30253 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY,
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING'MECHANICAL
30253
BUILDING PROJECT'IDF.NIPICATION
BUILDING AIIUR&55:, . SANI'T'ARY NO. APPLICATION SUBMMALL WEE
OWN ' E: ^l' `I j1Nby.� CO RACTON:S NAME: LIC • - "_
(JT Y/J-(]J( eL/Gf N/C CONTROLN
ANCIII'fEC'1IENGINEER: LIC NO: A RP ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid J�e -55by Applicant(Initial) HELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby afrrm h
at I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
QOZ with Section 7000jaf Division 3 of the Business and Professions Code.and my license is
DENTI
F W 0 ten full force and eB a PERMIT ISSUANCE ximWf ❑KITCHIiN RIsMOOEL
�UU License P .e, hic.N
F ZQtW Dam Cnntradnr APPLIANCHS-RESIDENTIAL CADDI'I'ION ❑PLUMBING RE-PIPE,
f ABOUT ECI S DECLARATIONCMULT'hUNll' CS'I'NUCI'l1RAl.
1�•+� PANELS
Zp 1 understand my plans shall be uood as public records MODIFICATION
UPTO 200 AMPS E-1 INTERIOR CCHIMNEY REPAIR
piatAt Licensed Professional 201-I(X10AMPS IMPROVEMENT
J Oat I am exempt Ern the RATION OVER 1000AMPS C BATH NEMODF_I�PAIIRR�IiM01sITION i
Q I hereby affirm that 1 OWNER-BUILDER
from the RATION License Law for the K 3IL U following tnasoa(Section 7031.5,Business and Frofessiens Gale.Any city or county SIGNS ELECTRICAL C OTHER k
u]LL OE which requires a permit to construct,alter,improve,demolish,or repair any structure
`mom] prior to its issuance,also requires the applicant for such Permit o file v signed statement SPECIAL Cl RCUIT/M ISC. 1
p. that he is licensed pursuanuo the provisions ofthe Contractor's License Law(Chapter 9
p0 (cnuanomaies with Section 701 of Division 3 ofthe Business unit Professions Code)or TEMP.M171'I7R OR POLE INST COMMERCIAL:
dyp�e C man he is exempt therefrom and the basis for the alleged exemption.Any volution of ❑NEW BLDG/AUDITION C DEMOLITION
W^m
Section
"OU
00 L5 by any applicant for a permit subjects the applicant to a civ 11 penally of
Nnot more than Five hundred dollars S500). POWDEVICES CTfiNANT CFGOD SI?RVICE
q [DLas owner oftheproperty,army anployees with wages as lheirsole compensation, SWIMMING PNB.ELECTRIC IMPROVEMENT
do me work,and the structmx is n u intended oroffered for sale(Sec.7044,Business C OTHER
6'3 end Professions Code:The Contractor's License Law does not apply to en owner of OUTLETS-SWITCHES-FIXTURES
property 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 NEW RES[DENTAL ELECTR SQ FT.
one.IL however,he building at apnwemem is sold within one year ofsatmpletion,the SQ.FT.PLOORAREA f1SQ.ET.
wrier-builder will have the burden of proving that he did not build or improve for put- +
fam of sale.).
❑ 1,as owner of the progeny,ant exclusively contracting with licensed contractors to - 2 91996
construct the project(Sec.71X4,Business and Professions Code:)The Contractor's Ll- 111L
cense Law does not n.
apply to an owner of property who builds or improves themonnd QI'Y. PLUMBING PERMIT JUL
who ro amts h r itch padoct,with a conuntro r(s)licensed pursuant m the Contractor's
License Law. U
PERMIT ISSUANCE ell U UT-C'n I IPTU
0 lam exempt under Sec. ,B&P C fur this maann
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury ane of the following dttluatiam:
❑ Thecae and will maimaina Ccnificme nfConumto self-insure for Workers Camper- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Cede,for the performance of the
work far which his permit is I...ed. FIXTURES-PER TRAP
C 1 have and will maintain Worker's Compensation Insurance,as required by Section
371X1 ofthe[.shot Code,for the performance ofthe work for which this permit'm issued GAS-FLA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP AI'N
My Worker' tiYFn,vnrunyLvvrric
t rand Palley o
Carrier: w Policy No.:� LIy /` GAS-EA,SYS'I'HM OVER 4(EA)
CERTIFICATE OP EXEMPTION FROM WORKERS'
'COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION MEN
(This sationneed non be completed ifthe pemdt is borrow hundred dollars 13100) GRF.ASE'IRAP
m las.) PLANCHECK FEB
Toy any hztinhe perany armanceobhe wad for subch ject
bottom it isissued.lshall SEWER-SANITARY-STORM EA.200 FT.
not employ any parson in any manner xn aur become subject m the W'arkery Compete ENERGY PP:E
Z sation Laws of California.Date
O Applicant WATER HEA'1'CR WNENT/ELECTR fPAID
ADING FEE
y NOTICE TO APPLICANT:Bitter making this Crodicate of Exerndion,you should WATER SYSI'EMOREATING
a ; become subject to the Workers Compansutlon provisions of the Lohnt CnJe,you matt LS FEE s
W forthwith comply with such provisions or this permit shall be deemed revokal. WATER SERVICE
6 Q '
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.<N'.
U0 Thereby ofFinn theuhere isvnm.awctinn lending agency forthe perforntance of Dmc Receiptp
W F he work for which his permt iv Issued(Sec 3097,Civ.C.)
0ULenders Name TOTALWLenders Address TOTALfy I esnify Nat 1 have redhis application and store than the above information is LDING PER
V) comer.l agree to comply with all city and county ordinances and state laws relating no QTY, MECHANICAL PERMIT FEE
U Z building construction,and herebyamhorim representatives ofhis city usonterupon she SEISMIC FEE Iry
above-mentioned property for inspection purposes.
(We)agree to save,indemnify mod keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEB
liahil Nies,judgments,costs and expenses which may in anyway acerae against said City ALTER OR MTD'IG MECH. PLUMBING FEE
In consequence of he granting al'thix pcnnin.
APPLICANT UN RST'ANDS AND WILT MPLY WITH ALL NON-POINT AIN HANDLING UNIT(TO 10,1g1(ICFM)
SOURCEoRF 'I .. MECHANICAL PEI?
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signa r l'ApplicardifiC tract etc EXHAUST EOOD(W/DUCp HOUSING MITIGATION FEE
HAZARD MATERIALS DISCLOSURE
Will he applicar f rebuilJing acupant snore orhandle hazWous materiel HEATING UNIT(TO 100.000 BTU)
as defined by he Cmc o unicipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
❑Yes 7 N - PAID
VENTILATION PAN(SINGLE RESIp) Date Receipt M
Will the air co am or nos a h alined by the B nue equipment or Join which
ernithazvNous air conwminanN as delineJ by the Buy Area Air Quality Munugement BOILER-GGMp(311PGR 100,0110 BTU)
u
Dishier? TOTAL:
❑Yes 7 N BOILER-COMP(OVER I01,1100 BTU) .
1 have read me mems ous materials AIR CONDITIONER
r5.2553 sunder Chapter me Cali- ISSUANCE DATE
bumia Health&Safety Cale,Sections 25585,23533 and 25534.1 matters mad tum if the NEW RESIDENTIAL MECH. SQ.-PT.
building does notcurrency have atenant,thato ismy res ponsibilitycanotifythett
of the requirtments which most bm e mpoor to ofa Cenificme af(kauptracy,an<y.
Owner or authorized agent Ilam TOTAL: ISSUED BY:
OFFICE