30863 ARPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY /p+�/�(�
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 30863
� O H V V
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICA•1'ION
BUILDTNGADDRESR tY `/ - SANITARY NO. APPLICATION SUBMITTAL DATE
0 Z T VC Gv' Lip v cjot Y � l�
OWNER'S NAME: PHONE: CONTRACT'OR'S NAME: LIC NO:
I,r 1 O _G N/C CONTROL#
ARCHITECT/ENGINEER: •V LIC NO: •J ADDRESS: ❑
rw
CONTACT: PHONE: BUILDING PERMIT INFO
WIN�� , �,5.�3 ❑ Co05ultant Fees Paid by Applicant(Initial) B ELF. PLUMB MECH
'pkk'f16 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
iMOcZ with Section 7000)ofuivision 3 mine Business and Professions Code,andmy license is RESIDENTIAL,
CO itfePERMIT ISSUANCE
v❑SFDWL ❑KITCHEN REMODEL
UUr Licensence ClaClassss effect. Co
Dan—
ntr tor - ❑
APPLIANCESRESIDENTIAL YI ADDITION PLUMBING RE-PIPE
to 444Zi
22 ARCHITECT'TSSDECLARATION Ll MULTI-UNIT []STRUCTURAL MODIFICATION Z O,jf q 1 understand my plans shall be used as public records PANELS MODIFICATION
0cz=� - - UPT0200AMPS El INTERIOR O CHIMNEY REPAIR
Licensed Profcss.mad 2U1-1000 AMPS IMPROVEMENT
�ked Oat I am exempt
from
DECLARATION OVER IWs)AMPS .❑13ATH REMODEUREPAIR ❑DEMOLITION
1 hereby.(irm hat I I exempt from the Cessions Ca License Law for the
yU following reason.(Section'/OJLS,Business and Professions Cnde:Any city or county SIGNS ELECTRICAL ❑OTHER
esu Y•I" hich requird a permit to construct,alter,improve,demolish,or repair any structure _
is issuance,alsam,eims theapplicam for such permit to fleaeignedxrnlement SPECIAL CIRCUIT/MISC. e
o that he is llcensedpurseantto the provisions ofthe Comrmis License Lov Empter9
(commencing with Section 7000)of Dmisom 3 of the Busiaessand Professions Codd)or TEMP.METER OR POLE INST. COMMERCIAL:
IS, c[E that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION El DEMOLITION
fi Seaioa'/03L5 by any vpPlicam fora permit subjects the apPlicuntmacivil penahy.f POWER DEVICES
Mm []TENANT FOOD SERVICE
nnomwrieax.fiveepropJty,or my employees
IMPROVEMENT
� �Lo the work,the property,r ntyemntendes withwred for sale
i(Sele compensation, SWIMMING POOL ELECTRIC ,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business ❑OTHER
63�^ and Professore Code,The Commences License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through - Rw
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FittW e�
sale.If,however the building or improvement is sold within oneyearofcampl num'the SQ.Pr.ELOOR •�V $/SQ.IT.
r-builder will have the burden ofpmving that he did not build or improve for put- �/��
pose of ealeJ. P
1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: ��yy
construct the project(Sec.7044,Business and Professions Cd1e)The Camracmds LI- lei 1/p
cense Law does not apply to an ownerofpmperly who builds orimproves thereon,and QTyY PLUMBING PERMIT FEE Lit-
who contracts For such projects with v cammemr(s licensed pursuantto the Contractor's
License Law. - PERMIT ISSUANCE /�rYG
❑I am exempt under Sec. •,BPCf i nn
O Nn^96y x N II- J -�`�f ALTER-DRAIN&VF,NT-WATER(EA) VALUATION
1• `mey.WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /►N p v-1�
hereby affirm mndcr,penally ofperjury one ceche following declamnona; / VV
I have and will maintain a Certificate of Consent to self-insure for Worker's Camper- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
action,as provided for by Section 3]00 of the labor Code,far the perfame nee of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700ofthe Labor Code,for thnperfarromm cif the work for which oils permit is issued. GAS-EA.SYSTEM-1 INC.4 OUT LETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are: .
Currier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA) r
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
HES(This section need not bo completed ifthe permit is Forane hundred drs
olle (SIW) B IN N[SION
or less.) GREASE TRAP PLANCHECKE -
1certify lhatinlhepsifmmanceofthework for which this Permit isissued,lshall SEWER-SANITARY-STORM EA.200 Ff.
not employ any person in any manner so as to M1ecome subject m the Workers'Cartoon. ENERGY 'E
Z satum Laws of California.Dace WATER HEATER WNENT2LELTR
'OZ O Applicant GRA EE
G rj1 NOTICE TO APPLICANT If,after making this CertMooto of Exemption,you should WATER SYSTENVEREATING
abecome subject to the Worker's Compensation provisions of the Labor Cade,you must SOILS
W forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
az{ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
I herebypfBrrethat them is a constractien lending agency for the performance of Dat Receipt#
IHwork for which this permit is issued(Sm.3097,CF,C.) -
O Lender's Name _ TOTAL:
W Lenders Address TOTAL:
I certify that I have read this application and state that the above information is - BUILDING FEE
.. r0./1 cored.I agree to comply with all city and county ordinances and state laws relatingto QTY. MECHANICAL PERMIT FEE
U 4 building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned properly for inspection Purlxsses. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hmmless the City of Cupertino mothe l ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said CitygLTER OR ADD TO SUCH.in consequence of the granting of Ibis peraid. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) '
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,00)CPM) CONSTRUCTION TAX
Signawm ofA,inu mCiamomr Dara EXHAUST HOOD(WIDGET) HOU SING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicam o,future building occupant stonomhandle hazardous material HEATING UNIT(TO 10Q000 BTU)
as dented by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety
Code,Section 25532m)? HEATING UNIT(OVER 100,000 BTU) -
E]Yes 71 No ' VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt#
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP QHP OR 100,0100 BTU)
District? TOTAL:
El Yea, []No BOILER-COMP(OVER 100,000 BTU)
I have read the haznNous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCEDATE
retain Health&Safety Cade,Sections 25505,25533 vad 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.ME
building does not carnally have a tenant,that it is my responsibility to notify the occupant
of Esp ox,irements which must be mel Primo issuance of.Cenificvte of Occupancy.
Owneror i nthmized.,cut Date TOTAL: ISSUED BY:
OFFICE F
i
H
RESIDENTIAL PROJECT COVER SHEET
caY of
Cupertino
Assessors Parcel Number: -6 9 - 610 -49/
Name of owner. YYl A R 10 N W ! N D SO fZ
Project address. 90 1Q1 A i NGU�oD RVE �e eefl nrc� Cf�X
Contact person. M K R k o ni vJ s oR Phone. 0o19 4 4 6— S 4::� -Z�
Fax.
Net square footage of lot. (as m ti
5 4 f'� ,
Egistine Proposed
Square footage: First floor: 5* o / 560 /p f
Second floor: N//-1 iU AL
Garage: If Lf O /✓ a
Are there at least two 10 foot by 20 foot clear spaces inside the garage? N
• On what floor(s) is work being done? Oy �sld� Dere
Brief description of work. �Da�e,�C Ua�r Do•c G�
Code editions: 1994 UBC (Y -N)1994 UFC (Y-N)1994 UMC (Y-N)
1994 UPC (Y-N)1993 NEC (Y -N)
Plan Review Process Work Book Page-7-
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APR 1 1997
BLDG. INSPECTION
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