30516 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERI IT PLUMBING-MECHANICAL 051V
3 J< ♦5 6
BUILDING PROJECTIDENTHTCA'TTON
BUILDING ADDRESS: . - SANITARY N(l. APPLICATION SUBMITTAL DATE
D 6 1 l� w w rrr�► fn�� Gkjo/
OWNER'S NAME: PHONE:' CONTRAC'IO SNAME: LIC NO.
�O/y Q NIC CONT Q) # /�
/ENGINEER, S S LIC NO: I�D ADDRESS: - � v
CONTACT: PHONE: 4 BUILDING PERMIT IN,FOO•(Jv
^A T ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLIUUMI BB M,EEC,H/
77 -1106 E2,
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
h S1 hereby affirm that 1 am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
CMZ witectioa700I)of Divixi.n 3 office Busiacssund Professions Gde,and my license is
> RESIDENTIAL:
=t lu- -full forceiteffect. PERMIT ISSUANCE ❑S• WL ❑KITCHEN REMODEL
ly... in
aVU License Class Cones APPLIANCES-RESIDENTIAL. ADDITION ❑PLUMBING RE-PIPE
oo y600 Dam _ Ts DEC.
ARCHfOe use DECLARATION El MULTI-UNIT ❑MODIFISTRUC7URAL
MODIFICATION n Z I understand my plans shall be used as public accords PANELS � MODIFICATION.
p Z— UP TO 200 AMPS
r.,W Licensed Professional - ❑INTERIOR F)CHIMNEY REPAIR
y Y�„'4j - OWNER-BUILDER DECLARATION 201-1000AMP5 IMPROVEMENT
C C OVER IOW AMPS C1 BATH REMODEUREPAIR E]DEMOLITION
Q 1 hereby affirm That I am exempt from the Contractor's License Law for IM1e
a d U following mama.(Sootier,7031.5,Business and Profession.,Code:ANry city or rummy SIGNS ELECTRICAL. ❑OTHER
R,m which requires a permit to aoummct,alter,improve,demolish,or repair any awcmre
F LL•Oa prior m it issuanecido,repriresthcappBcant forsuch pemnuo file asignedsa¢mcnt SPECIAL CIRCUIT/MING.
that he is licensed pursuant to the provisions ol the Conapector s Laterse Law(Chapter 9
Iy�OO (commencing with Section 7")of Division 3 clime Business and Professions Code)or TEMP.SISTER OR POLE INST. '
d X Cl C that he is exempt therefrom and the basis for the alleged exemption.Any violation of /ADDITION [I DEA10LITION
W- un
Section 7031.5 by any nppliovm fora permit subjects applicumm ucivil penuhy of POWER DEVICES- ENA . FOODSERVICE
M Z ore than f.hua .it doll...($500).
I,as owner oflhe property.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC Ip/PROV, T
vi . nl
the work.and the dcture is not intended oroffcr014
ed for sale(Sec.] ,Business ,�1�^,F�
toy m and Pmfeenlons Cssie:You Cmeman Ps Ultuse Law does net apply man owner of OUTLETS-SWITCHIS-FIXTURES
el. property who builds or imposes thereon,dad who does such work himself or through
his own employees,provided the such improvements are not intended or offered for SIC RESIDENTIAL ELECfR SQ FT. -
xmvaH,however.the building or imp rovemem is sold withal one year of completion.the SQ,FT FL 0 ' RfAr) $/SQ.FT,
er-builder will have IM1e burden of proving that he did not build or improve for par- #4J!
pose f ). �#♦_
❑ Ln limproperty. exclusively contracting withl d—comments. to ,�
constructth project(S YOi4 Business dP fie: ,Cd )Th C m mer L'- x
who co d t apply to a m puny ie builds eC d QTY. PLUMBING PERMIT FEE 0.' :•TRO
who tends focxuchprojects with,wow tu(s)fsunnedpu; anon theQrmmcnnv /•
License law. PERMIT ISSUANCE `UrrNl�Nll
I]I am exempt under Sec. B&P C fur this rtamn VV
ncrIlare ALTER-GRAIN&VENT-WATER(CA) - VALUATION .
Pq WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
�IJ IhaVC end will rnaimein bCenificam.f Consent instil-insurcfor Worke.'.Cempen- DRAINS-FLOOR.ROOP,AREA,COND. - ♦ -
sad.n,is provided far by Section 3100 of the labor Code,far the perfnmunre of the STORIE. TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Cmnpensation Insurance,as required by Section
32W office Latin Code,far IM1e pecfrnmanceofthe work for which this person is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS 'OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number art:
Carrier: 'Policy No.: GAS-EA.SYSTEM-OVER 4(EA) �' lf�r�, 1+I/�
CERTIFICATE OF CXEMPTION MOM WORKERS' - -'(�
COMPENSATION INSURANCE - GREASEJI,NDUSTRL WASTE INTERCEPTOR
DING I 'INION FEES
(Tlis section need not be cangslered if the permit is fornne M1tmdreJ dollars(EI W) GRCASP.'1'RAP
nr less.) PLANCHEC
Toy any that inthe inony manner
nce rofas to becrowsufor bjectch ,,Permit flaWisisued.ipso SEWER-SANITARY-STORM EA.2110 FT.
notemployparsoniaany manner so as mbeutme suhjea mums Wnrken.'Cnmpen- - ENERGY ETF.
ZZ ration laws of California.Date WATER HEYfER WNENT/IiLBCTR
O Applicant GRADING
y NOTICE TO APPLICANT:If,after making this Ccnificate of Exemption,you should WATER SYSTEMIfREATING
; become subject to the Worker's Contpensudnn provision.of the Lalmr Cwio,you mud SOILS FEC
UX forthwith comply with such pmvidorem this permit shall be devoted revoked. WATER SERVICE
¢, Q
q CONS I iso conNLI?NDlNGAGENCY NLW RESIDENTIN.PLMit. ' SQ.FT. PAID
vO Thereby affirm tree there isaconstmeti.n lending agency for the performance of Date` lieceipt#
the work far which tars permit is issued(Sec.3097,Cie C.)
0 Fs Lander'.,Name � - TOTAL:
O UJ Lenders Address - 'I 1.
�' a I certify that 1 have it this application aad mute that the above informed..is BUILDING ,F .rx
N mnen.I agree to comply with all city and county nnlirmiev,and v,oc laws relining m QTY. MECHANICAL PERMIT FEE O
Z maliingcomuaetia.,and herthymahin,s,m,mouod,,z fmiccity tnenteruptm the SEISMIC FEE
abovootentioned property for inspection purposes. - PERMIT ISSUANCE
(We)agree to save,indemnify and keep heartless the City of Cupertino against ELECTRIC FC
It.bilities,jidgment.,cosls and expenses which may in any way meres.ennat said City AUUERORADDTOMECL
consequencein of the granting of this permit, PLUMBING FE
APPLICANT UNDERSTANDS AND WILL COMPLY N' LL NOH-POINT AIR HANDLING UNIT IT MECHANICAL FEE
O 10.000 CFSfI
SOURCE REGULATIONS. -
AIR HANDLING UNIT OVER IBM)CFM) CONSTRUCTION TAX
Stgnamre APPlicuntlConwctm • Dec IiXHAUSIHOOD OMMUCT) HOUSING MITIGATION SEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or for..building oecupamt smreor handle h.m.dom malarial HEATING UNIT LTO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
Code.Section 25532m)'I HEATING UNIT(OVER lig),i OBTU) '
❑Yen L]N. VENTILATION PAN(S NGLE RESID) PAID c
Will thea applicant or filum building ncu t use equipment or devices which Date -• Receipt x
PP 6s Pan .ArBOILER-COME OHP OR 100.000 BTU)
:mit hamNous air contaminants as defined by the Bay Arta Air Quality Mamtgemem _ .. TOTAL'
District? ' BOILER-COMP(OVER 100,000 BTU)
E]Yes C]No -
I have mad the hammisaw materials requirements under Chapter 6.95 of the Cali- Alk CONDITIONER ISSUANCE DATE
famia Health&Safety Cede,Sections 2551)5,25533 and 25534.1 understand metal the N12W RESIDENTIAL MECH SQ.FT -
buildingdocs not comedy haves¢trent,the it is my ewponsibility to notify the occupatn -
of in,requiremems which most h met prim m issuance of a Cenific im of Occupancy.
Owner or authorized.gent Date ISSUED BY:
OFFICE