30843 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
I O8 /I Q
BUILDING PROJECT IDENTIFICKIION V/•}N
BUILDING ADDRESS: SANITARY NO. - rAPPLICATION SUBMITTAL DATE
,2,�-,? " iseAlblls e2,-4
Q7
0W ';R'SN �yPHONH: CONTRACTOR'SNAh1 . UC NO:
Ree 7,Vvo &Fij 194- 13�r ,efe.1�/ 1,Alb642 Goo 7-Z N/C CONTROL#
ARCHITECT/IjNy1NEEk: LICNO: ( 1O2�SS:S Jq(N�?U,�p 4-X1 I;uO
TA ❑ `
CONCT: Z• PHONE: tl/'T BUILDING PERMIT INFO
fe 9G Fg7o ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
ElEl El
LICENSED CO.NTRACTOR'S DECLARATION
1 hereby affirm hal l raFEE
n licensed under provisions of Chapter 9(commenciQTY ELECTRIC PERMIT ng JOB DESCRIPTION
OCZ with Section7000) [Divisimt3u(the Business and PruPosxionz Cale,and of licence is
CM) 1n y PERMIT ISSUANCE ' RESIDENTIAL'
a-F ,.full force and1„fRv p X1,5" ❑SFDWL El KITCHEN REMODEL
<UU License Cls Lich
H¢W Date Commmnr APPLIANCES-RESIDENTIAL OADDITION D PLUMBING RE-PIPE
F- N a ARCHITECTS DECLA 1 PANELS- ❑MULThUNIT L1 STRUCTURAL
Z O o, I uuderxwnd my plans shall bo used ns public Teen#. - MODIFICATION
O Z� UP TO 2W AMPS
O ` _ ❑INTERIOR ❑CHIMNEY REPAIR
F-L�F4I Licensed Professional - 201-10WAMPS IMPROVEMENT
ay C C 6 1 hereby affirm OmN um a elm DEpt ER DE he C ntractor's License Law for the OVER 1000 AMPS O BATH REMODEIIREPAIR O DEMOLITION
W 3 a F fallowing reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL, ❑OTHER (lie '1 �
y which requires a pent to comtmea..1111.improve,demolish,or repair any swctum
1"1=06 prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC.
that he is licensed un the Pthe Contractors License Law(Cha t 9 _
y pursuant provicinnxn per
00 <enmmeneingwih Scetion]IXNB ofUivixion3aRhe Huxincsxend l'ndcssiom Codcl or TEMP.METER OR POLE INST COMMERCIAL'
m m e C hat he is exempt therefrom and he basic for he alleged exemption Any violation of O NEW BLDG/ADDITION D DEMOLITION
WM"' Section 7031.5 by any applicant for a permit subjects the applicantto a civil penalty of POWER DEVICES '
ul^tn (TENANT ❑FWDSERVICE
not mart than fivo hundred dollars(551101.
F.Z Y MROVF,hTENT
❑ 6o the work,
, the propeny,or mycmntended wltbwagcs rsalei(Sale mm,Business SWIMMING POOL HhECfRIC
$a'[- will Jo lesions ands structureContactors Licensed eroffiemd Law
rotapply to an Business ❑OTHER
u1^m and Professions Code:The Contractors License Law docs not apply w an owner of OUTLETS-SWITCHES-FIXTURES
'
a.3— propeny who builds or improves hereon,and who docs such wrack himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ P-L
sale If.however,the buildo,orimpm,carcot is sold within one year of compleinn,the ��ss SQ.FT.FLOOR AR EA $SQ.FT.
owner-milder will have the burden of proving that he did not build or improve par- C OF WretIIUYV
poseofsaleJ. -
1,as owner of the property,am exclusively contracting with licensed contractors no AL:
m,lm d the pmjetl(Sec 7144,Busiar,and Proms,ion,Code:)'ne Cannot is Li-
crow Law does not apply to an owner of property who builds or interests thereon,and QTY, PLUM BING PERM] PEE
who contacts for such projects with a comractar(s)licemed pursuannu he Cmimmon,
License law. PERMIT ISSUANCE.
❑ I am exempt under Sec. ,B&I'C horhis reason _
Owner Dale ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE Y
I hereby affirm under penalty of pejery one of the following declarations3-
•❑ 11.ave and will maintain nCenificmc ul Cnnsemmself-in surefor Woher's Colnpen DRAINS-MOOR,RWI',AREA,CUND. STORIES TYPE CONSTRUCTION
,mint,as provided for by Section 3900 ol'the Latin Code,for he performance of the
w rkforwhichthispermitisismd. FIXTURES-PER TRAP
1 have and will mai min Workers Compemation Insurance,as required by Section
3]W ofthe L:F Cd f:odm perfoona sof the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP APN
My War s
an m mean r d Pnliuy in am
//,,' s
Carier. Policy No.: 1Y�'6 RY6 GAS-EA.SYSTEM-OVER 4(EA)
'RTIFICATE OF ' EMWIONF'ROMWORKF.RS'
COMPE'SATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTER
BUILDING DIVISION FEES
(This section noel no he completed it the permit is lorone hundred dollar l�Ellq) CREASE'I'RAP or less) PLANCHP.CK PL'E
Icenify that in the performance ofthe work for which his permit is issued l shall SEWER-SANITARY-STORM HA.200 FT.
,� xatimn,pr, rt'Ca op in any mamrcr yr�n lkT9pny(:hgct he Worker'Compen- ENERGY FEE
Z O Applitan q 6M'r'a A L{aR L T WATER HEATER WNENT/ELECTR.
/ GRADING FEE
y NOTICE APPLICANT IL after making this Comficam of Exemption,you should WATER SYSTENUTREATING
I" , become subject br the Workers Compensation provisions of the Labor Code,you most SOILS FEE
{a!J forthwith comply with such provision tor this permit shall be deemed revoked WATER SERVICE
d Q
CONST RUCUON LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.IT. PAID
V 0 l hereby affirm that there is a conmroction lending agency for the performance of Dote Itpt#
the work for which his permit is issued(Sec.301 Civ.C)
(~ Lenders Name TOTAL:
VVl
. Lender,Address TOTAL:
4 1 cenify that I have read this application and snm that he above information is BUILDING FEE `\
F rescotme[.I agree to comply with all ciryand county entrances and state law,relating,. CITY MECHANICAL PERMIT FEE
V Z building construction.and hereby auhorm representatives o(his city menteruponhe SEISMIC FEE
above-mentioned propeny for inspection mr,o e, PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City o(Cupenin t against ELECTRIC FEE
liabilities.judgmems costsandexpenses which may in any way acme againstmid City ALTER OR ADD TO MECH. PLUMBING FEE
in asequence of the gmming of Thi emit.
APPLICANT UNDERSTANDS D WILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT(TO 10,00111 CFM)
S(1U GULATIONIS. MECHANICAL FEE
AIR HANDLING ON]r(OVER 10,0W CPM) CONSTRUCTION TAX
Sigimua"o(AppheantsCoulmemr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will he applicant or future building occupant store or handle baaardous material HEATI NG UNIT(TO 100.000 B'FU)
as definel by he Cupertino Municipal Code.Chapter 9.12,and he Health and Safety
Code.Section 25532m? HEATING UNIT(OVER 100,000 HUD
❑Yen No VENTILATION FAN(SINGLE RfSID) PAID
Dale Receipt#
Will the applicant or future building occupant use equipment or devices which
t hazallou.air contaminants as defined by he Bay Area Air Quality Management BOILIiR=COMP OHP OR IfO,gq BTU) TOTAL:
District? -
E]Yes El No BOILER-COMP(OVER 100.010 BTU)
I have read the BarzNousmaterialstequiremen6 oder Chapter 6.95ofhe Cali- AIR CONUITIONFR ISSUANCE DATE
bomia Health&Safety Code.Senior,25505,25533 and 25534.1 understand dtm if the NEW RESIDENTIAL b1ECH. SQ.PT.
building does not curendy have a tenant,that it is my rcspn smility m notify the occupant 4Pof the mt timinents which must he met prior to issuance of a Cenifune of Occupancy.
Owner or mphorizd agent Date TOTAL] ISSUED BY:
OFFICE .