30006 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERM]'I'NO. 30006
7 O O Of/��
V
BUILDING DIVISION APPLICATIONI'ERMIT PLUMBING-MECHANICAL 3
BUILDING PROMICT IDENT'IFICAT'ION
BUILDING ADDRESS: ®>� SANITARY NO. APPLICATION SUBMITTAL DATE
�v bb Vic gxviso
f OW AMF-eau re / �j'HONE ��� CONTE ,TOR:ti NAM¢Ne velO 1'IC NO:
IY/ C dol NIC CONT L
A 1 ' DNGINEE]L AD RESS:Ce rer Arc s o ❑
SQ, so AcS ' '240
CONTACP PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ME,CH
RT
LICEN eD CONTRACTOR' ECLARATION QTY ELECT RIC PERMIT PEE
I harehy nmrm mar I am rmnsed inner pmvisnas of chapter 9 aminamor,IQWZ JOB DESCRIPTION
y 00 with Section 7000prf Divid,o3ofthe Business unit Professions Cale.andmy license in PERMIT ISSUANCE t� J 6J SEOWL KITCHEN REMODEL
F full f eco ane effect.
�UU License Class Lica APPLIANCES-RESIDENTIAL '
I- 'W Dme Convacmr a❑�A'DDITION ❑PLUMBING RE-PIPE
tsiARCIII"fECI-S DECLARATION $rMULTI-UNIT ❑STRUCNRAL
ZFO = PANELS
Z 1 understand my plots shall be used as public records MODIFICATION
0Z_Q UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
rot; Licensed Professional 201.1000AMPS IMPROVEMENT
s ..l OWNER-BUILDER UE Ce CouniON OVER IOW AMPS O BATH REMODEUREPAIR ❑DEMOLITION
C 6 1 hereby alfrm that I OWNER-BUILDER
from the Convacmr's License Lew for the
s6d0LLU following reason,(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
al F" which requires a permit to em suveL uher.improve,demolish.,repair any mmcmrc
primm as is
mce,also re"do"the epph afar such pemtiuo fileasignM atmemem SI'F.CIAL CIRCUIT/MISC.
<
� that he is licensedpursumnastheprovisionsoftheContmcnn'sLicenseLaw(Chapter9
QC (commencing with Section 7000)of Division 3 of the nosiness and Professions Code)or TEMP.lol OR POLE INST. COMMERCIAL'
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION �O DEMOLITION
{c Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
M'm ❑TIiPROV " ❑FOODSERVICE.
nm more than fif th mmed property.
or
my employees
IMPROVEMENT
�60Lotowner
ewo,k,fthe properly,or myemntended orowagesas ered rae(Sec.sole compensines, SWIMMING POOL ELECTRIC
Q will Professions
ands he Contractor's
License
Law
wdoesotaply to an Business QDTHER
u�] unit Professions Cnde:imp COs there's License fatty dies not apply to if owner of OUTLETS-SWITCHES-FlXTURES AUG 28MIb
6 hpropertyis own who builds or improves thereon,and who does such sore deed(it f through
his own employees,provided that such mentis old within arc nos immn.f io owered fir NEW RESIDENTIAL ELELTR SQ FT. _
owneLhnwer will have tthe bur en ofprmengtat hddoncyldorimrove torthe a� SQrFT.PfAOk AAF. �ttll.a% 5/SQ.FI.
owner-builder will have the burden of proving that he did not builds improve torpor, :211047')
I+ >
Imseofsele.). � Dam/,Cg-14S� S.r 7Cl , fiL/J Z /yey7
01,as owner of the property,um exclusively contracting with licensed contractorsm F. TOTAL: OA
moomsthe pmjc((Sec.7M4,Holmes,and Poifessions Code:)*1 he C.... esti Li- —a p
ase Law does not apply munownerofpr.pcny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
V �O �S• '�
who contracts for arch projects with a contraction)licensed pursuant to the Gmttac m's
License Law. PERMITISSUANCE
1 am exempt drier Sec. ,B&P C f this rem.a
r -- ALTER-DRAIN&VENT-WAMR(EA) /ILU
Owner
WORKER'S CDMPhNSA'1'ION DECLAItAT10 BACK FLOW PROTECT.DEVICE ` /�/Q / Z�+ a
1 heathy nmtm under penury of perjury ciao(tM following dedamti.ns: J
] Ihuve unJ will muinminuCenificnm.(GatsenuaelGinsure fir Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
radon,as providW for by Section 3700 of the Labor Code,for the performance of the
work for which this permit in issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
37W ofthe labor Cole,for the performance ofthe work for which this permit is issued. GAS-EA.SYSMM-I INC.4OUTLETS OCC.GROUP APN
My Worker's Compensmion Insurance carrier and Policy number ore:
Carrier. Policy Na: GAS-HA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
- ('Otis section need not be completed lithe permit is fortune hundred dollars(SIM) GREASETRAP
coless.) PLANCHECK PCE /
I certify that in the performance ofthe work for which this permit is issued,l shut[ SEWER-SANITARY-STORM EA.210 FT.
not employ any person in any manner m as m becomesubject suhjeco the Workers'Compen- ENERGY FEE
ion Laws of Califomia.Date WATER HEATER W/VENfELECTR
z Q Applicant GRADING FEE
y NOTICE TO APPLICANT.If.after mokingthis Cenificnm of Exemption.you should WATER SYSTEM,TREATING
.a� become inmost to the Worker's Compcnamnm powisimrof me[..bar Code,yma must SOILS FEE
fnnhwim comply withsuch pravisinm or this permit shall he deemed revoked WATER SERVICE
0. Q CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT, PAID
L) O I hereby affirm that them is a construction lending agency forme performance of Data Receiprp
ar the work(a,which this permit is issuel(Se,3W7,Civ,CJ
4L F Landless Nome �I TOTAL:
V Lender's Address TOTAL: y p6
/ e BUILDING FEE
1.., 1 ccnify that 1 have real this application end slate that the above information is
Fa LO) correct.l agree to comply with all city and county ordinances and state laws miming to QTY. MECHANICAL PERMIT FEEL
U building construction.and hereby authorize representatives of this city to enter upon the SEISMIC FEE 3e3, �6
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE �r
(We)agree to save,indemnify nod kmp harmless the City of Capetian.against /�g f o e
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. r
n consequence mf the gmming of this permit. PLUMBING FEE liar,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,010 CPM)
q pr C
SOURCE REGI .ATIONS. MECHANICAL FEE /01-2 ,
AIR HANDLING UNIT(OVER 10,M)CFM) CONSTRUCTION TAX 763 `�t
Signal of Applicant/Contractor U EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEC
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material BEATING UNIT IT 0101,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the health and Safety
Cale,Section 25532(a)l HEATING UNIT(OVER[00,00)BTU)
❑Yes ON. VENTILATION PAN(SINGLE RESID) PAID Date Rmeipta
.Will the applicant or future building occupant use equipment or devices which
•emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) ,TOTAL.
District? BOILER-COMP(OVER 100,010 BTU)
❑Yes 0 N
I have tend due forardous materials tequireincom under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUAN
mono Health&Safety Code,Sections 25501,25533 and 25534.1 understand that if the NEW RESI UENTIAL MECH. SQ.FT.
building does not currently have a mount,that it is my responsibility to notify the occupied
of the on uiremems which must be met prior to issuance of a Cenificate of Occupancy. y
Owner or authorized agent Dole TOTAL: p ISSUEDBY:
OFFICE