30954 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT N0. J/] 95
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J (•F
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
q d �i� ?-4vg1
OWNER'S NAMI HO CONTRACTOR'S NAME: LIC NO:
- �J� sokTa B0. W/n✓ala.s c. 65T 3. N/G ONI�
ARCIIIJECTAENGINEER: IG ADDRESS: ❑
///LW FuATOaO /=,t/s'HGuIT
CONTACT PHONE: - BUILDING PERMIT INFO
i C -Z..S ❑ Consultant Fees Paid by Applicant(Initial) L .E PLly�ap MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEEILVJRv
1 hereby affirm that I am licensed under provision of Chapter 9(commencing .JOB'DESCRIPTION
w0C) with Section]aq)orDivision 3 of the B miness and Pmfessloos Cole,and my license is RESIDENTIAL,
F O full farce andeSttt. PERMIT ISSUANCE —
CL,E m 3, /, 6�^J013. ❑SFDWL ❑KITCHEN REMODEL
aUU hicensc Clns Lic.H
hzw Dam 4y r Cuntm�a. <•iTiri �✓/f//h APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE PIPE
(„Din ARCHITECT'S DECLARATION ! ❑MULTI-UNIT ❑STRUCFURAI.
in� 1 understand my plus shall be used as public records PANELS 1
ZO Imo^ MODIFICATION
OZ— UPT02IXIAMPS Ll.�rr
El INTERIOR CHIMNEY REPAIR
F.~� Licensed Pnr(essional 201=1(0)AMPS IMPROVEMENT
FF.t, OWNEmexempt m m the Contractor's
OVER lap AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
C¢�
D. 0.Q 1 hereby,(Orth that 1 am exempt from the Cssions or's License Law for the
p(36I' which following
re,u reason,permit
7031.5, t,alter,ness improve,
ve,demolish,
Any city somomy SIGNS ELECTRICAL [I OTHER
t{�tll Y.y which requires a permit to construct,alcor,nnprove,demolish,or repair any slrucmrc
Eric''it issance,alw requires the applicant for such 1rm1110 file n signedstatemem SPECIAL CIRCUIT/MISC.
F„!(} that he is licensed pursuantto the provisions of the Contractors License Law(Chapter l
W�CCO (commencing with Section]ap)of Division J of the Business and Professions Code)or TEMP.METER OR POLE INST. tIANMN
a X e C that he is exempt therefrom wd the basis for the alleged exemption Any violation nr BLDG/ADDITION ❑DEMOLITION
�,,,m Section7031.5 by any applicant for a Permit subjects the applicantto a civil penalty of POWER DEVICES1-ZT t mom than five hundred dollars Will ANT ❑FOODSERVICE
f ❑Las owner ofthe propene,or my employees wish wages as their sole compensationSWIMMING POOL ELECTRIC ROVEMENT
F will do the work,and the structure is not intended or offered misule(Sec.9044,Business ❑OTHER
In3 and Professions Code:The Como-aloes License Low does not apply to an owner of 2,! OIITLEI'S-SWITCIfFS-IgXTURES
propene who builds or on,mrves thereon,and who does such work himself or through
his own employees,provided that such impmvemems am not intended or offered far NEW RESIDENTIAL ELECIR SQ FT.
sada If.however the buiddingor improvement is sold within one year ofcompletion,the SQ.FF.FLOOR AREA) A 1 0 $'SQ.ET
wnerbuilder will have the burden of proving that he did not build or improve for par
ptsse of sale.).
❑ 1,as owner of the pnspcny,am exclusively contracting with licensed contractors to , FEB '11 RECT
construct the project(Sec.90W4,Business and Pmmssions Coders The Contractor'8 Li..
nu law does not apply to an owner of propene who builds or ourselves thereon,and QTY. PLUMBING PERMIT FEE
whocontmctx forsuch projects witha conaaxnl(s)lirensed pursuant of the Cantrelm'x CITY Ur LUN HiINO
License law. PERMIT ISSUANCE
FI I am exempt ander Sec. ,B&1'C fonhis reason
ALTER-DRAIN&VENT-WATER BA)Owner Date VALUATION
WOR KERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICEEl rr1
I herehyaffirm ad,,penolty ofpc
ajuryuneol'the following declarations: \ ��
(have and will maimain aCcnificse of Conecm to ulGins..for W'orker's Compeer- DRAINS-FLOOR,ROOF,A ,GOND.
.nation ax provided for by Section 37W of the Labor Code,for the performance of the STORIF_ TYPE CONSTRUCTION
work for which this permit is issued. fl ,R TRAP
5af
P I have and will maromm Workers Compensation Insurance,as required by Section �
3700ofthe Lahm Code,for the performance ofthe work for which this permit is issued. GAS-EA.SY2 ZINC.4 OUTLETS
n OCC G It APN
My Worker'v Cnm wet at Insurance cartittand Policy nypt�e5 a,2. ,e�6 GAS-
Carrier A11HA�Vs�GJ PQNL/. policy No,: f73 EA.. E ER 4(EA)
CERTIFICATE OF EXEMP DON FROM WORKERS'
COMPENSATION INSURANCE GREASE DU. 'ASTE INTERCEPTOR
("is section need not be completed if the permit is for one hundred dollars(S la)) BUIL NO DIVISION FEES
or less.) GREASE TRA PLAN HECKF E
Toy anytbs int he performanymannoo nero as
work for suicluhili permit is issued.'Com
halln- SEWER-SANITA '-5 EA.2W FT.
not employ any Califon i any manner m as m become subject In the Workers'Compen- [N Y
Z Applicant
anws of Californiaa Ilntc
O WATER HEATER WN SLE
z Applicata GRA r( EE
!n boroomNOI subject
APPLICANT.If,after making this Certificate m Exemption.you should WATER SYSTEM?REATING
became zco mt y the Worker's h pre Compensation provisions of sine coedLabor Code you man SOILS FEE
forthwith comply with such provisions or this permit.Bhnll be deemed revoked. WATER SERVICE
a �
z CONSTRUCTION 7LENDING AGENCY NEW RESIUEhT1ALPI.MB. SQ.FT. PAID
U 0 Thereby affirm that them
ere is is a construction lending agency for performance of ate ReceiptM
th
0 e work for which this permit is issued(Sec.309].Civ.C.) NON
L Lenders Name
r Lender's Address L TOTAL:
1 comfy that I have read this application and state than the above information is BUILDIN E
to correct.l agree to comply i�
g ivy wim,amlyandc ,re,ordinances QTy, MECHANICAL PERMIT FEE
C.) athav ingennswctiropert here byxmhonrereprcsenmtiven of this city mentor upon the SEISAtICF `
above-mentionedpropene for inspection .
(We)aree m keep ha
gsave,indemnify(cosi keep hannlms the City of Cupertino againstPERMIT ISSUANCE. ) ELECTRIC F
liabilities.judgments,costs add expenses which may in any way necme against said City ADD TO MECH ALTER OR
lk
in asequence officegramm,of this permit, i - PLUMBING FEL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
10
SO AIR HANDLING UNIT(TO III,1%Itl CFM) L
rUL TIO'.. MECHANICAL FE
AIR HANDLING UNIT(OVER 10.00f)CFM) CONSTRUCTION TA,
Signature ofAp Contractor Dom EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS Date
MITIGATIO E
Will me applicant or And.re building receiving store orhdle harmrdous material HEATING UNIT(TO IOOW ABTU)
as coined by the Copenimt Municipal Cods,Chapter 9.12,and the Health and Saba,
Code.Section 25532(al? HEATING UNIT(OVER I W,000 BTU)
0Yes XNo N
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building equipment lir devices which Uma Rttei p
emit haesdom air contaminants as damned by M1y the me Bay
A Area Air Quality Management BOILER-GOhiP CHP OR I00,000 BTU)
Distrix, TO L:
El Yea XNo BOILER-COME(OVER IW.1100 BTU)
1 have ford tM harallous mammas reAIR CONDITIONER
q M533 an under Chapter 6.95 of the Cull- ISSUANCE DATE
ferric HeJth Safety xiuns 25505,235JJ and 25534.Ito modytth that if the NEW RESIDENTIAL MECH. SQ.FT
WBding do.co is rid tenam t oto is mytagfnsin mbinnodfOthe occupant ccupacy.
1 �col .11 poor to issuance oraceniecme or aapa<r.
re, li2 /I— 97�-
Owne or num agent Darc TOTAL:I ISSUED BY:
OFFICE