30906 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT No 30906
BUII,ITING DIVISION APPLICATION/PERMIT I'LlIMI41NG�MECHANICAI.
BUILDING PROJECT IDENTIF'ICAT'ION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
♦ 1 -k —7—A5-
OWNEQVINAM11:11 CONTRACTOR'S NAME: LIC NO: 7IyV
_ N/C CONTI'ROLa
ARCHITECHEN °GIN' : LIC NO: gpDBMS: ' ❑
CONTACT: PHONE: Y BUILDING PERMIT INFO
❑
Consultant Fees Paid by Applicant(Initial) BELECT PLUMB C
VQ 7?`I-&371 OElM
LICENSED CONTACTORS DECLARATION
QTY ELECTRIC PERMIT PEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
W00 OO with Section 7000)o(Division 3.Dhe Business and Professions Code,and my license is
WOO , PERMIT ISSUANCE
=-- IDFNTIAL-
in full force mJ,trey-,_,�1 SPDWL ❑KITCtIF,N REMODEL
aZU )at, e��aa-.�.I� _,e�nt,�� ��J—Lie.p APPLIANCES-RESIDENTIAL - ❑ DDITION ❑PLUMBING RP PIPE.
Xaa Dale{-Fy_-GFya�C DELL_
�F �s'J ♦e�J ARCHITECTS DECLARAt'ION ❑MULTI-UNIT ❑STRUCTURAL
(..D y PANELS
ZOoZ I understand my plana shall he used as public records MODIFICATION
OZ4_C1 UPTO 2E)AMPS ❑INTERIOR El CHIMNEY REPAIR
F.y.,E Uq Liccnrod Promotional 2EI-IINNIAMI'S IMPROVEMENT
Oat I am exemptiRaa'ihc RATION OVI?ft If00AMVS BATH REMZ01fI/RE ❑DEMOLITION
'�j` 1 hereby u[Tinn thin l um exempt from the Contrumnr's License Luw for the Aµ/
03L O u followinga (Section 7031.5.Hasincss and Profcasinns Code:An t t OTHER /t/G
'3 m,F r sort. y,an, ara county SICN$BLECfRICAI. ��"" /+ 1-
m which e 10 it,or i permit m mm,thic,alcor,improv.,dcm.it t of repair any comae L Ol504G
F'1'J06 hotheshecsumaersonae to ffic owkiousto The Conrctoiuoicense awJsm¢mem SPECIAL CIRCUIT/MISC.
that be en licensed personal ar the of Division
ofof t e Business
License Law(Chapter 9
Taal y��0 (commencing with Section 7lXNB of Divisinn3uf the Business and Professions Coder or TEMP.METER UH IY)LIi INST. COMMERCIAL:
L 1 ethe he is exempt(brief.,.and the basis lir(he alleged exemption.Any violation of ElNEW BLDG/ADDITION ❑DEMOLITION
X-E Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
W-y ❑TENANT ❑FOODSERVICE
not mare than five hundred dollars(551X0
F_Z Y IMPROVEMENT
Sad ❑I,as owner ofthe pmlKnY,or myemployaswith wages as their sole compensation. SWIMMING POOL ELECTRIC
fFG willdothe work.andthe strucmrtiannl intended or offered mrsole(Sec.1044.Business ❑OTHER
Wno and Professions Core:The Commune's Licenw Law does not apply to an owner of OI BTS-SWITCII&S-FI%T _
a 3- property who builds or impmvcs thereon,and who does such work himself or through
his own employees,provided that such improvements vre not intended or offered for NEW RESIDIiNT'IAL ELECTR
sale.If,however. e building or improvement is sold within e yearofbomplelien,the SQ.FE BOOR AREA $/SQ.Ff.
thon
owncolimilcoar will have the burden of proving that he did not build m improve for puf-
poaoftenc).
0 h as owner of the property,am exclusively contracting with licensed,omeacmrs to TOTAL:
o osmu,the project(Sec.IOW,Busincas tad Professions CNet The C.O.—to,r s Li-
cerise Law doesnot apply it)an owner of property who builds of improves thereon.and QTY. PLUMBING PERMIT FEE
who rmaracls far such projects with a comrsemrfs)licensed pursuant to the Comracrors
Lmvnse Lar. PERMIT ISSUANCE
❑1 am cacmpt under Sec. ,B&P C for this reason
Owner Date ALTER-DRAIN&VENT-WALE R TA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK ROW PRO'IT=DEVICE
I hereby affirm area penalty oflrtjvry one of the following d,ch m mal
+❑I have and will mainrrina Cenificmeof CommnOo sdGinsurefor Worker's Compen- DRAINS-FLOOR,ROORAREA.CNDSTORIES TYPECONSTRUCTION
nation,as pmvidN Cur by Scction 3]0X1 of the Labor Code,for the pafoumuce of the
work Gr which this permh is isxncd, FIXTURES-]'FR'I RAI'
❑1 have and will maintain Worker's Contpcnsaeon Inometim as mquimcl by Section
370X1 tittle Labor Code,lir the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.J OUT 1.171'S OCC.GROUT' APN
Ca Wurkcr'e Compensation �urunce cmrief and l NO.,nyryb
My
Policyol., �" 9�Vaa�� GAS-EA SYSTEM OVER 4(GA)
C f11TCA'TE OI'E%FiMPT10N FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRLWASTE INTERCEPTOR
BUILDING DIVISION FRES
(This section need not hccnmplmeJ if the permit is fns one hundred dollars l$IWI OR EASE TRAP
Or ass.) PLANCHECK FEF.
I certify that in the peromearcref1he stock for which flan permit is issued,Lvhell SEWER-SANITARY-STORM EA.203 FE..
not employ any pawn in my manner so as m subject become subjeco the Workers'Compen- ENERGY FEE
0Z 'alto.Laws of Celifomia.Ilam WATER HEATER WNENT/ELEC R GRADING FEE
Z Q Applicant
y NOTICE TO APPLICANT:IL after making this Cenificate of Exemption,you should WATER SYSTEMCREATING
become subject m the Wolds Compensmi er provisions of the Labor CN.,you most SOILS FEE
forthwith comply wish such provisions orchis termer shell be deemN revoked. WATER SERVICE C
a � z loot
0 Z CONSTRUCTION LENDING AGLNCY NEW RESIDENTIAL PLMB. SQ.FC PAID Dale acipt a
U 0 (hereby affirm that them is a construction lending agency for the performance of
the work fur which this permit is issued(Sec.3097.Civ.C.)
0 1- Lender's No..
U LeadsAM.. TOTAL BUILDING FEE
1 certify that I have read this application and mate that the ante information is
,P. .cancer.)agreeaS comply with all city and county ordinances and state laws rela6c, ,, QTY. MECHANICAL PERMIT FEE
V Z building construction.and hereby umhoriu representatives of Nis cirymcnmr upon the SEISMIC FEE
above-mentioned progeny for inSpcclion purposes. PERMIT ISSUANCE /
(We)ugme to save,indemnify tad kap hamdcsx the City of Cupertino.,aid,( ELECTRIC FCB 3
liabilities,ludgmenls.costs and expenses which may in any way seem,against said City ALTER OR ADD TO ME Cl I.
in nscyacme ofthe grunting of this Permit. PLUMBING FEE
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIF(TO IIIJXNICFM)
SOURCE REGULATIONS. MIiCHANICAh FEE ✓
AIR HANDLING UNIT(OVER 10,00X)CFM) CONSTRUCT ION TAX
Signature of Applicant/Contractor Dam 17XHAUS'I'11001)(W/DUCT') HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hamrdoux material HEATING UNIT(11)103,1NID BTU)
as defined by the Cupertino Municipal CN,,Chapter 9.12,and the Health and Safety
Cas,Section 15532(a)l HEATING UNIT(OVER 10,8X)BTU)
❑Yes ❑Nn PAID
VENTILATION PAN(SINGLE R&SID( Dam Receipt of
Will the applicant nr future building Occupant use equipment or devices which
knot hawdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP DEP OR 100,030 BTU) IOTA Q
District' BOILER-COMP(OVER 103003 BTU)
❑Yes ON. in
AIR CONDITIONER
flute madthe h oJk.Susumu, lsrequim33 and
Chapin6.95ofthe Cali- ISSUANCE DATE
fomia gcWth&Safely Cada.have
5505.25531 mW 25534.I uaorstmJ cul if the NEW RESIDENTIAL MECH. SQ.FT. I
building docs WI currently have v mount,that it is my responsibility to notify the Occupant r
of ere uw hm Ibe aro issuance of a Cenifine of Occupant,
ud ag n Dae TOTAL: ISSUED BY:
OFFICE