30063 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF C UPERTINO BUILDING-ELECTRICAL PERMIT NO. 30063_O O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILD(NGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
09260 t.3 /c!.rii"`�uelP, I l' ./'1na �
OWNCR'�$,N�AIdji:: (� THONG: CO RACrOR'SN E: /+ LIC NO:
Xf&e-,v / !Y�'- Lx —266 " Lir !sf' ��PAKd/C'.%�� q2—?2 N/C CONTROL
ARCHnECT/ENGINEER: LIC NO AjGG IIR .S: �S ,r ¢p ��• E
NO'CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG LLECr PLOMB MECH
LICENSED CON']RACTOR:S OF LARATION QTY. ELECTRIC PERMIT FEE ❑
1 hereby uflinu that 1 nm licensed antler pmvisiam of Chapter 9(commencing JOB DESCRIPTION
Z with Section 70(%gofDivimad 3ofthe Bromarsand Professions Crabi my license is RESIDENTIAL'
00[ PERMIT ISSUANCE
<<FVU LiceinflnaefaCo. eOect:�- ,Lp ' Lrcn Z �2 ❑SFDWL [I KITCHEN REMODEL
fnQOW. Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION O PLUMBING RCPIPE
).,'N ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT DSTRUCTURAL
0M,
Iandersmndnry plmoslwllbrummuspohlierecords MODIFICATION
C.7 UPTO20AMPS
r4F-4 Licensed Puifcssional [ INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-1000 AMPS IMPROVEMENT
a' -t I hereby affirm that I am exempt fmAt the Commoners License Law for the OVER I"AMPS 0 BATH REMODEUREPAIR 0 DEMOLITION
W O p,U following reman.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL 0OTHER
Y7 a LL which requires a permit to couarnei,and,improve,demolish,m repair any moncone
prim to its i ornme.alsorequires dc.ppli.m for such permit no fileuxignedmetement SPECIAL CIRCUIT'/MISC. M
y Loulawlicemedp...artro the pmvisionsofdan Curvatures License Law(Chapter 9
^<f (commencing with Section 7")of Darmon 3ofthe Business and Professions Cost)or TEMP.MITER OR POLE INST. COMMERCIAL:
L O O that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDrnON 0 DEMOLITION
Secdon7031.5 by any applicant for n Permit subjects the applicant to o civil penalty of POWER DEVICES
41^rn []TENANT ❑FOODSERVICE
ZZ not momthanfive lmndhiml perty, rmyempl. IMPROVEMENT,
Q ❑Lmownork,the prupeny,onnyemployeedmidlewages m their sole compensation, SWIMMING POOL ELECTRIC
will dothe work,and the structure isnotintended Law does
sale(See.
to an Business ❑OTHER
and Professions Code:The ova,thctor's and. law does not apply s if owner of OUTLETS-SWITCHES-FIXTURES
�' ^ properly who builds or improves thereon and who doea such work himself f through
his own however,
building that tach mentis old within art not intended ur offeced far NEW RESIDCM'IAL ELECTR SQ Q
aale.lf,heweventhevethe bading rer of prmenn isat heid one thand ofcomPlefonthear. SQ.PT.FLOOR AREA S/SQ.
rowner-builder will have the burden nl'proving When he did not build m inrpmve for bur-
c.). I ;.
I,as owner of the properly,an,exclusively contractingffiswith licensed con..... s m TOTAL: Tai C/ naw_
nnawd the project(Sec.o an Buxiness and Professions Code:)The esmmcton.I.J. II`Fflq
cenreLaw does nmapply toon ith.exfpreemah who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
wwense Law.far such projects with. licensed pursuanttothe Cnmmnora
License Low. PERMIT ISSUANCE I'�%'T•v
❑tem cpcmpt under sec. ,B&PCfor this reason
Owner orae ALTER-DRAIN&VENT-WAI Ell(1i) VALUATION
WORKERS COMPENSATION DECLARATION BACK MOW PROTECT.DEVICE
I hereby vffum under Penalty of perjury one of the following declanniom:
I have and will maintain a Cenificme ofComennn self-insure for Workers Cooper- DRAINS-FLOOR,RODE,AREA,COND. STORIES TYPE CONSTRUCTION
43700.fth,
n,as provided for by Section 7]00 of the Labor Gde,for the performance of He
for which this permit is issued, FIXTURES-PER TRAP
have and will maintain Worker's Compensation Insurance,as repdral by Section
Luh..Code,for the pedodded.ofthe work for which Nis permit is issued. GAS-EA.SYSTEM-1 INC,4 OUTLETS OCC.GROUP APN
Workers ompensationlnsurhnce carrier mW Policy num bear:er: n Lao+s Policy Nm; %51rZ( '�l G. GAS-EA.SYSTEM OVER 4 IRA)
CERTIFlCA'IE OF E% MITION FROM WORKERS'
COMPENSATION INSURANCE ORFASDINDUSTRL WASTE LNIERCLPFOR
BUILDING DIVISION FEES
(This section need not he completed if the permit is for one madned dollars Ht do)
or lese.7 GRF.ASI?TRAP p1,ANCHLCK PGE
I cenifydou in the Ndmin once ofthe work fm whichthis permit is issued,Ishall SEWER-SANITARY-STORM F.A.200 FT.
not employ any person in any manner so as no became subject to Ne Worloi CoriENERGY FEE
Z sauon Laws of California.Data WATER HEATER WNENT/ELECTR
O O Applicant GRADING FEE
h NOTICE TO APPLICANT.If;after making this Cenificme of Exemption,you should WATER SYS'I HMITREATING
abecome sabjec(to the Worker's Compensation provisions of the Labor Gavle,you must SOILS FEE
fJa forthwith comply with such provisions or this permit shell be deemed revoked. WATER SERVICE
Q6.
CONSTRUCTION LENDING ding., Y N[W R[SIIII[NTIAL PCMB. SQ.IT. PAID
VO Ihereby.1hichni ami,
isaconoer.30lendingagenq fonhe performance of Date RaeiptR
the work for which this permit is issucJ(Sec.7097,Civ,CJ
O !-� Lender's Name TOTAL:
os I have Ixnder' Address TOTAL:
certify than 1 he read this application and same that the above information is BUILDING FEE
r0A cooi l agree to comply with all city and county ordinances and state laws telatingm QrpY. MECHANICAL PERMIT FEE
U z building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
shove-mentioned property for inspection purposes.
Oce)agree to save,indenmify and keep harmless the City of Cupertino against PERM ITT ISSUANCE ELECTRIC IT
Ichi titles.judgments,costs and ex,an'es which any in any way accmcr,enm said City gLTHR C3R ADD TO MECIi.
in consequence of the granting of this permit. PLUMBING FEF?
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(701(1,000 CFM)
MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,0011 CFM) CONSTRUCTION TAX
Sigmmum of Applica,dJCmtnwr Mata EXHAUST HOOD(WIDUCD HOUSING MITIGATION FEB
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant once or handle hasardous material HEATING UNIT(TO IN),"BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade.Section n532DD HEATING UNIT(OVER IIX).W(1 BTU)
❑Yes DNn
VENTILATION PAN(SINGLE 813510) PAID Date Retch,u
Will the applicant orants a building by the B use equipment or devices which HOLLER-COMP(7HP OR 1 00,000 BTU)
emit District?
nus air contaminants as deBneJ by the Bay Area Air Quality Management TOTAL:
0islrim?
El yea, 0 N BOILER-COMP(OVER 1010.001)BTU)
I have Won the heamdnus materials requirement under Chapter 6,95 of the Cali- AIRCONDITIONER ISSUANCE DATE
food.Health&Safety Code,Sections 25505,25573 and 25534.1 undemmd that if the NEW RES[DENT'IAL MECH, SQ.14.
building does not currently have it tenant.that it is my responsibility to nerdy the recupem
of the requirements which mum be met prior to issuance of a Certificate of Occupancy.
Owner or amhoriuJ agent Date TOTAL: ISSUED BY:
OFFICE