31310 (3) APPLICANTTO FILL IN INFORMATIO I HIN RED LI E -US BALL POINT PEN ONLY
CITY OF CUPERTINO 1 BUILDING-ELEQRICAL PERMIT NO. 3•� O
BUILDING DIVISION P LICATION/PE MIT PLUMnING-NECHANICAI, y
BUILDING PROJKCI'(DENT ECATION
BUILDING ADDRESS'. SANITARY NO. APPLICATION SUBMI ITAL DATE
U/Q � J C trt<A4 Yi E Ld
OWNERSNA E: HEINE / CO. ACTORS NAME: LIC NO:
NIC CONTROL X
ARCHITECT/It NIIR� LiC N R S�v I�l �"J ❑
CONTACT. PHONE: 1/ 7 IY BUILDING PERMIT INFO
Tui &1y ''•k` Const llanl Fees Paid by Applicanl(Initial) BLDG ELECT' PLUMB MEC!
LICENSED
DCCONTRACT OR'S Il ICLARATION QT'Y ELECTRIC P17RMIT PFEE1 hereby stern that I am licensed under proviotar,of chapter 9 Rommendng JOB DESCRIPTION
QaZ with Section9(10 )of Division 3 ofthe Businessand Professions Cala and my license is RESIDENTIAL'
00 PERMIT ISSUANCE CUT' LiceuluClaand effe ¢ X� SFDWL ❑KITCHEN RE,\10DEL
QZU F/rep` APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RGPIPE
NQ 6 Date Contmc�• E+q{ryn AHCHIT[LTS DECLARATION ❑MULT6UNIT ❑STRUCTURAL.0 unJcdonJmy plunx shall he teed us public records PANELS MODIFICATION
ZO�j UPTO 100AMPS O Z ❑IN'TfiRlOk ❑CHIMNEY RI7PAIR
FHF-W Licensed Professional 201-1000AMPS IMPROVEMENT
CYC; OWNER-BUILDER DECLARATION OVER 1000AMPS [IBATH REMODEI/REPAIR ❑DEAIOLITION
6�0
C 6 T hereby affirm that 1 am exempt from the Contractor's License Law far the
f6 V following labor.(Section 7031.5,Business and ProfessionCode: Ts
CoAny city ter county SIGNS ELECTRICAL ❑OTHER
R!3 LL 1-• which requires a Permit to construct,alter,improve,demolish,or repair any structure
prior or itslssmrmq aloinuirec the up,heam kaab,h permit to fl,a,igmedoormcat SPECIAL CIRC UI'1'/MISC.
SS "y that he ix license)pursuamrothe provisions nRhe Commemr's License l.aw(Chapter9
Wm
Cp0 (mmencing with Section 7r'011)of Division 3 of the nosiness and Professions CodTEMP METER OR POe)nr NS COMMERCIAL
6 6 ey that he is exempt therefrom and the basis far the alleged encmption.Any violation of ❑NEW BLDG/ADDITION C3 DEMOLITION
X N Section 7031.5 byany applicant fora pe.it,.bj.t,theappliconnoa civil penalty of POWER DEVICES ii, TEN ❑
ANT FOODSERVICE
W not more than five hundred dollen S500). IMPROVEMENT
IMPROVEMENT
I] Las owner of property,or my employees with wages as their sole sstmpensntion, SW'IMMI P OL :L IC
$a�� will do the work,and the sWeture 1%not intended crmlemil for sale(Sec.71144.Busincss [I OTHER
W and Professions Code:The Commnor's License Law does not apply m an sono of )TITLE' -SWI CHES-FIXTURES Q
�'3 property who employees.
or improves t such i,and who does melt tine himself oared for
his own employeehe provided that such improvements arc not intended Pfd nr offered for NEW RESIT 'Yf1AL ELE SQ FT.
sale lL however.the building or improvement is mlJ within one year n(cnmpinion,the SQ.FT.FL 4F4® EISQ.FT.
-builder will have the burden of proving that he did not build or improve for pur-
Torofenle.). APR y �
1,as owner of the proper,,am exclusively contracting with licensed contractors no D�'qD
ronsvuct the project(Sec.7014.Business and Pmfcssinns Coded The Ganlmemr'i Li D q[(L
cen.eL-.w does not apply m an ownerofpmpcny whobuilds orimproves thereon.and QTY. PLUMBING PER IT FEE clfl
who contracts far such projects with a conaactori licensed paramount the Commences rVVf- LL
License Law. PERMIT ISSUANCE CI 1/GNU
❑I am exempt under See .B&P C for this reason
ALTER-IIHAIN&VENT-WATER(EA) VALIJA'I'ION
4rnweer, WORKER S DECLARATION BACK ROW PROTECT.DEVICE L
I hereby.Rote under penalty of perjury one of the following Jeclker',C s:
lhmve and will maintains Certificate of ComemmCode.for the Worker's Comp the DRAINS-PLOOR.ROOE ARfiA,COND. STORIES TYPE CONSTRUCTION
cation,as Provided for mi Section PW of the Lubtr Css1e,for the performance of the C.
' work have
this Permit is issued. FIJ(TURES-PER TRAP Y I hl
1 have and will maintain Worker's Come of the n Insurance. h require)t i Section I l
3700 ofthejLeAarypCode.for t�hewryrtisrmance of the work for
Ww�hichythis
2permit is issued. GAS-EA.SYSTF.M-I INC 40U'fLETS OCC.GROUP AI'N
My/Carticrrkcta T {SLFir -re/e— a Polcy No.:11L(1�f�%�<e{�' GAS-EA.SYSTEM-OVER 4I
EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRfASFl1NDUSTRL WAST ti INTERCEPTOR BUILDING DIVISION fS
(1'his section need notb:completed lithe perino is forme hundred dollars($I W) GREASE IRAI'or less) VLANCIII?CK PGE S,�J
I certify that in the ierinrmance of the work hp which This permit is issued.)shall SEWER-SANITARY-STORM EA.200 FT.
not emson ploy any perin any manner m as to become subject to the Worked ComPen- ENERGY FEE �Q
0 z sation Laws of California.Date ' WATER HEATER W/VENDELEC R
z Q Applicant GRADING FEE
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYS'IENP TREATING
h
become ithiellmdoe W..keis Coin wooation pro Sinn.ofbe Laborm Code,you ust SOILS FEE
7 foMwith comply with such provisions or this perm's shall be deemed revoked, WATER SERVICE
Q
�z CONS7AUCTIONLLNUINGAGENCY NEWRESIDENTIALP Mn. SQ. ri
PAID
Data Receipt 3/Oo
•
U C) I hereby affirm that them is a consumerism lending agency for the perfommnm of
[4 F the work fur which this I><+mil is issued(Sec.3097.Co,C.)
O U Larder's NameTOTAL:
Lender's Address TOTAL:
W I certify that 1 have read this application and state that the ab ve information is BUILDING Ed: /
h corral.l agree to comply with all city and county ordinances and state laws relating is QTY. MECHANICAL PERMIT FEE
C.),Z building consouction,and hereby authorize representatives ofthis city m enter upon the SEISMIC FTE
above-mentioned property for inspection purynsa. PERMIT ISSUANCEELECTRIC PER
`y 4�
(We)agme m save,indemnify and keep harmless the City of Cupertino against
Iiahilitics,judgments,coils and expenses which cony in any way accrue against said City ALT ER OR ADD TO MECH. Z•'"v •�
in nscaluence of the granting of This permit. PLUMBING PER.
76
APPLICIINTU DERSTAN AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM)
SOURC RE AT10Nit 5. p MECHANICAL PEE 45-1-
,
1((d AIR HANDLING UNIT(OVER 10.00 CFMI CONSTRUCTION TAX
�Signamm of ApplicanUContmctor� � �amm EXHAUST HOLD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mcupam store orhandle hazardous material HEATING UNIT(TO 10),010 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25321)l HEATING UNIT(OVER 100.000 BTU) q /�
❑Yes 0N (0 q PAID
VENTILATION FAN(SINGLE RPSID)4. Z• O pate Rpeiptp 4�j/
Will the appliwot or future building occupant use equipment or devices which
t hazardous air contaminants as defined by the tiny Area Air Quality Mrnogement BOILER-Q)MP(3HP OR 100,0010 BTU) TOTAL
Al"Distrat? s BOILER-COMP(OVER 100,1001ITU)
0Yes Xa
1 have real the hvaNnus materials requirements under Cha 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
quiet Mer
fnmia Health 1'afety Calc,Sections 25505,2.1.113 and 25534.I unToddy lin that if the NEW RESIDENTIAL MECII. SQ.IT.
huildin ted t ra+tly havcu ant,thvt it i.niy respmrsibilhfil.o.rOve occupant
of the nus which mow tet prior to issuance oft Certificate I'(kcu ancy.
Owner or emhome agent to TOTAL !. ISSUEDBY:
OFFICE