30070 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO. 3 0 0 17
O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO APPLICATION SUBMITTAL DATE
21+93- TERRRcF 2t.vE (AkRe&T ► wc�
ONAME: P i0? . -� Ok&R;}NAME LIC NO:
R, S LI NO: NIC COM'RULN
ARCHITECI9ENGINEER: IC NO: - ADDRESS: # /'�'br J ❑
CONTACT: PHONE: .SAv - BUILDING PERMIT INFO
L_J Consultant Fees Paid by Applicant(Initial) BLDQ ELECT _ PLUMB
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE •��L�/ ,vL-PB'.
1 hereby aRrtn that I an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
E�0X00 th Section7")ofDivision 3 of the Businessand Professions Code,and my license is RESIDENTIAL:
0 with PERMIT ISSUANCE
m full force and cRcct.
�Ul!� License Class Llc.k - OSFDWL [I KITCHEN REMODEL
F�41 Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Fly ARCHITECTS DECLARATIONPANELS ❑MULTI-UNIT ❑STRUCTURAL
Z p to Z shall ec
1 understand my plans all he used as public rords MODIFICATION
OZ- UPT0 2M AMPS
A ❑INTERIOR [3 CHIMNEY REPAIR
FgC Licensed Professional 201-IgX)AMPS IMPROVEMENT
Wu OWNER-BUILDER DECLARATION
Contr ON OVER TWO AMPS ATH REMODEUREPAIR [I DEMOLITION
X„^yTfj 1 hereby.(firm that I am exempt from the Cosions C s License Law for the
Wu 3 V following ream.(Section 9031.5,Business and Professions Cale:Any city nr county SIGNSELECTRICAL ffj OTHER
Y7 ot which trquires o permit m"1 the
tilte,applicant
improve.demolish.m an 1 an repair any structure
>. Oat he
slcets i,a nsedpuruanttoires tovisiosattar
ttar sucConewmn-a License
Laedoamment SPECIALCIRCUIT/MISC.
} tears. licensed Sectiou0the 00).Msiom of theehadw s Licensetaw(Cusle) 9
If
GAO dew he isc arnapthnstaft 7011 it th basis far m theeged exempton.Aand ny
or TEMP.MEIER OR POLE INST COMMERCIAL:
d y=y that he is eumPt therefrom and the hams for me alleged exemption.Any violatimt of ❑NEW BLDG/ADDITION ❑DEMOLITION
4X1 m Sectian]031.S by any applicant for a renrawijects the.Pplicanuo a civilpenmtyof PO WIiH DEVICES
Iq-,yt more than live hundred dollars($500). ❑TENANT ❑FOOD SERVICE
2C ❑ 1,as owner of to Properly,or my employees wit wages us their sale compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
WC will dote work,and toxhucntre is not intended ornffned formle(Sec.7044,Businns ❑OTHER
d ion
1 �_ anProfesss Code:The Contractors License Law does nm apply to an owner of OUTLETS-SWITCHES-FIXTURES
properly who builds m improves thereon,and who does such work himself or through
his own employesi,provided tat such improvements are not intended or oRertsl for NEW RESIDENTIAL ELEMSQ FT.
a.[.:If,however.the building or improvement is sold within one yew ofcompletion,the SQFT,FLOOR AREA 5/SQ.ET.
owen,builder will have the burden of prwi ng that he did not build or improve for par- • Z•,
P of"b")
I,as owner of the properly,sin exclusively contracting with licensed conoonnrs to A
a tpJUN
O
onswo project(Six.7040 Business and Professions Codc:)The CoJu
ntrubm's Li- 191t. 96
cense law,does not apply tow owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a comparmrbs)licensed pursuant o to Communes
ensee.
(]cl ons ae tunder See. D&PCfor this ream. PERMIT ISSUANCE • I1 J, UrOUrcriflfil _
nor UQAA ALMR—DRAIN&VENT—WATER RA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
• I hereby alTmn under penalty of perjury one declarations:e followingdeclarations: r
❑I haveand will maintain a Certificate of Convent to self-insure for Workers Campen- DRAINS—FLOOR,ROOF,AREA.GOND.. STORIES TYPE CONSTRUCTION
swain,as provided for by Section 37M of the labor Cale,for the pMormattce of the
work for which this Permit is issued. IXTURM—PER TRAP 0
1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Gale,far the Performance of the work far which his permit is i....M. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUT' APN
My Wmrkerx Cnmpensetiom lnsumn<n cumin and Policy nnmMrure: '
Cartier. Policy No.: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF MCNAPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This action need not be completed if@e permit is forms hundrtddollan($100) BUILDING DIVISION FEES
or less.) GREASE TRAP
PLANCHECK FEE
leaning thntinin any
as
work for whichthis the Workers
q IEsn. SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner ar us m become xuhjcenn the Workers'Cnmpcm ENERGY FEE ,.
O Z satin.Laws of California.Date WATER HEATER WNENT/ELECfR
Z Q Applicant GRADINGFEE
NOTICE TO APPLICANT.If,after,making this Cerlifiew,of Eaempion,you should WATER SYSIEMRREATING
a , become subject to the Workers Compensation previsions of the Labor Cade,you must SOILS FEE
foMwith comply witsuch provisi0nsorthis permit shall he deemed revoked. WATER SERVICE _
Q
CONSTRUCTION ONLbmi lem AGENCY NEW RESIDENTIAL PLMB. SQ.IeT PAID
V O Ibemby uffrm that there isvcongrunion lending agency for the perform...... Dme R et
to work for which this peimit is issued(Sm.3099.Civ.C.)
O F' Lenders Name TOTAL:
ULanders Address TOTAL:
1 certify tat I have read this application and state that the above information is BUILDING FEE
N correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V buildingconstramion,and hereby umhorircrepresentatives ofmis city toemter upon the SEISMIC FEE
.have-mentioned Properly for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep hartnless the City of Cupertino against ELECTRIC FEE.
liabilities,judgments,costs and expenses which may in anyway accrue against said City ALTER OR ADDTO MECH. PLUMBING FEE
in consequence of to granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING MIT(TO 10,000 CFM) MECHANICAL ME
REGULATIONS,
AIR HANDLING MIT(OVER 10,000 CFM) CONSTRUCI'IONTA
SignaturemApplicant/Conaaaor Date EXHAUST HOLD(W/DUCT) HOUSING MFUGATIO
HAZARDOUS MATERIALS DISCLOSURE
Will the.pplicant or future bailding m cpant storeor handle harardous material HEATING UNIT(TO 100.000 BTU)
as dcfnnd by the Cupertino Municipal Cade,Chapter 9.12,end to Health and Safety
Code,Section 23532(a), HEATING UNIT(OVER 100.000 BTU)
❑Ye. ❑No VENTILATION FAN(SINGLE RESID) W- PAID
Will to aPPlicam or future building occupant use equipment or devices which Date I Receipt p
emit h.zallous air communicant as defined by the Bay Area Air Quality Management BOILER-COME UHP OR 100,000 BTU) -
District? TOTAL:
❑Yes ❑No BOILER—COMP(OVER 100,000 BTU)
I have cession haanmops matMelarequirements power Chapter&95 of the Cali AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cale,Sections 25505,25533 and 25534.1 understand tat if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant,toe it is my responsibility to notify to tecupant
of to requirements which most he met prior t.issuance of a Certificate of Occupancy. '
Ow ner or authonud agent Date ISSUED BY:
OFFICE