Compenwtio Insurancecartierand Policynum1w,me:
Carrier g17- 0 O Policy No.: I ;ta J ?�"/ GAS-EA.SYSTEMOVER 4f EA)
CERTIFICATE 017 EXEMPTION FROM WOR KERS' Gk1iA$FJINDUSTRI.WASTF.IMERCEI'l'Uk
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section hand not be completed if the permit is for one hundred dollars ISIBE GREASE TRAP
ar less.) PfANCHECK FEE
I certify that in the performance ofthe work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any man �o Mcmme cit it)the Workers'Compen- ENERGY FEE
ncr s 7
O z sainn Iawsof�Omia.Date WATER HEATER WN1iirELECIR GRADING FEE
Z O APprcant
rte. NOTICE TO .I'AN'EIf,aacrtnnking this Cam'niaade of Ealadmma,you should WATER SYSy EMOTEATING
a , hecomc subject to the Workerenint
Worker's Compensation provisions of the laha Code,you mSOILS PEE
W forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
5Z CONSTRUC'f10N[.ENDING AGENCY NEW RESIDfiNT1ALPhMB. SQ,FT PAID Date Reccitu
U ZI hereby affnn that there is a concoction lending agency for the performance of
the work for which this permit is issued See.3097,Civ,C.) TOTAL:
Q U Lenders Name
Lender's Address TOTAL:
UJ 1 certify that 1 have read this application and said that the above iofnrmurrlon is BUILDING FEE.
In correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U building conslmctinn,and borehyoudhoriee representatives ofthis city to enter upon the SEISMIC FEE
above-meaioned property for inspection purposes PERMIT ISSUANCE
(We)agree m save,indemnify and keep haranim4 Ne City of Cupertino against '1.1[LTRIC FEE
liabilities.judgments.costs and expenses which may in any way accrue against said City ALTERORADDTOMECH. PLUMBING FLE
in comcyuenec of the"mating of thin perngh,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00 CFM) MECHANICAL ME
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFb11 CONSTRUCTION TAX
Signature of ApplicaMConaacmr Dae EXHAUST HOOD(WMUCI') HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE /
Will theapluesid orfnturc building rccupam store or handle hamrdommatedal THEATING UNITCYI IM."BTU)
as defined by he Calms.Municipal Code.Chapter 9,12,and the Health and Safety
Code.Section 255320)] HEATING UNIT(OVER 1D0.M01 BTU)
D Ye, ❑No VENTILATION PAN(SINGLE RESID) PAID gam ReceiptN
Will the applicant or future building occupant use equipment at devices which BOILER-COMP OHP OR 100.000 BTU)
emit hazardous air comaminan,as defined by the Bay Area Air Quality Mome
nageng TOTAL:
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes Ohio
I have real the haevdo,areaken,gralaremeins We,Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE,DATE
fomia IIcalth&Safety Code.Sections 25505,25533 and 25534.1 understand that if Ne NEW RESIDENTIAL MECH. SQ.EC
building does nod currently have a Icahn,,that it is my gesp alihilhy m notify the occupant
of the requirements which must he met prior In issuance(da Cenilieam of Occupancy.
Owner or uurhurieeJ.gem Dam TOTAL: ISSUED BY:
OFFICE