30165 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY'
CITY OF CUPERTINO IIUILUINL'.ELECTRICAL PERMIT NO. ' 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MF,CI3ANICAL
BUILDING PROJECT OJECT IDENTIFICATION
165
BUILDINGADDRE SANITARY NO. APPLICATION SUBMITTAL DATE
E ,� 1-1)WN
CONTRAL90R"NAME: LIC NO:
r"' / S� !• r I- 'y NIC CONTROLa
\RC ITHCUENGINEER: LIC NO, ADDRESS: T ❑ .
'ONTALT: - E
PHON :
- BUILDING PERMIT INFO
.�� •/ ❑ Consultant Fees Paid 6 Applicant Initial
,• � i Y PPii (Initial) •BLDG ELECT PLUMB MECH '
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT I'CE ❑ ❑
1 hereby affirm Ihm 1 am licensed under praviuo s of Chapter 9(commencing - JOB DE$CRII'TION _
OZ nfu Sect 71Ng0 fDry mon3ofine Business end Pnstns nn,Code and my he se i. RESIDENTIAL'
�-
in farce and T C PERMIT ISSUANCE
QUU License�{�ss�Lie.N ❑SFDWL C1 KITCHEN REMODEL
.Zed Dine—r,•• ZT--9.6 Contrechm APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
I„ 7y ARCHITECTS DF. RATION PANELS (3 MULTI-UNIT ❑STRUCTURAL ,
ZOa2Z Iunderhand myplan,shell be used a public records - MODIFICATION
OZ-'0 - UPTO200AMPS ❑INTERIOR - ❑CHIMNI3Y REPAIR
r4l-, aI Licensed Professional 201-101g)AMPS IMPROVEMENT
OWNER-BUIL DER DECLARATION Ot-1000 MPS
yy�x C 6 1 hereby affirm that 1 em exempt from she Contractor's License Law for the AMPS ❑NATE RF.MO�IDF.IIREPsAIR DF.MOLSION
ad
W a S U following reason.(Section 7031.5,Business and Professions Gale:Any city or county SIGNS ELECTRICAL ❑OTHER
f� W wh ch re9ul es pc t so cont,frout, 11 i p e demolish. if op y fracture
�y prior to its issuance, Is y the applicant r:uch poroul topit g d statement SPF.CI Al.CIRCUIT/MISE �- ,-
g� y Ihmh Ip uanu the pro is mst[m C ta LiCen,cLa (Claptcr9 -
to DO
(c.notionC,nbw 111 Sl,t t 701 Laskin.i of(l 11 in'n and Poe"itanx C to)or TEM R MI I Wt OR POLI.I NST.
thud he in exempt themfi all and the bass for the alleged Caen pt'ion.Any violinon of - NEW BLDG/ADDITION [I DEMOLITION
y Se11irTO15 by anyapplicant f ap rnl subjeca lhcnpplic II "Ips ahy of POWER DEVICES
znotrame than live handle,]dolls($50f1). FOOD SERVICE
FG ❑ I, woes fsh property r y ployeea with wagon uv lh 1 p ani n SWIMMING POOL ELECTRIC I PR EMENT '
$y' ill do the k dine mr,mre':not' inomedoroBered far sal (Sec 7044 Bu,in ss C}OTHER
YI unit Professions Code The Contractors License lax does not apply to on owner of OUTLETS-SWI I CHUM-FIXTURES 4
�/r _
6 3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided than such improverems all,not intended or offered for NEW RESIDENTIAL ELECTR • SQ FT.
sale.If.however,the building or improvement is sold within one year ofcompletion,me SQ,Fr.FLOOR AREA QSQ.FT.
owncrbuilokr will have the burden of poising[but he did not build or improve for par- RT I
prow of sale). , P N s�
❑1,m owner of the propery,inn exclusively contracting with licensed Commi tors to TOTAL:
Conswe[the project(Sec.7614.Business and Prurand.ofs CodcJ The Comments',Li-
cense law does not apply to an owner of property who builds or improves themon,and QTY. PLUMBING PERMIT FEE ��O
who com
onoran rorsuch projects with a cdmaor(s)licensed puraminl to the Contractor's (2
License Law,' PBRMIT ISSUANCE r'f
1 all,exempt under Sec. ,II&PCformisreason airy
Owner
AMER-GRAIN&VENT-WATER(EA) ` VALUATION
' Dum
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO'17eCr.DEVICE
I hereby a]Rrm under penalty of perjury one of the following declensions
I have and will maintain a Certificate of Cnnscntto self-insum for Worker's Cumpes- DRAINS-FLOOR,ROOF.AREA.COND. STORIES TYPE.CONSTRUCTIONnation,m provided for by Section 37M of she Iallo Code,for she performance of Ne -
work for which this permit is iss.M. FI%'1'l1RES-PER TRAP
L have and will maintain Workers Compensation Insurance,as required by Section
3700 of[he labra Cale,for she performance ofshe work for
jpwhii hthispermisisissued. 1 GAS-EA.SYSTEM-IINC.4OUTLETS OCCLGROUP AIN
CrnWorkpls Com�e�tin^n�. resice carne Policy NaY uz 4E'JE1<9p GAS-FA.SYSTEM OVER 4(G) -
CERTIFICATE OF EXEMPTION FROM WORKERS')ZI$$•COMPENSATION INSURANCE GREASE/INIIUSTRL WASTE INTERCEPTOR
(This section need net be completed if she permit is for one hundted do][.,(S10aBUILDING DIVISION IF
nr less.) GRIEASE'1'RAP
PLANCf1ECK FEE
Loy any thin in the any mmencee0h1wrnktar which this perosis isissued,lshdl SEWER'-SANITARY-STORM F.A.200 FT.
ntl employ any pmson is any manner so e,in hecnme euhlect to the Wnrker,Compen- ENERGY FEE
O ,'7. Anion Lnwx ol'Culiforniu.Uma WATER IIIIAI IR WNENT/ELECTR
7 Applicum GRAVING FEE '
G NO rich TO APPLICANT If,alter making this Ccnificmc of Exemption,you should WATER SYSTHMG REATING
ahecome subject or the Worker's Compensation pmvaions of the Labor Code,you must 'SOILS FEE •,�
LTJ fnnhwith comply with such provisions or this permit shall be dcemcd revoked. WATER SERVICE
Q
7z CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB. SQ.Fr. PAID tDate Reccipa
U O IherehyaRim that mere isaconswainn lending agency roe heperfninamax of
L4 E' [he walk far whim mil permit is issued(Sec.3097.Civ.C.)
O U lenders NameTOTAL:
Uj Lenders Address A
1�•, Lia I certify that I basic read this application and state that the above information is - BUILDING FEE
V) correct.l agree to comply win all city and county ordinances and state laws rcla[ingto QTY. MECHANICAL PERMIT FEE
U � building construction,and hereby cauterize representatives of Nis city roenter agenda, SEISMIC FEE
above-mentioned property for inspeaion purposes.
(We)agree m save,indemnify and keep union" a City of Cupertino against PERMIT ISSUANCE - ELECTRIC FEE .
liahilitiev,judgmcnis,costs and expenseswhnmyinml ay acerae against said City ALTER OR ADD TO MECIi.
in nseyuencc of hc6mntingof isper PLUMBING EEE
APPLICANT U UERSTAND,'AND LL COMI A WITH ALL NON.POINT AIR HANDLING UNIT TO 10.0110 CPM) f
SOURCE :GI ,ATIONS, MECHANICALFEE a
/ AIR HANDLING UNIT(OVER 10,000CFhD CONSTRUCTION TAX
Si mreol Applicantf m[acmr Dine EXHAUST ROOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE -
Wiilltheapplicantorfuturebuildingoccupant store or handle hozardmis material HEATING UNIT DO 100.110 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and me I Icalth and Safely
Cale Section 255320)P ����I//// HEATING UNIT(OVER 100,010 BTU) '
C]Ys
1a VENTILATION PAN(SINGLE RFS ID) PAID
Will the applicant or(future building occupant use equipment or devices which Data Rcceips M
mi[honorer.,air conundrums a4 defined by the Bay Alan Air Quality Management BOILER-COME'LIHP OR 100,00()BTU)
ivriat? 1. TOTAL:
❑lies ❑Nn BOILIER-COMP(OVER 100,00011TO,
i Fs
I hove read the harwdnus materials requirements undrr CAIR CONDITIONER
hapter(s95 of the Cull- ISSUANCE DATE _
forma Health&Safety Coda,Sections 255b5.25533 and 25534,1 mulcrshmd that if the NEW NESIDIIN'PIAI.MECH.' SQ.FT.
building dnea not Currant,have alenum,that aismy on"noihility m mirythe evencirl
of lbs raryiremenss which must be me[prim to issuance of it Cemlicale of Occupancy.- '
` Owneforumhowdugenl Date
ISSUED BY:
OFFICE -'-