30988 (2) APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY - - -
CITY OFCUPERTINO _ BUILDING-ELECTRICAL • PERMIT N_D., On Op
BUILDING DIVISION, APPLICATION/PERMIT PLUMBING-MECHANICAL
3.BUILDING PROJECT IDENTIFICATION
ILDING ADDRESS: SANITARYNO, APPLICATIONSUBMITTALDATE
ios"�r �ioG�✓lCi.✓ Coc��i 07LI- -len
TiW 'SNAME:� l-OE:'� • C TRACTOR'S F: 'A ,LICNO:,t,
S wSrAlN/C L CON9'ROL#
ARCHITECT/E INEEk:' LIC NO. A RESS: ���Jot ❑
' '.CONTACT: - ` ' PHONE. vn', BUILDING PERMIT INFO
_iQ, ❑ Consultant Fees P9id by Applicant(Initial) BI ELECT PLUMB MECH
LICCEEN/SSEDDCCONNTRACTORSDECLARATION QTY, ELECTRIC PERMIT FEE
1 h by firm that 1 licensed de pr f Ch pt 9( mend., JOB DESCRIPTION-
❑CZ, wnh5 f Wk10) Iph ton of the Basta sand Profess on C d nil my Tcense is
aOO PERMIT ISSUANCE - ) -
�F to fullfrc and effect. L - ❑SFDWL ❑KITCHEN REMODEL
aUZU Lice c� Lie# APPLIANCES RESIDENTIAL' ❑ADDITION ❑PLUMBING RE-PIPE
y6 Date Cammrmr ,
RCHITLCT MULTI-UNIT - ❑STRUCTURAL
Fpm PANELS ,
•z OmI t d ndmyplunsshall M1vterser! .public records MODIFICATION
OZm'� - UP El INTERIOR El CHIMNEY REPAIR
T0200 AMPS
�+� m
Licensed Professional t 201-IOMAMPS IMPROVEMENT_
_ OWNER BUILDER DECLARATION OVER.1000 AMPS ❑BATH REMODF.IAREPAIR ElDEMOLITION
C� 1 hereby affirm th r 1 rept from the Connector's demur :A.,c ty o far the _ -
ip5�O d U folio g e n,(Section 7031.5,ii roars d Prof ns fide Any ctry or coumY SIGNS ELECTRICAL [_1OTHER
t++�WO F•' which q rea perms t t t,alter, p d I'h repo r y structure _
pnart t .:urn to commies the apple tf hpermit t filestarenrom SPECIAL CIRCUIT/MISC. a ,
111•ggq•���... th.t ti b licensed pursuant t thp f the Contractors
t t -License L (Chapbr9
an
CO (commenting with Sects 9000)H Di,i,ial'3.ftha Bisires,indP f s n C de)or TEMP METER OR TO L EVOT. COMMERCIAL:
t1y, a that he is exempt memEmn and the basis for the alleged exempt m,Any violation of ]NEW BLDG/ADDITION ]DEMOLITION
W N Section 9031.5by any.pplicam for a perroolumjens the applicant to a civil partly of ROWH CRIVS '[]TENANT ❑FOOD SERVICE
not more than five hundred dollars(SSW).
t I IMPROVEMENT
aQ 6 El I,ns owner of theproperty,nr my employees with wages as their sole compensation, S O LECfRIC
Q will do the work,.ad thesuucmre is not mtendWmro[(ened Em,rb Beo.9044,Business ❑OTHER
Land Pmfidad ns Code:The Contractors License Law does rat apply to'aa owner of -/ITCHES-FIXTURES
" 'propeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for ARE/ ENTIALELECIR SQ Fr.
sale.IL however the building or improvement is sold within one year ofedmplvtion;theSQ.FL FLOOR AREA $/SQ.FT.
overar,buildervill have the burden of proving that he did not build ar improve for pis
❑I,m owner of the propeny,a xdm
usively coraning with licensed cnntracmre m 'TOTAL:
come,
La the Project(Sec.%044,Brldr ofe vnd Professions Cale)The Contmhor's i
cense Law,aces not apply to an owner of property who builds or improves lh d Q PLUMBING PERMIT FEE
who contracts health projects with.eommemrG)licensed purdoaono theC
License La, PERMIT ISSUANCE, t
❑ 1 sm exempt under.!cc. ' B&P C
6 `_
Owner Data ALT W VALUATION
WORKER'S COMPENSATION DECLARATIO BACK FLOW PROTECT.UP ICE
I hereby affirm under penalty of perjury one of the fnllowi I dolls:
❑Ih a nJ ill maintmn aCenAcme of Conserv to self iron, er',C en- DRAIj$SSU6&, ftrAI$Ca,P1915) II)KA COrnp TORIES TYPE CONSTRUCTION
cation provided' f by Section 37M of the Labor Code, t trman of the -
workforwa,diddspermitisisruad. FIXTeontra�r and/0- Om!. y keep OMP;@ @
0 I macron will maintain Workers Compensation•lusdmr:a Ione Swtlon
3700cidthe Labor Code.for the eformnnce of the work for tabic t' issued. GAS'
pp is per 0II=p15yIH {1hx'JlETISti I ;."[�.! a I OCC.GROUP ANN
My Workc Com corm W��r �I�{ it Policy nn •r -
CnneF /�(J uic,Nm n (. GAS Eank&� rev�I.S..I�Or..nr.' on .
CER'fIFICAT,OFF.XF.MPTION FROMWORKE - GRE �YfJ f71N'>7, to
COMPENSATION INSURANCE f 4 ,BUIL DIVISION FPHIS
(This sedan need notbe completed'fthe permit is Entire h reddollars(siou) GRE 3 thirtyda .S PLANCHF.CK
nr less) i _
I certify that in the performance afthe work for which thi. rmitisissued,lshall SEWER-SANITARY- RMF*nu.not employ any person ern
a nny manner do ad m hecmm subject he Workers Compel- - ENERGY F
OEE
0 Z satin.Lows of California.Date ,WATEF10tWNE GRADING F
.7 Applicant
G NOTICE TO APPLICANT,If,aper making this Certifier tf Exemption,you should WATER SYSTEM?BEATING FEF
C✓ become rubjed to the Workers Compensation provisio the Labor Code,you must
forthwith comply with such provisions or this permitshs edvemedrwoked WpTEalur
CONSTRUCTION LENDING ENCY NEW F.SIDENTIAL PLMB, PAID '
- Date Receipt#
V Ihercby of&mthanhem is construction len gagency for the performance of e _ -
the work for which this parol Is issued(Sec.309], v.C.7 -
w H Lender's Name f TOTAL:
�V Lenders Address ' � �" � TOTAL: r -
DJ 1 rattly that 1 have read this.pplleauon d dram that tibo4e informmion is BUILDING PEE -
Eon correct 1 agree to comply with all city..."do
nd co. ordinances and stem laws relating to QTY, MECHANICAL PERMIT FEE -
U
building Conrtmetion.notereby authoriicrep .outativae of this city to enter upon the SEISMIC PEE
above-mentioned propeny forindpecicn purp es. yr PERMIT ISSUANCE
(We) me tb'save,indemnify and le harmle";d,City.of Cupertino against ELECTRIC FEE y
lirbllltles,judgmente,wnts.ndexpenses wF may in any waysccme against said City ALTER OR ADD TO MECH -
in onsegoence of the granting of this perm _ PLUMBING FEE
APPLICANT UNDERSTAN S AND W L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('IO 10,000 CPM)
SOUR E EGULATION MECHANICAL PEE ' .,
1
AIR HANDLING UNIT(OVER 10,(1110 CFM)
,CONSTRUCTION TAX
tirgaintaraw'Ap,lin t o racmr - -' '" Dat EXHAUST HOOD(WMUCT) t HO USING MITIGATION PEE
HA RDOUSM ERIALS DISCLOSURE
Wllltheappliennt or future buil gacapant.emre or hAdlehazardous material HEATINGUNIT(TO 10Q00()BTU),' '
as defined by the Cupertino Municipa ode,Chapter 9.12,and the Heath and Safety - -
Code,Second 25532(e)P, _ HEATING UNIT(OVER 100,000 BTU) `d.l -
[_]Yes
Y ❑N VENTILATION FAN(SINGLE RESID) PAID - -'
f ip t - Dab Recoipt#
Will id[heit malt future building occupant ase equip n nt deo ccs whish
milt bazaN us air come'mno t as defined by the Bey'Arav Air Q alit)Management BOILER=COMP(3HP OR 100,000 BTO),. -
TOTAL: -
Dillrmt? I I - BOILER-COM
❑Yes CIN. - _ -
' 1 have l the hmatdousmaterial,4equiremeous older Chapter 6.95 or the Cali AIR CONDITIONER'
reaISSUANCE DATE -
famia Health&Safety Code,Sections 25505,25533 and 25534.I a.&pater I that if the NEW RESIDENTIAL1 L MECH. SQ F1'. I _
luddingdoesnotcurc ly vca bnan4 that It is mymspansibility muotify the occupam
f th imments w art et poor to issuance of a Cvnitlentc of cupanc + -
ort' Date TOTAL:tom, - ISSUED BY: