30176 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPEi RTINO BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - - SANITARY NO. - PPLICATION SUBMITTAL DATE
oSQr10 216
OWNER'S NAME: PHONE: CO RACTORN NAM M LIC NO
i' Q D LISOII h 33$ Nrc CONTROLia
ARCHITECT/ENGINEER: tete LIC NO: - DRESS: ❑+ ` "
yo ./j1 e c c+
CONTACM, - PHONE: BUILDING PERMIT INFO
V ' ��^ 6 rX1
❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB e El
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMIT FEE ``f T
I hereby affama that I am licensed under-provisions of CM1aprcr9(commencing JOB DESCRIPTION
00.'zwith Sectian90W)of Division 3ofthe Bisineksand Professions Code,and my license is
❑]0 0 p� PERMIT ISSUANCE RESIDENTIAL,
FW in full force and eR?z - 33 C ❑SFDWh ❑KITCHEN REMODEL.
a" iLivers less Lurfi 'APPLIANCES-RESIDENTIAL. ❑ADDITION El PLUMBING RE-PIPE
Dale — eatn.c t psoNh.
�. d ti ARCHITECT'S DECLARATION - ❑MULTI-UNIT ❑STRUCTURAL
H 7 N PANELS
$O y I and,rs.nd my plena eM1ml be used ns pubdc records DIFICATION
ptol , UP TO 200 AMPS'
�-' F{Qy Licensed Professional I ❑INTERIOR HIMNEY REPAIR
qq 201-1000AMPS IMPROVEMENT
S yg2� OWNER-BUILDER DECLARATION '
��jj CCLL PPi�G] I hereby affirm that i am exempt from the Contractor's License Law for the OVER 1000 AMPS 0 BATH REMODEUREPAIR 0 DEMOLITION
0,U following reason(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
rR O a" which requires a fermi,to conslruat,alter,impmva,demolish,m repair any structureprior.its isseance:uh.requires the applicant f.rsach permit 1.lileasignedslalemeat SPECIAL CIRCUO'/MISC.
pN.
that he is licereadfmmanvo the pmv+sinnxof the Cmnmc.r',License Law(Chapter 9
QD (commencing with Section 9000)of Division3 of,he Businessand Professions Code)., TEMP.METER OR POLE TEXT. . COMMERCIAL:
dp�c y that he is exempt therefrom and,ha basis for,he alleged exemption.Any violation of D NEW BLDG/ADDITION ❑DEMOLITION
p( Le
Section 7031.5 by any applicant for a Permit subjects the applicanto a civil penalty of POWER DEVICES ❑ ❑
WW re, mo. TENANT FOODSERVICE
not than f
five hundred dollars(85!10).
a S6 I,as owner oI the roetr,orm Ioees with woes as their sole cora ,inn, SWIMMING POOL ELECTRIC MPROVEMENT
Q ❑ p p y yemp y g pens#
3 roand dothework,andtheh,Cmitisnot a Liceador offer ed for Sala(Sec.. # Business OTHER
and Professions GNe:The Cnnithereo License Laws sac no[npplY[o an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves.creno,trod who does such work himself on,hrou th
his own employees,provided that such imp...comets soca.,intended or offered for NEW RESIDBNTIALELECTRSQ FT.
sale.If,however the building orimprovement is sold within one year ofermple,ion,the - SQ.FT.FLOOR AREA _ $/SQ.FT.
n-
owner-builder will have the burden of proving,hal he did no,build or improve for pu
pose of s ileJ. -
❑ 1,ae owner of the propeny,em exclusively comrectlng with licensed commemrs m TOTAL A
consumer the project(Seo.9044,Basineo and Professions Cade:)The C.ntmetere Li-
cense Law does not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT PER
who contracts for such projects with a umtmenums)licensed pursuant to the Contractors
License CaUC �
Us . - - PERMIT ISSUANCE I/ '9176
- ❑ lamexemplunde^Sec., ,B&PCfardri.reason L/ w7
ALTER-DRAIN&VENT-WATER(EA)
OwnerData vF.,ks y; pT10N _
. - _
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /YU
L hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Conseal.self-iusere for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND, STORIES TYPE CONSTRUCTION
sad.n,m provided for by Section 3700 of the Labor Cade,Tote performance of ma
work for which this permit is issued. FIXTURES-PER TRAP '
❑L have and will maintain Workers Compensation Insurance,as required by Section
3900 of the Labor Code,for the performance of the work for which this permi l is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP APN
IN Work,S5'gg�rpensation LrWruwar rand Policynn �yq
Cameo ` ala Lti i ric Policy No.: L 7 7 T L GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXIi PTLON FROM WORKERS' - ^
COMPENSATION INSURANCE GRF,A9MNDUSTRL WASTE IN]'ERCEPTOR _ } BUII,DINO UIVLSLON FP,ES
(This section need a.,be completed if,hapavnhI,for..hundred dollars I$Fair GREASE TRAP -
It..) - PLANCHECK FEE" -
Icerifythat inthe performance ofthewark for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 PC
.of employ any person in any manner so as 1.become sobject a he WorkersCompen- ENERGY FEE
O Z smi.n Laws of C.Iifomia.Date WATER HEATER WNENT/ELECTR
Q Applicant - - GRADINGFEE -
y NOTICE TO APPLICANT:If,carr,making this Cenificme of Exemption,you should WATER SYSTEMOREATING
abecome subject.the Worker's Compensation provisions of the Labor Cade,you most SOILS PEE -
W frinhoah comply withsuchpmor,ens or this permitshall be deemed revoked WATER SERVICE
CONSc ONLENDINGAGENCY NEW RLSIDENTIAL PCMB. '+ SQ.FT. PAID
I hereby affirm that theaen is is acone.uction lending agency for the pemiormnnoe.f Date Receipt8
IL thework,for which this Permit is issued(See 3097,Cie O) r
0 V lender's Name, TOTAL:
W Lender's Address TOTAL:
L eci ify Iher i hove read this application and state that the above information is BUILDING FEB
h correct.I agree.comply with all city and county ordinances and slate laws relating to QTY. MECHANICAL PERMIT FEE
V building conoretrucand hereby aummizetnpresen.tivcs Mark city,.enmrupon the SEISMIC PEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE -
(We)agree to save,indemnify mad keep harmless the City of Cupertino against ELECTRIC FEE
liebilities,judgments,costs and expenses which may in any way same against said City MTERORADDTOMECH.
in nsece
coquenof the granting of this penniL PLUMBING FEB
APPLICANT UNDERSTANDS AND WILL C MPLY WITH ALL NON-POINT^ AIR HANDLING UNIT(TO 10,000M)CF -
SOU E CATIONS. - MECHAN[CAL FEE
1 ] ALR HANDLING UNIT(OVER 10.0d"CFM) CONS RUCTION TAX
Signature of ApplicanUConlmctor - DaleEXHAUST HOOD(WMUCT) HOUSING MITIGATION PEE
HAZARDOUSE
MATERIALS DISCLOSURE
Will,hcapplicanmrfuture building occupant smrecr handle hazardousmmerial HEATING UNIT('1'0100,000 BTU)
as defined by me Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
- Code,Section 25532(a)?v HEATING UNIT(OVER 100,003 B9'U)
Fl Yes [I No - PAID
VENTILATION PAN(SINGLE RESID) Date Receipt# '
hazardous
the air comet on future building by the B use ea Air Quality
.r devices Management
,BOILER-COMP GHP OR 100,000 BTU) '
emit hazallous air ammminunis its defined by the Bay Arca Air Quality Mammgement TOTAL:
Distria9 _ -
BOILER V
❑Yes FINo -COMP(OBR 100.000 BTU)
I have mad the ardn
hazu.nationals requirements und Chapter 6.95fatALR CONDITIONER,
e Cali- •- ISSUANCED TE
forma Hedllh&5 f ty Cod,,S 1 .255()5 25513 d 25534 1 d , d tit t if,he NEW RESIDENTIAL.SUCH. -SQ.PT.
bnildme d e.not rune lly have.cement,ma,it'.n y adstmalitalit,mussily the...,at `
of the requircurears which nus,be met poor to issuance of o Certificate of Occupancy,
Owner or authorized agent Data TOTAL: ISSUED ITT&
OFFICE