30270 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-FLECTRICAL PP.RMII ND. O O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MIECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADIJRESS'. �¢ SANITARY NO APPLICATIONSUBMITTAL DATA
d U� a A� 1_T%
-- Ow'E 'S ) �s P - /� M1T
CORACTOR;SNAME: LIC NO.
K US ��►{ O/� � NIC CONTROL*
ARCHITECT/ENGINEER: LIC NO: VV ADD ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) RD ELECT PLJ MB MECH
❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 n..70 arnmi mat to.licensed Bri ander and
Pone omishorter 9 mnmmendnF JOB DESCRIPTION
=1'Z with Seen.. Division3ofthe Business ane Fr.fessinns Code.ens my liccnm it RESIDENTIAL:
—� in full force and eflca PERMIT ISSUANCE
s Ur- OSFDWL D KITCHEN REMODEL
<U V Date—
Class Lin.a
Zty Da¢ Contractor APPLIANCES-R6SIUENTIAL ❑ADDITION C1 PLUMBING RE-PIPE
"<aARCHITECT'S DECLARATION ❑MULTI-UNIT -1 STRUCTURAL
h Z 1 understand my plans shall he u.A aaccord,accord, PANE S
s public cos MODIFICATION
Z.—" UP TO gal AMPS ❑INTERIOR ❑CHIMNEYREPAIR
Licensed Proicuumal
'n License Law for Nc
OWNER-BUILDER DECLARATION
201-lap AMPS IMPROVEMENT
y j D ER �
Y W nn but 1 am exempt from Ne ConuanorOVER lap AMPS BATH RE AIR N
3aUfollowing resom (Section 7031.5.Business and Professions Code:Any city or county
w< 1 hereby off SIGNS ELECTRICAL
a O m which rectum a permit to cou sruct.alter,improve,demolish.or repair any structure rtJ
g 'nar to its ins..alao reeptres heaptilicanr frmch permit to fileasignedsutemcnt SPECIAL CIRCUITMISC.
!!7} that he is licensed pursuant to the provisioitam,Canmam.r's License Law(C'baprer9
Yip trommencing who Section7000laf Division 3 of the Business and Professions Code)or TEMP.METER OR POI-1 INST. COMMERCIAL:
o W Jut he is exempt therefrom and the basis for are alleged exemption.Any violation of D NEW BLDG/ADDITION D DEMOLITION
_K_y Section 7031.5 by any applicanifor a Permit subjects the applicant to a civil penalty of POWER DEVICES
not mom man fire hundredsonars la5lrol. OTENANT El FOOD SERVICE
Z< I,u owner of the rt,or emlovees with woes in their cum IMPROVEMENT
D ProPe Y Y ' g pensa.nn. SWIMMING CIRIC
5=0 •'it]dome work.and the Will is not intended moffcred for sale(See7(W Business DOTHER
3 m and Professions Code:The Contnmm's License law'dos not apply to an owner of OUTLETS-S H ES
property who builds or improves hereon,and who dotes such work himself or through
his own employees,provided that such Improvements are not intended or offered for NEN'RESIDENTIAL ELE SQ ET.
sale.IL however.the building or improvement is sold within one year ofcompletion,are SQ.FT FLOOR AREA S/SQ.FT.
mater-builder will have me burden of pmving that he did not build or improve for put-
�owne y
er of the propsrny,am exclusively contracting with licensed contractors to TOTAL:
w t the project(See.TBW.Business and Professions Cade:)The Commemes U-
E
, P [
acme law does not app1Y t. owner of propenr who builA or im'rovcs thercan,and QTY, PLUMBING FEE.. JUL. s 5 1 a F
who emseaeu mor catch
sswiNaconvacmrts7licenud Wrsuam res the Convenor's � >
License-
B&P r this PERMIT ISSUANCE
❑pun exam a ,Sec. , fo . "_
ALTEk-DRAIN&VENT-WATER(EA)
Owns Dale VALUATION
COMPENSATION DECLARATION BACK FLOW PROTECL DEVICE
al'bend mill
under penalty of Perjury otic of the following declarations:
1 lovemum
and will for
n a SeCerin37Mcam of the enuoCode.sum for Workers Cooper- DRAINS-FIAOR.ROOF.AREA,COND. STORIES TYPE CONSiRUCT105
work f a Provided hi for by Section 3700 of the tabor Code,for he performance of the
work for which thispemat is orkerrkerFlXTl1RFS-PER TRAP
[3 and mai
1 have will nuin Worker,Compensation Insurance,as mgfcti by Section
My orthr,aborCran Cudafor hsurancmanmulad work for which this permit is issued. GAS-EA.SYSTEM.
1 INC.40lITLETS OCCGROUP APN
CaWorker's Compcnsamn Insurance canter and y No.:number,art:
Carrier: Policy Na.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFl CO OF COMPENSATION
EXEMPTION FROM WORKERS'
COMP replete ON INSURANCE GREASE/INDUSTRL N'ASTE INTERCEPTOR BUILDING DIVISION FEES
(Thissurion need car hcomplacd if the pcmthis for oirc hundred dollars Is 100) GREASETRAP �
or less.) PLANCHECK FEE
Toy any that in he Performamaymannce rofNeu'otkfarwhich jetho therthe at is Wokersued.I shallCompn- SEWER-SANITARY-STORM EA.2W FT.
net employ any person in any manner nn as m become suhjen m the Workers Compcn- ENERGY FEE
Z
scion lavers of California.Date
�
Z Applicant W/WATER HEATER vEM1T/ELECTR GRADING FEE
fq
NOTICE Tj.1.theWad IL after makingmusvisiosof of Exemption you should NATER SYSTEM/@EATING
'1 ; beeomc subjuno the w'odcrs Compensation provision of he labor Cada you mutt SOILS FEE
IL
forthwith comply with such Provisions or this permit shall file deemed revokW. WATER SERVICE
Z) z CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB. SQ.ET PAID
G 0 I hercbyaflhm that them is a emilen tum leading agency fm he performance of Date Ree pts
f' the work for.Men this permit is issued(Sec.3097,Co.C.)
Iandef's Nunn
(L21) I-cndir's Address TOTAL TOTAL:
F, y I cenif,dor I have mad his application and rum that me a,vc information is BUILDING E
(n counter I agree res comply with all city and sl unry mhources and some laws relating w QTY, MECHANICAL PERMIT FEE
fJ Zbuilding conswnmises ion.and hereby authorize repmsenrofrhi.s city tocmerup.n the SEISMIC FEE
adMve-mentioned pmreny for inspection purposes. PERh11T ISSUANCE
(we)agree to save,indcmnifv and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any wry accme again.a said City ALTER OR ADD TO MUCH.in consequence of the granting of this pernir. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.a10CFM)
SOURCE REGULATIONS, MECHANICAL FE
AIR HANDLING UNIT(OVER 10.001I CFM) CONSTRUCTION 1AX
imaltimm APPlicont.Contreebo Date EXHAUST HOOD(W/DUC )
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FE
Will Neapplicaut.,future building occupant stofeor handle harrahm,ai l HEATING UNIT(TO,100.000 BTU)
as defined by the Cupar inn Municipal Code,Chapter 9.12,and the Health and Safety
Code.Scene.25532(al". HEATING UNIT(OVER 100,000 BTU)
❑Yes F1 No
VENTILATION PAN(SINGLE RESID) PAID Date kecetpta
•f Will the applicant or future building stocapom use emyalem or devices which
emit harcal air a.nmmitmnta as defined by the Bay Area Air Quality Management BOILER-COMP OHP OR Initial BTU)
^Dinner,
El Yes [3 No BOILER-COMP(OVER 100.010 BTU)) TOTAL:
I have read the huallous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
loris Health&Safety Code,Sections 25505.'_5533 and 25534.1 undcaand that if the ISSUANCE DATE
bulldlnl not currently haven tenant.Nut it is myresrttusibiliiy,to notify he occupant NEWRESIDEN'TIAL SIECH. SQ.ET.
of he requimmentr which must he met poor to issuance of a Irroncuc of Occupancy.
Uwner m authortud agent Dam TOTAL: ISSUED BY:
IMF
OFFICE