30713 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT DPEN FONLRIGAL PERMIT CITY 0P CUPERTINO NO.
30713 BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJECT'IDENTIFICATION
BUILDIN'GADDRESS'. SANITARY NO APPLICATION SUBMI PIAL DATE
2 14 °I l VAT A/El C U P 2 o C/, .
W R'S NAh�E: Y ONE: I CONTRACTOR'S NAME: LIC NO:
11n 1 1 A ST-I�s R L n I� • NIC rII\CONT1ROL p r
s NRCHRUCT/ENGINEER: l v[l] LIC NO: k 1. ADDRESS:- : V� ke
CONTACT:
L, �AtiTFut/L t 4lAIVaJ (qP�H�E` 41INFO
� - 68`
❑ Consultant Fsys Paid by Applicant(Initial) BLDG ELECT PLUMP MF.CN
J�1 s �0 2SS- 21 �!fsiis ;?!�, ;*, �.
LICENSED CONTRACTOR'S DECLARATION QTY ` ELECTRIC PERMIT FEE
I hereby aferm mat 1 am licensed ander pmvisbns of chapter 9(commencing JOB DESCRIPTION
wOZ with Section 90001of Division 3 of the Business and Professions Code.and my license is aRESIDENTIAL:
�- p Infill fireeaodeffen: PERMIT ISSUANCE ❑SFDWL ❑KITCHEN RIiMODEI.
QUU License Class Contract.,
APPLIANCES-RESIDE'TIAL ITION ❑PLUMBING RE-PIPF
yQL Date _ GValDECL
F.Dm ARCHITECTS DECLARATION PANELS MULTI-UNIT ❑STRUCTURAL
w understand Z p I undeand my plans shall be used public records ��� MODIFICATION
OZN, UP TO 200 AMPS IN ❑CHIMNEY REPAIR
Licensed Professional 201-10011AMP5 ' 1n1YROVEMEYI'
X .OWNER-BUILDER DECLARATION
C d'Q 'i hereby affirm ma I am exempt from the Contractor's License Law for the OVER 1000AMPS ❑BATH REMODEIIREPAIR ❑DEMOLITION
yK0uJj R C.U following reason.(Section]031.5.Business and Professions Gale:Any city or county SIGNS ELECTRICAL ❑OTHER
y which requires a Permit m conswn,alter,improve,demolish,or repair any swcmrc
OQ prior o its issuance,also requires the applicant for such pemtiuo file a signed statement SPECIAL CIRCUITMISC.
mal he is licensed pursuant to me provisions of the Contractor's License Law(Chapter 9
�COE (commencing with Section 9000)of Division 3 ofthe Business and Professions Coded or TEMP.METER OR POLE INST COMMERCIAL:
d a p C that he is exempt therefrom and the basis for the alleged exemption.Any vi,`a` of ❑NEW BLDG/ADDITION s ❑DEMOLITION
xl^ Section by any applicant pimtii subjects the applicant to a civil Penalty of POWBR D-VICUS
m^m _. []TENANT ❑FOOD SERVICE
I.
not more than five hundred duller,($500).
IM EM&NT
SQ �I,azowner of me property,ar my employeeswith wages nstheirsoleaompensminn, SWIMMING POOL ELECTRIC
will do the work:andmestruaure knit intended on.f1cmd hirsue(Sce.9114L Business O R
W m and Professions Code:The Contractor's License Law does ono apply n)an owner of OUTLETS-SWITCHES-FIXTURES
13 property who builds or improves thereon,and harries such work himself nr Through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ ET
sale.ILhoweveq the building orimproventent ismId withinore'varssfanmpletion,the SQ.BE FLOOR IIA $/SQ.1.7..
rte
Imildr,will base the hard—of,ro,in,lhtM1 JJ outl IJ p f par
p f: I )
fth "a'"', IY sartractia,withh cJromwousm
nartiamep ) t($ 9044B : 11 1 '. Code)9heC t sL.
seLaw does notapply t l property whia hurids or inprovesthereon,and QTY PLUMBING PERMIT FEE FC
ho contrives forsuchp ject,e'Ih:war, t (O l eessW pnrrnl m the Co hanors RV
Liam,Law. PERMIT ISSUANCE V ur�111\\yV
❑ lam mtunder Sic. ,If&F C For la,renson G
Owner OI 12 `2,3- ALTIiR-DRAIN&VENT-WATER(EA) p-SVALUA'PION
WORKERSCOMPENSATION DICIARAI ION BACK FLOW PROTECT.DEVICE 'y(l'�
I herebyaffirreu I penalty nfper) y Ilh fnlL gJ (ons: f-t(D
•(] I have and will matinam a Certificate ofConwnit llinsu Worker's Coloper. DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 390)of the Lubar Code, or the terf unrince of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required Is Section
3900 of Ne Labor Cade,for the performance affair work for which this permit is issued. GAS-EA.SYSTEM-1 INC.a OUTLETS DEC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number am:
Cartier: Policy No.: GAS-EA.SYSTEM-OV ER a(EA)
CER I'WICAI'F.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
NUILI IV 'ION Fl3FS
(This section need notommpleteAif the permit is baonc hunJrtJ dollars(Sta)) GREASETRAP
or less.) PLANCHECK FEE
I certify ma nine permoraneeofthe work for which this permit is issued,I,hall SEWER-SANITARY-STORM FA.2M FE
not employ any person in any manner so as to become subject m the Worker Compe'n. ENERGY FEE 1 /�
ZZ sation lawsmf Cahmin a.Date WATER HEATER WNENT/ELELTR
Applicant GRADING FEE
In NOTICE TO APPLICANT:If,after making this Cmificate of Encraption.you should WATER SYSTEMO RRATING
I^ ? become subject to me Workers Compensation provisions of the Labor Code,you muss SOILS FEE
forthwith,comply with such previsions or this permit shall odeemcJ revoked. WATER SERVICE
nO
�.Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Dae Receipts
U 0 Ihereby affirm matmcre is a conswction leading agency for the perfommnce of
me work far which this permit is issued(Sec.3119.Civ.C.)
U Lenders Name TOTAL:
U Lenders Address TOTAL:
} y I certify that I hove real tees application and smm that the move information is BUILDING HE
F- rn correct.l agree to comply with all city and county ordinances and state laws reining to QTY MECHANICAL PERMIT FEE
C) Z building conamaetion,and hereby aumnrme represenmtivesofthis city tocrecr upon the SEISMIC FEE
above-mentioned property for impaction purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FP i
Iiabilmesjudgmces,casts and expenses which may many wnyaccmcir,mm olid City ALTER OR ADD TO MECH.
consequencein of the granting of this permit PLUMBING E
APPLICANT UNDERS'T'ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO 10,000 LEND
SOURCE REGULATIONS. MECHANIC LIgiE ,O
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUC ONTA%
Signature of Applicant/Cermiclor Date EXHAUST HOLD OVIDUCT) HOUSING MITIGA FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle Aazurdoux material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Coda Chapter 9.12,and the Health and Sufcry
Code,Section 25532m)P HEATING UNIT(OVER 1000)H'fU)
❑Yes 0 N VENTILATION FAN(SINGLE RESID) PAID Uate Rcccip N
Will the applicant rat future building occupant use egcupmm�l or dike,which
BOILER-COMPIMPOR I00,00011TU)
Disnina -
mil hazardous air amraminanlx us refined by the Tiny Arca Air Quality Munngenteot 'AL:
;I1 ❑No BOILER-COMP(OVER 100,000 BTU)
I have read the hazardous inairials mcurriacalS mNer Chancr 0.95 of the Citi- AIR CONDI'1lONHR ISSUANCE DATE
fomes Hwhh&Safny Code 5cdians 25505,25533 send 25534. undcixmnJ mal If the NE3W RESIDENTIAL MECH. SQ.PT.
build 6d : I sly have ntettnt th't t Y :p nsCeifi l tf Oc sancY.m _
atm eq ' menC 'ti,h must he nctprol fu Cant I f0 'upancy.
Owner or numnrized agent Dale TOTAL: ISSUED BY
OFFICE