30600 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 30600 VO1.•SOO
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRfSS: - - SANITARY NO, APPLICATION SUBMITTAL DAT[
a2 2A�= IC A-n/zj=
OWNER'S NAME: PHONE: CONT'RACTOR'S NAME: LIC NO:
fD 5Cy LLE NIC CONTROL#
x0 CHITEC iENGINHER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
e6stlleb W �C/d/C(F� �s'�^190. ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby nRrm that 1 sm licensed under,ard imas of Chapter 9 ha mmencing
0AFti1„D�p 2Oay n
RESIDENTIAL
iand effete' PERMIT ISSUANCE
�UULicenseClass Lia# APPLIANCES 0SFDWL
O KITCHEN REM
ODEL
Dae C r ❑ADDITION OPLUMIHNGREPIE
ARCHITECTS DECLARATION
ECL ON 'ANES El MULTI-UNIT O
Iudrstundmyplans shall heuwiduspublic records MODIFICATION
OxJ Oil T0200AMPS
Licensed Pmfeasiontl [I INTERIOR 0CHIMNEY REPAIR
OWNER-BUILDHR DECLARATION 2111-IgNIAMPS IMPROVEMENT
W Q 1 hereby affirm that I an exempt headline Cmaracmex License Law bertha OVER I000 AMPS 0 BATH REMODEUREPAIR 0 DEMOLITION
3 a FFvfollowing reason.(Section]OJLS,Business and Professions Calc:Any city or county SIGNS ELECI'RI C1 OTHER
r� which requires u permit m construct,alter,improve,demolish,or repair any standardt��txx 6, priannils issuancq of...rcyuires the applicam besucM1 permit In lilen xigneA stntemem SPECIAL CIRCUI'IIMISC.
r.�Q$ that he is licensed Pursuanto the provisions of the Contractor's License Law(ChapterH
GG (commencing withSection 0000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
a yy Do that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
p(^INS Section]031.5 by myapplicant fora permit subjects the applicant tot civil penalty of POWER DEVICE. TENANT ❑FOOD SERVICE
Z} not more than five hundred dollars(11500).
^at La owner of the norm leen with woes as their sole compensation, SWIMMING POOL : i IMPROVEMENT
0 ❑ pr'Pe Y Yd a Y 8 Buss 0OTHER
will dothework,andthe he Con card orawdufor sale(Sec,7(W.aBusiness
and Professions Cale:The Contractors then' Licene Law does not apply m it owner of OITI'LETS—SWI'I'CHIiS—PI R
�', ^ property who bullss at improves that
thsuchi turd who ales such rintended oro through ,
Isis-
his own employees.provided that such impmventents are not intended or offered for NEW RESIDENTIAL Ii1.CCi'ft PT.
sale.If,however,The building or improvement is cold within one years(completion,due SQ.FI'.FLOOR AREA $/5Q.PT.
owner-builder will have Ne burden of proving that he did not build or improve for Pur : '
Vai TOTAL:
owner of the prapcny,n mma
xclmivcly contracting with licensed mms m
answer me project(Sec.7044,Business and Professions Cale:)The Cummcmr's Li- QTV. PLUMBINGPERMIT FEE SEP 2 5 "i996
cense Law does not apply m an owner afprnperty who builds or impmves thereon,add
won contracts for such projects who o c.mmerngs7 licensed putsnnm m th.Contractor's
License Law. PERMIT ISSUANCE w
❑ Tarm exempt under Sec., ,I3&I'Cfor Nisreason �rllf V: 4sdn LttluiV
ALTER—DRAIN&VENT—WATER(EA)
nw... 'LBowAM2D /LLC n,. — VALUATION
WORKER'S COMPENSATION DECLARATION PACK FLOW PROIECT'.DEVICE
I hereby affirm under penalty of perjury one mthe following decimations:
❑ locus andwill mmintainuCertificute nfComm�uo mlf-imure for Worker's Compen- DRAINS—FLOOR,ROOF.AREA,COND. STORIES TVPI:CONSTRUCTION
said.,as provided for by Section 37M of the Ldaa Cade,for the Ferfnmmnee of the
work for which this wnni,is i...ad. FIXTURES—PER I RAI'
0 1 have and will nminwin Worker's Cma,a nstnion Leonard.as disputed by Section
Told.fthe Labor C(de,for the performance ofthe work for which this permit is issued. GAS—EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP qPN
My Wartela Compensation Insurance caner unit Policy number are;
Camel. Policy No: GAS—EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE GREASFJINDUSTRI,WASTE INTERCEPTOR
(This section need not he completed ifthe pemtit is(Drone hundml dollars 1$1001 BUILDING DIVISION flil5
or loss.) GREASE'I'RAP
511AID
HECK PEE
I wnify th'ut'nt the pttformanceof tbcwork l'or which this permit is issuW,[shull SEWER—SANITARY-5'TORM EA.200 FT
not employ my person in any manner m oa m become subject to the Workers'Comped. GY FEE
QZ all..Laws of California.])are WATER HEATER W/VENT/F.LECER
Z Applicant ING FEENOTICE TOAPPLICANT.If,after making this Cenificae of Exemption,you should WATER SYSTEMTREATING
become subject to the Worker's Compensation previsions of the tabor Cale,you must PEEforthwith comply with such provisions m this permit shall be deemeddevoked. WATER SERVICEz CONSemisaONLENDlNGAGENCY NRW RESIDBN'1'IAl.1'LMB, SQ.lef.
U O lfahereby whic irmt permit
ismed(Seaconstruction0 landing agency for performance of Dare Receipt It
4. 1^ the Under
for which this pcnnit is issued(Sec.J09],Civ.CJ
Isnder's Name TOTAL:
Lenders Address TOTAL: S
It^^ a 1 certify tom 1 have rend this application anJ state that the uMrve information is BUILDING TLE
(A correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U building construction,and hereby amharin representatives ofthk city to enter upon But SEISMICFEE. .
above-mentioned property for inspection purpmcs.
(War agree to save,indemnify and keep humrless the City 01 Caperton against PERMIT 19SUANCR ELECTRIC FEE
Iiahiliues,judgmcnls,cndsand expnrses which armymeny way.cma.,aimtsaid City ALTER OR ADD TO MIiCtL t
in consequence of the grunting of His permit. PLUMBING PER O
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Commucmr Data EXHAUST HOOD(W/])PICT) HOUSING MITIGATION FEE
RDOUS MATERIALS DISCLOSURE
Will the applicant or l'umre building occupant store or handle haturdom material HEATING UNIT TO I01,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health sand Safety
Cada,Section 25532m)'1 HEATING UNIT(OVER 100,0011 BTU)
E]Via, E]No VENTILATION BAN(SINGLE RESIDE PAID
Date Receipt#
Will d the applicant in future building by the Bt use equipment or Marta which BOILER—COMP(JI IF OR IIpp00 BTU)
emir hazaMous air cnnmminan¢m defined by the Boy Area Air Quality Management
Ui.aricp TOTAL:
F1 Yes ❑No BOILER—COMP(OV RR 100,000 BTU)
1 have read the hazardous materials mmirmands under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
forma Health&Sefety Code.Sections 25505,25533 and 255]4.1 understand that if the NEW RESIDENTIAL MECH. SQ,F7.
builA;amc.�me a ant, iti s'nabilitry t.notify the occupem
.fti et no ce ofaCeniftcaa of0ce
Owme TOTAL: ISSUED BY:
OFFICE