30149 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PLRMITNO. 30149
BUILDING DrvIs1GN PLICATIONfPERN1IT PLUMBING-MECHANICAL
BUILDING PROJECT'IDENTIFICATION
BURDING'AD15RE55: SANITARY NO. APPLICATION SUBMITTAL DATI
Pau#J& O I C44 0 /
NEWS NAME' PHONE: CfSNTR CfOR'S NAME: LIC NO:
I C 1.. - NIC P OI.
.Q' GINEE - 1.1 'ADDRESS:
N J
CONTACT. PHONE: I'-_ J BUILDING PERMIT INFO
I y y Consultant Fees Paid by Applicant(Initial) _Ili BLDG ELECT' PLU61B MECH
AN N403,)
O s 60 tfgb %,A �r/3
LICENSEDCONTRACOR CLARATION LF To
QTY ELECTRIC PERMIT FEE
I herehy affirm Hm L am licensed under provtsi0ns of Chapter 9(commcnrias JOB DESCRIPTION
�0p with Section 7")cfDnsi.a3.flhe Business and Professions Calc.and my licemeis PERMIT ISSUANCE
IAL
a in full forte end eRcer. Jg• Cp SFDWL LI KITCHEN REMODEL
QF.0 License Cla.
fn64 Uate�Cumracmr APPLIANCE'S-RLSIULNTIAL ADDITION C3 PLUMBING RE-PIPE
P„psp A 'HITELTS D[Ch RATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
x OO Z 1 un cultural my plans shall b,used as public records MODIFICATION
OZkO UP T02W AMPS []INTERIOR ❑CHIMNEY REPAIR
�� Licensed Professional 201-I003AMPS IMPROVEMENT a OWNER-BUILDER DECLARATION OVER HMAMPS ❑BATH REMODEUREPAIR CD DEMOLITION
yp,0 W 1 herehy affirm that 1 um exempt from the Contractors Coal,:
License Lew for the
's<3 d U following hues. (Section]Omar,Business and improve.
denons Calc:Any city nr cnuiny SIGNS ELECTRICAL ❑OTHER
uull�LLO which requires a permit to conswch cher,improve,demolish,or repair any structure
priormits issuance,elm requires the applicant for such permiuo Rle aigned statement SPECIAL CIRCUUUMISC.
[p.vWvW��� That he is licensed postontto the provisions ofrhe Comracrors License Low(Chapter 9
Ogap it-
(commencing with Section 7")of Division J ufthe Business and Professions Code)or TFAIRMlfl'I?RORPOLDINST pT��/�`
6 s"e C that he is exempt thcafmm and the brsis for she alleged exemption.Any violation of ❑NEW LD9G/ADIZp'1 ❑DEMOLITION
Section]031.5 by any applicant for.permit subject the applicant'..civil pe..hy of POWER DEVICES 5
m TENANT J[IiJ FOOD SERVICE
M
not on than frvc hundred dollars($SW).
6 �L.sownerofthepmpcoytme Nta tinumdeswithweedforshcirmle 0,44.8 sines SWIMMING POOL ELECTRIC IMPROVEMENT
C andwill dmhe work,Code:
The Curelsnot intended Law does
or applyt a Business THER Vis - v
and Property
who
ills imp Contractors License Law does not apply hs if owner of OIITLF.9:S-SWITCHES-FIXTURES
o' .. his o ny who builds or improver Hereon,and who rices such tine deed or ar through
his awn however
m provided that such impmvcments are notvo year oft or offered for' NEW RES IDfiNT1AL ELCCTR SQ FT.
sale.R,hower will hvilthe burin offroint isat hedid noneild or improvefogthe SQ.FT.FLUOR AREA ESQ.FT.
owner-builder will have He burden of proving that he did not build or improve for par.
Paso of sude.).
03
❑I,es owner of the property,nm exclusively contracting with licensed contractors usTAI ' (r� tutu t
construct the project(Sec.7614,Businesa and PmfaW..s Cad...... Cnntmnors Li- up—
come Law does not apply to an owner of property who builds or improves Hereon,and QTY. PLUMBING PERMIT FEE
ns
who comracis forxuch projects with a comrocmgv)licensed pursuant m the Contractor's
Ltsenm Law' PERMIT ISSUANCE.
1 ata exempt under Sec. ,B&PCho Hismon
es
ACO
IN
Owner Dam BACK F OW PRO ECT DEVICE (HA) ypI,UATION��
WORKER'SCOMP ENSATION
mofmcfDECLARATION BACK FLOW PROTECT.DEVICE ` '
I hereby ill maintain
ai under penalty of perjuryene of the following dedamtions
sj.a.asand wie main mi Section a�rhe37M nf,hc Talon,nt to Coda,fare for Workedssempan.of the DRAINS-FLOOR.BOOK AREA,COND' STORIES TYPE CONSTRUCTION
Wkf s which
(ha for na Section 3]W of the Labor Cods,,for uta perfommntt of the
'y1,far which His permit ix issued FIXTURES-I'F.R TRAP
37 1 have and will maintain Worker's Compensation ce ofthw rkfor which
as requihis permit
by Section
l]W of the laborCafe.forthe perfonrrence of rhe work for which this permit is issued. GAS-BA.SYSTfiM-I INC.40UTLFTS OCC.GROUP APN
My ker Ci Insurance cooler and Policy nurdlerk,.
ee +�/LY �gaa.F_Pnlicy RO '0 GAS-CA.SYSTEM-OVER 4(FA)
dfiTIFfC COMPENSATION
ATION INN IRAN WORKERS'
COMPENSATION INSURANCE GRPASFIINDUSTRL WASTE INTERCEPTOR
(This section need nor be armpletul ifthe permit is Intone bund¢d dollars is 100) NUILUING DIVISION FPPS
GREASETRAP
or lase.) PLANCHECK FEE �s
Loy any Hain He any manero as t work for which His petioliisiss'(7mapn-I shall SEWER-SANITARY-STORM EA, fT.
not employ any person in any manner so as m became subject m the Workers'Cumpen- ENERGY FF.F. �
smion Lows of Calif con.Date
O WATER HEATER W/VENT/ELLCfR
7 O
Applicant GRADING EEE
G ln NOTICE TO APPLICANT:If,after making this CeniOcate of Exemption,you should WATER SYSTHsUTRF.ATING
a5: become subject o the Worker's Compensation provisions of the Lniwr Code,you must SOILS FEB
{la
forthwith comply with such provisions or this permit shall he doomed revoked. WATLR SERVICE
0. Q
CONSem is a0NLENDINGAGENCY NEW RESIDENTIAL PLMB. $Q.FT. PAID
L)O T far
rwhich rte that Here ie...al( eaconstruction0 lending agency for the lwrfnrmnncc ofU. Dal 'eip1M
the work for which this penrdt is issued(Sea J1197,Civ.CJ \
O V fender's Name TOTAL:
LLI Lenders Address 140V . 60
(~ y 1 certify Mat I have real this application and xmm that the eMvc infnrtninion is BUIL G ' E �1
correct.I agree to comply with all city and county ordinances and state laws relatingm QTY. MECHANICAL PERMIT FEE
V 7building construction,and hereby amhorin,representatives of this city In enter upon the SEISMICF]i /s
.bove-mentioned pmpeny for inspection purposes 'I'LRMI'1'ISSUANCE(We).gree to save,indemnify and keep harMess He City of Cupertino against ELECTRIC
Iiabil hies,judgments,costs and expenses which may in any way accrue againsisaid City ALTERORADDTOMECH.
in consequence of the graining of this permit. PLUMBIN EE `' D
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GM 10,500 CFM)
SOURCE REGULATIONS. MECHA CAL FEE
AIRHANDLING UNIT(OVUR IO,(NMCFM) CONSTR NTAX
Signmumof ApplicenUCmdmsmr - D.te EXHAUST HOOD WIDUCT) HOUSING MITIG TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building receptor store or handle haaardous material IIEATING UNIT GO 100,000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532my' IIEATING UNIT(OVER 100,000 BTU)
❑Yee ❑Nn
t VENTILATION FAN(SINGLE RFSID) PAID
1 Will the an ai em it furore h efi.eg by he B use e a Air mor devices which
Irate eceipt M
vanL".11111
dnus.v conmminams as defined by the Bay Area Air Quality Management BOILER-COMP IJHP OR IW,OIIU BTU)
iTOTAL:
es 0No BOILER-COM P(OVER I W.0M BTU)ve readrhe homNous mntedals AIR CONDITIONER ISSUANCE DATE
reqirtmnu under Ch.ptn 6.95 of the Cai-
h&Safety Gale,Scnions 25505,25533 and 25534.1 understood that if He NEW RESIDENTIAL.MECH. SQ.Cr
e col amend,have.tenant.that it is my,aspnnsihidly m carry therecupamment which must be ion prior to issuance of a Cenificate ofOccupancy.
0mrized agent Date >1111 Lid ISSUED BY:
OFFICE