30371 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 30371 0 ^ 7 1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 'x•.(J `{l
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESX SANITARY NO, APPLICATION SUBMiFTAL DO-0 kt &s, jaD RQ
OWNER'S NAME' PHON17: CONTRACTOR'S NAMG:���, / LIC NU: YO2�
GV L 'X NIC CONTROL#
�RCIIITECT/ENGINEER: LIC NO: ADDRESS: ❑
ZA 2'tiG6(00fft& 39, 5 'e R D 1.
CONTACT. PHONE: - C/3'(If BUILDING PERMIT INFO
(WvC (U'`)43
ElConsultant FeeS Paid by Applicant(Initial) BL,.DGr ELECT PLUMB MECH
T f fYJ f]� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTy. ELECTRIC PERMIT FEE
I hereby arum mal 1 am Ettaed nnaer provismma of chapter q anmmtneing JOB DESCRIPTION
WOO with Section 7000)of Division 3 of me Business and Profess1ior,n,s.Cale.and my license is
�Fa,�� in full Trroornd erred. 6ZlV Z� PERMIT ISSUANCE 9S' 60 RESIDENTIAL:
MRUU License Chas LIc.X lx+ ❑SFDWL ❑KITCHEN REMODEL
i.zW Date Contractor, ')'(I APPLIANCES-RESIDENTIAL s ❑ADDITION ❑PLUMBING RE-PIPE
AIS6FITECTS0[CLARATION
PANELS El MULTI-UNIT ❑STRUCTURAL
Z 0 h m shM u
Z I understand my Alaall sed a s.public record -
C Z—0 UPT0 2M AMPS MODIFICATION
W Licensed Proresalomvl ❑INTERIOR [I CHIMNEY REPAIR
2014000AMPS IMPROVEMENT
YW OWNER BUILDER DECLARATION C1 BATH REMODELREPAIR EI DEMOLITION
Q 1 hereby affirm the exempt 1 wn from the Contractors License Law for the OVER I0X00AMP5
K 3Com.OF following reason.(Section 7031.3,Business and Profi inns GJe:Any city or county SIGNS ELECTRICAL ❑OTHER
F.u,O mQ which requires a permit to construct.alma improve,demolish,or repair any aaamurc
NJ prior it,Its issuance,also requires the applicant for such Permit to file a signed casement SPECIAL CIRLVIT/MISC.
Hy ran he is licensed pumunnlmme provisions ofthe Contractors License Law(Chapter 9
P.DO (rommencing with Seuion 7(gp)of Uivision]ofine Business end Profession..CaJe)or TEMMISTER OR POLE INST. COMMERCIAL
d a than he is cacmpl therefrom and rhe basis far the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
9''p^,o, Section 70J15b any applicant fora
Y Fermit,wbjens the applicnnnna civil penalty of POWER DEVICES ❑TF ANT
FZY not more Nun five hundred dollars($50% ❑FOOD SERVICE
Ek
Rxn ❑I,vs owner of the pntpeny.onny cmployms with wages as Ohtirsole compensation, SWIMMING POOL ELECTRIC PROVEl IET
F.. will Bothe week.and the structure is not imcnde ierottcred forsale(See.9044,Busineax� ER
G3 m and Professions Cade:the Contractor's License law Jces not apply to an owner of 3 OUTLETS-SWITCHES-FIXTURES v
Fameny who builds or improves thcrcon,and who J«s such work himself or through
his own employe,,provided that such improven¢n¢are not Intended or offered for NEW RESIDENTIAL F:LECTR SQ IT. p `
sale.IL however,the building or improvement in sold within one year ofcompletion.the �ORAREA" '-" S/SQ.FT
owner-builder will have the burden of proving that he did not build or improve for Pur-
pose lir,ale). 22 19CB
El 1,as owner of the prapeny,am exclusively contracting with licensed contractorsm TOTAL:
eonamet the project(Seo.7194,Baines and Professions Code)The Contractors Li-
sense Law does not apply to an owner of property who builds or impmves thereon,and QTY, PLUMBING PERMIT FEE
who contracts her such projects with a contractor(s)licensed pursuant to the Contracmrx Cll'! Ur Vt��U11U tU
License law. PERMIT ISSUANCE -
❑ m I aextma
pt title,Sec. ,B&P C for this reason
Owner ALTER-DRAIN&VENT-WATER IEA)
Doc VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following JMamtlons:
I base and will maintain a Cenificam ofCawrI no self i...nofor Worker's Compen- DRAINS-FLOOR.ROOF,AREA,COND.
cation,m provided for by Section 37M of the Labor Core,for the Performance of me STORIES TYPE CONSTRUCIIOC
{�Por which this Permit is issued. FIXTURES-PER TRAP
QI have and will maintain Workers Compensation Insurance.as required by Section
3700o17the Labor Cale,for me performance of'he work for which Ohio permit is issued. GAS-EA.SYSTEM-I INCA OUTLETS OCC.GROUP ppN
My Worker Con nytion lnsurrrl1nce eerier and Policy numbeggfp: /�ti GAS-EA.SYSTEM-OVER Cartier. STI- EC�AN Policy No.: 11FG_r_
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(This motion mend dol be completed ifthe permit is roc one hundred dollars X I(1) BUILDING DIVE IN FEES
or less.) GREASE TRAP
!PAID —
U
!Dam
E
To
Loy anymatinthe anymannrolas notrkfur which lM1is Permitisiaru'Colmallam- SEWER-SANITARY-ST(IRM EA.204 FT.
not employ any permn in any manner so as to hecoms suM1jed to the Warkerc'Compen-
sZ action Lewy of California.Date
O Applicant WATER HF:AfI1R WNEYT/ELECTR
N NOTICE TOo to the Worker's
Compensation
this Cisions for F"Nor Codyouushoodd
am', WATER SYSTEMOREATING
become subject y the worker's Compensation permit
of the labor Cede,you must
forthwith comply with such provisions or permit shall he deemed revoked. SOILS
O WATER SERVICE
C
'Uz CONSTRUCTION LENDING AGENCY NEW RESIDF,NTIAI,PLMB. SQ.FT.I far by whihfait at Permit i isaca (Sec.301 Civ.
agency for permrmance of Rcceipta
� ,r the wok fm which Nis permit is issued(Sec.3097,Civ.C.) '
Urondo's Name
Lenders Address TOTAL:
r'� 96 I remify mut I have rtait this application and gam mat the ohms information is TOTAL:
h cnrtea:iagree m<omplY with all city and county 9rJinan<es and cram laws retrain m FEE BUILDING PEE .N
U Z buildingconstruction.and hem-by g QTy MECHANICAL PERMIT ✓✓gV/
inns yaurtiorirercprescnmtivlis of this city nt enter upon the SEISMIC FEE
,Heli-(We)ro ed pro,arry ams for impaction an keep hs. PERMIT ISSUANCE ,
(We)agmen to save,indemnify and kith harmless the City of Cupertino against
ty - ELECTRIC FEE
in
cunce of the
eoosing ft his esmit. Huyinany way,acerae againstsail City ALTERORADDTOMECf1.
APPLICANT of thegrannie%of this permit. PLUMBING FEE.
SOURCE
AND WILL COMPLY WITH ALL NON-POINT AIR UNIT(T010,(NM)CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION FAX
Stgnamre
HAZARDOUS
Ume EXHAUST HOOD(W/DUCO
US MATERIALS DISCLOSURE EPAID ?f�44
IGATION FEE
Willm the Cucantorl'umre building Code,Chamsnam or h5ndle Healloandnomarm)Softy HPATING UNIT(TO ItlB,g1H B'IU)
a deRned by me Cupertino Municipvl CNtpmr 9,12,and the Health and Safety
Code,Sandman 25532la)'! HEATING UNIT(OVER 100,000 BTU)❑Yes (Iigo VENTILATION FAN(SINGLE RESID)will me applicant infurore building by the B use equipment or devises which m Receipt X
emit hazardous air contaminants as JcfncJ by the easy Arca Air Quality Management BOILER-COMP OHP OR 100.000 BTU)
District' TOTAL:
❑Vias BOILER-COMP(OVER 100,1100 BTU) _
I mai, it the harallous mmerials mr,ma n em,andcr Chap¢r 695.frac Calm AIR CONDITIONER
f9mia Health&Solely Code,Sections 25505,25533 and 25534.I understand the it Ohe ISSUANCE DA
building delis not currently have a tenant.that it is my responsibility to notify me occupantNEW RESIDENTIAL MECH.
of the eequimmcnes which must be mel priorm issuance of a Cenif icatt of Occupancy.
Owner or mahn imd agent Dam TOTAL: ISSUED BY.
OFFICE