30148 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - 'BUILDING-ELECTRICAL PERMIT NO .^ O �a
BUILDING DIVISION APPLICATION/PERMIT PLUMBING'MECHANICAL J< VY
NUILIIINC PROJECT IDENTIFICATION
BUILDING ADDRESS: "' SANITARYNO. APPLICATION SURMITTAI,DATE
VW I- 77
OWNER'S NAME: PHON11i )CONTRACTORS NAME: LIC NO:
Y/W NIC COST ROL#
�1RCHITRCT/ENGLNEER: LIC NO: ADDRESS. 1❑ (o
CONTACT. / PHONE - BUILDING PERMIT INFO
D❑ Consultant Fees Paid by Applicant(Inilial) T_ BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARAATION /LMS` aC �•
QTYELECTRIC PIiRMI'P FEE
I beach,affirm that 1 am licensed under provi is of Chapter 9(commencing . JOB DESCRIPTION
0.'Z with Section 7000)of Dlvisien 3oftha Businca and Professions Code,andmy license is
PERMIT r-a. f� PERMIT ISSUANCE T
rC❑ lull e Class
and effect, 66/S"J
in
Class Lie.as "OWL OKI'I'CHINREMODEL
Controcmr APPLIANCES-RESIULNTIAL ADDITION C3 PLUMBING RE-PIPE
❑y A ICHITECCd DECLAR4TDN1 PANELS OMULTIUNIT ❑STRUCTURAL
Ov�Z 1 understand my plans shall be,used as public records , MODIFICATION
Z=fO a UP70200AMPS El INTERIOR [I CHIMNEY REPAIR
1:4h Licensed Professional 201-10WAMPS IMPROVEMENT
44 OWNER-BUILDER DECLARATION
1 herehy affirm thin I am exemptthri
train e C.oloo,o ',locmue Law m the OVER IIKIOAM1IPS_ 0 BATH REMODEL/REPAIR 0 DEMOLITION
3 G.U following reason.(Section 7031.5,Business and professions GMs:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a permit to c.nstotal,alter,improve,demolish,m repair any structure
Iriarm b,i,wm,a,also mgnima thoapideme forlorn permit'.flait,gnN itatenteot SPECIAL CIRCUIT/MISC.
E;!(Q� that he is licensedpersuantto the pfvisnonsef Ne Conhamors license Law(Chapterit
..CO (commencing with Section 700gaof Division 3 of the Bminessand Pmfes.sions Cude).r TEMR METER OR POLE INST. COMM RC AJ'
K n m Nat he is exempt thexfmm it the basis I'or the alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
x,,,y
Section 7031.5 by any applicant for o painful subjects the applicant to a civil penalty of POWER DEVICES TENANT OFGGD SERVICE
'~-_< not more than five hundred dollars($500).
Las ownerof the norm em k,us wilhwa was Ncirsole cam - MPROVEMENT
❑ Ptope ct Y P Y B pBusinen, SWIMMING POOL 131.ECTRIC
L. will dothe arms,irk,andhe ctuare Contisnotintended oroffered awdosmak(Sec.] aBoniness DOTHF.R
1+150 and Professions Core:The Contractor's License Lew does not apply w if owner nl' OIITLIH'S-SWITCIIES-hIXTURliS
a .. hpropertyis own who builds pr improves themh h and who does such work deed(it of through
his awn ttnpinytts,provided thin such intproventents aro not intended ar offered for NEW RESIDRNTIAI.ELECIR $Q FT. '
sale.If.howcver,the building or improvement is sold within one year ofcnmpletion,the O ^ SQ.PT.FLOOR AREA $/SQ.1T.
owner.mihlsr will have the burden of proving that he did not build or improve for pur-
pnneafsala.). I
❑I,as owner of the property,am exclusively contracting with licensed mntrecmrs to
construct the project(Sec.7044,Business and Professions Code.,The C.mf<tor's Li- /s
c sc Low does not apply to an ewnerofpn,perty who bmtrf.or improves themon.and CITY. PLUMBINGPEUAIT PEE C I
who contracts for such ptojecrs with a contractor(s)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
O l and exempt under Sec. ,II A P C frominre...n
Owner
ALTER-DRAIN A,VENT-WATER(FA) VALUATION
Datta
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTI;C`E DEVICE -2,7
1 hereby affirm under penalty of perjury one of the following decorations: /w
,]Ihave und
sit ll maintain a Certificate of Consent it sell-insure lar Worker's Contpm- DRAINS-FLOOR,ROOF,AREA,COND, STORIES TY PC CONSTRUCTION
satim,.provided for by Sermon 377 of the Latest,Craft, performance e,for the perfoance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Contpensadom Insurance,as required by Section
3700 ofthe My Warkcr'nACeu Ce mntl nm;ucecarde ofth,anti .,it ffor whiandes permit iiss I...id. GAS-IiA.SYSTEM-I INC.4OUTLETS licy OCC.GROUP APN
Cartier Policy No.:tri `• GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSA'I[ON INSURANCE - GREASE/fNDUSTRL WASTE INTERCEPTOR
('this section need made completed if the permit is for one hundred dollars IS 100) - t �_ BUILDING DIVISION FEES
or less.) - GREASETRAP ` PLANCHECK FEE �r
I certify Nat in the perforomere of the work forwhiuh this permit is ismed•I shall
nSEWER-SANITARY-BYOB I
m employ any person in any info.,sous.become mbu
jeco the Workers'Cafpen- - ENERGY FEE �..
Zsatim Luwsof Gdifornia.Date
� � Applicant WATER HEN'RRW/VENT7.'�L?R GRADING FEE
y NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTIiM/PHEATING r/
F
sae suhjeot to the Worker's Contpenm1lon Provision,of the Labor Gwc,you mast Nh SOUS PHB,
forthwith comply with such provisions.anis Pemrit,hall be dccmM revoked. WATI2R SERVICE JKell
Q
CONSTRUCTION LENDING AGENCY NEW IIESIDI?NTIAI.1'LMB, SQ,FT. PAID
U l far whin thi that themisond(Secu alending agency for the Perfomtance of Data ReceiptM
' W � the work fur which this Permit is lxsued(Seo.3aM)],Civ.CJ
0 Lender's Name TOTAL:
WLenders Addrea TOTAL:
0. I certify lbw 1 have read this apphc.dom mud state that the above information in BUILDING FEE �r
ZI emmeL l agree mcomply with all adyand county nrdimrncesand,am. owsichamgm QTY. MECHANICAL PERMIT FEE
V building consrfnion,and hereby authorize reprtxnmtives of this cirymenmr uPnn Ne SEISMIC FEE
above-mentioned property for inspection purPo am. ILI,CLE)
PERMIT ISSUANCE
(We)agree to save,inm
denify and keep harmless the City of Cupertino against ELECTRIC FEE L `
liabilities,judgments,oosu.and expenses which may in any way seems against said City gLTIiR OR ADD TD MECH.
I.consequence.fine gfming ol'this pc.it. PLUMBING FEE,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(T(1 Ia,OW CFM) ii- ail IC
SOURCE REGULATIONS. MECHANICAL IEE
/ � /s p ' 7 /_Q f AIR HANDLINGUNIT(OVER 10.000CPM) CONSTRUCf10NTAX
Stgnamm alA tm./ConuDO Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS ilATER1ALS DISCLOSUREhandl
r Wilby applicant m lutuni Municipal
ode.Chapter
sate 2.and the
Health
oandns Safety HEATING UNIT(TO I(0,g0 BT117
d,defined io the Cupertino Municipal Cnde.Chupttt 9.12,and the Hctdfh and Safety
Code,Section 255326a0'! HEATING UNIT(OVER 100,000 IT TO)
F7 Yet 'O No PAID
VENIffAT10N FAN(SINGLE RESIU) Dote Receipt4
Will the air contaminancant or ts as
defined by the nt Bay AequipmemofdManaemes ent BOILER-COMP(311P OR 100,0(10 BTU)
e hazallous air comaininants as defined by the Bay Arca Air Quality Management TOTAL:
Jt6a G17
71 Yes E3 No _ BOILER-COMP(OVER 100,000 BTU)
1 have mad the hicaslous materials p AIR CONDITIONER ISSUANCE DATE
,5,255 nemsuMcr Chapter to Cali
fnmia Heuer ffi Safetyarently GNc,have
ting 25505.is'my
and 25534.1 understood to if rho NEW RESIDEM'IA I.MECI I. SQ.FI'.
of the
relding doesnotcuwhich have atenant,thato isray sofa Certifcato entitythelanny.medium
of the reyuirementn which must he met prior to issuance oraCmiOcate of Occupancy.
Owner or...htmed age. _ Data TOTAL: ISSUED BY:
OFFICE