00030072 (2) APPLICANTTO Fl-LM INFORMATION WITHIN RED LINES-USf BALL POINT PEN ONLY Sat pO ,-3
CITY OF CUPERTINO BUH DTNC.-E LEcrRICAL MIT N0,
BUILDING DIVISION ! APPLICATION/PERMIT - PLUMBING-MECHANICAL 03001
•1 BUILDING PROJECF IDENTIFICATION
BUILDING ADDRES SANITARY NO. APPLICATION SUBMITTAL DAI
OW PHONE: C 0µe NAME: LIC
S! �� M —- — mTl/•J NIC CONTROLN
•ARCHITECFIENGINEER: LIC NO: ADDRESS: �///Y ❑
CONTACT: PHONE. Bl11LDING PERMIT INFO
/apt �/IGZIg Gt�l'3�r/ -1793 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECO
❑ ❑ ❑ W—
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hemby affirm that Tom Iiciamod under tacoo arts of Chapter 9(commencing JOB DESCRIPTION
"Z win Section70XBof Division lefthe Rosiness and Pr Tessio rCtde.ppnd my license is RESIDENTIAL:
1�-0F inlulltoreeanffefkV '3 'T7 PIiNMIT ISSUANCE
W �.w.++ccw 6—:L; ./ J ❑SFDWL ❑KITCHIiN REMOUEI.
Nu Licenses'. Lica APPLIANCES-RESIDENT'IAl. ❑ADDITION ❑PLUMBINGRE-PIPIT
y Q i Date Conpacw
Fly ARCHITEMX DECLARATION / PANEL-S ❑MULTI-UNIT [I STRUCTURAL
Z O y Z I mderetaml my plans shall he used as public records - MODIFICATION
OZN-0 UP TO 20o AMPS [I INTERIOR 0CHIMNEY REPAIR
r�:11-ul Licensed Professional 201-1000AMPS IMPROVEMENT
..I OWNER-BUILDER DECLARATION
y�y 0 6 1 hereby affirm that 1 am emm�pl from the Carnation,License Law Inr the OVER IINXIAMPb ❑BATH REM F.II PAI EM I,ITIQ
X 06 UF following mown.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL �(]OTHER _
IIss113 41 NG which requires a permit m conxtmc,ober,improve.demolish.or rePmr any sweore
Fu'0_t prior to its issuance,also weapons the applicant for such pemtit to file a signed statement SPECIAL CIRCUIT/MISC.
dol he is licensed pursuentto the provisions of the Conoacwres License Law(Chapter 9
al p;p0 (commencing with Section 7")of Division 3 site Business and ProfessionsC(Ale)or TEMP.METER OR POLE INST. COMMERCIAL:
Il y that he is exempt therefrom and he basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
a ^- Station 7031.5 by any applicant for apermilsubjects the applicant oacivil prnaltyof POW17RDEVICES ❑TENANT 0FOOD SERVICE
n more than live hundred dollars(&500).
.F.Z i^ IMPROVEMENT
Q O d.,hd wenhT lM1e property,or my etnplayccs with wage as lM1cir talc compensation, SWIMMING POOL ELECT RIC
W C will dothewnrk.sadn The Com is nm intenina c Lae dols .,.1,111.M.Business ❑OTHER
S 3 and Professions Codm The oyes then' Lnd w law docs nm apply to if owner of O -SWITCHES-FIXTURES
his opropar,who builds or improves mereon,and who does such work himself or through
his own however,
the
provided ohm such improvements arc not intended or offend for LNTIAL ELECTR SQ lT.
oda B.bower will have
building rnimpmvement issoldhwithin one aild or improve
the SG FT.FLOOR AREA bISQ.FT.
cr-builder will hove the burden ofproving that he did not build or improve Ibr pur-
e
I,as owner of the pmpeny,am exdusivdy canbaming with liccnscd contactors mT011.
'A :
,emanation,project(Sec.Iota,Build's and Pmfcvsinns Gds)The Contractor's came Law docs not apply to an owner of progeny who builds or improves I cream.and QTY. U I15 T FEE
who contracts for such projects with o commpursuant muc
ctims)licensed pursuano the Commr s
License law. FERMI]'ISS N
❑ I am exempt under Sec. .B&P C for this reason
Owner Datc AUFF-R-DRAIN&VL ' WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE, oorr..
I hereby amrm under penalty of perjury one of the following declarations: t.'l O
❑I have and will maintain a Certificate of Conant to self-insum for Worker's Compact- DRAINS-FLOOR,ROOK AREA.GOND.
sation,as provided for by Section 37M of the Labor Code,for the performance of the S RIEti TYPE CONSTRUCTIIN
work for which this Permit is issued. FIXTURES-PER TRAP
khave one will maintain Worker's Compensation Insurance,as required by Section
idde,labor Code.lorthe lanl'ornince althe work fiawhich this pennil la issue, GAS-ITA.SYSTEM-1 INC.4 OUTLETS OCC,GROUP APN
My War Tan insurance carric Put Pnli .. .// 3 Q/
Contac Policyop • U GAS-EA.SYSTEM-OVER4(EA)
ERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIYINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section acted nut be complest ifthe permit is fnrune hundred dollars($10) GREASBTRAP
or
le"'.)(This
Plili
I rectify that in the performance of the work for which this permit is Issued,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any pt—m m any mmncr I,—m becnne.mhjecl m te hWorkcrk Con.p.a. ENERGY FEE
OZ motion Laws of Calilirem,Date WATER HEATER WN&s`FX-LECTR GRADING FEE
Z Applicant
NOTICE TO APPLICANT:If,after making this Candidate of Exemption,you should WATER SYSTE VI REATING
F' ? become subject to the Weaker s Compensation provisions of the labor Code,you must SOILS FEE
ELI ,.,, finhwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE .-_ -
_-
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FL �iPAID
Z
r7 /Date\ Receipt# t--
L)0 l hereby utfimh that hem is it constmction leadingagcncy lin the Nimmmnce of Y, A
the work for which this pennil is issued(Sec.3097.Co,C.)
U Lunde',Name I kat( TOTAL:.
L) Lender's Address TOTAL:
} l$1 I candy that I have reel this application and state that the above information is BUIL El ZOO II I+
Mcorrect l agree to comply wlthaR city and county ordinances and state laws relating in QTY, MECHANICAL PERMIT FEE fIvf(
U ,Z building couslnetlmn,and hereby authorim representatives of this city to enter epotthr ISEISMIG FEE L.l
abovementioned property for inspection purposes. PERM]T ISSUANCE
(We)agree to save,indemnify and keep handles,the City of Cupertino against tBLECTkIC FEE
liabiluo,judgmenrs.dosis and expenses which may in any way accrue against said CityALTER OR ADD TO MF.CH. L—'
in nu9uence of the gmming ofthis permit. PLUMBING FEES— -----
APPLICAIJI C DERSTANDS AND WILL CO PLY WITH ALL N -PO T AIR HANDLING UNIT(TO Hk010 CFM) MECHANICAL FIRE
SOURC J ATI('t�I�k
LgtJ yp AIR HANDLING UNIT(OVER IB(X)U CFM) CONSTRUCTION TAX
Signam tApplicanUConlmcmr Jan HXHAUS'FIfOODIW/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE /
Will the applicant or future building occupant store or handle hauNous material HEATING UNIT(TO 10).0)0 BTU)
as definod by the Cupertino Municipal Code.Chapter 9.12,and the HaaM1h and Safety
Cade.Section 25532(a)y HEATING UNIT(OVER 101.000 BTU)
O Yes ON. VENTILATION FAN(SINGLE RESID) PAID Dam ReceiplN
Will the Igt,frmot or future hollding occupant use cqulpumnt or device,which
t hmaNnus air ttmtaminants us AcEnee h the Bu Arcu Air Quality Management BOILER-COMP(THE OR IB)JXX)BTU) Teb
Y Y 6 TO3'AL:
Tone'? BOILER-COMP(OVER 1011,0X)BTU)
EYes ❑Nn
I have mail the hazrd
aousmaterials rcqme
ument under Chapter 6.95 of the Cali- AIH CONDITIONER ISSUANCE DATE
fomis Hialm&Safety Code.Sections 25505,25533 and 25534.1 understand that If the NEW RESIDENTIAL MECH. SQ.Fr.
hallding de red,i renly have Imam,that it is my respnnsibillly lnnrnifylhanecupont �/ -^ �
of Wri
e valuirecros whim most b:met prior m isoancc of a Cenircate of0ccopency. I V
O d"cur,momair!.,a., Date TOTAL: ISSUED BY:
OFFICE