30265 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL 30265
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BUILDING PROJECT'IDENTIFICATION G J
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
L ve
OW ER'SNAME: PHONE: , CONTRAkTOR'SN\ME: LIC NO:
NIC COM'ROL# -
�ARCHDECT NGINEER: LIC NO: ADDRESS: ❑
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CO ACT: xo E:
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Consultant Fe¢s Paid 6y Applicant(Iniliap BUILDING PERMIT INFO
BLDG IiLECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE - -
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
M�Z with Section9000).1 Di,kion3ol 1MRminaxsand Pnrc,mr,Cm1c.mdmy licemels RESIDENTIAL:
O PERMIT ISSUANCE
F in full Toro,and a eat.
❑SFDWI. ❑�{ITCHEN REMODEL
QZU
Li Class Carl, N
Nab Date Cumrunor APPLIANCES-RESIDENTIAL OADDITION PLUMBING RE-PIPE
ARCI{ITECT'S DECLARAI'[ ❑MULTI-UNIT El STRUCTURAL
ZOOV,z Immrstandmyplans shall ktisedus public¢coals PANELS MODIFICATION
UP TO 20o AMPS
Licensed Professional [I INTERIOR L1 CHIMNEY REPAIR
201-IINXIAMPS IMPROVEMENT
��
OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
6 I hereby rm am mth
that I exept from e Contractors License U.for Ne [I OTHER
�2 O d affi
W 3 U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
2N which requires a ponuil to construct,altor.improve,demolish,or repair any structure
0; primemiuissuance, loirm,no,sthe applicam for such pcm,ino lilcasigneJ stamment SPECIAL CIRCUIPMISC. -
E } that he is licensed pursuanto the provisions of the Comm
rtors License Law(Chapter 9
C4 ro
e'ao (commencing with Section 7000)of Division 3 of the Business and Professions CWe)or TEMP.METER OR POLE I. _ COMMERCIAL'
112 p C that he is exempt therefrom and the basis for the allugcd exernption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
x�r iA Section]031.5 by any applicant for aparmit subjects the applicanun a civil penalty of POWER DEVICES'.
I+f�mthan C3 TENANT ❑FOOD SERVICE
Cydnot mom woe five hundred dollars y camp. IMPROVEMENT
wiLas owner theand propcuctrelnycmntended w offerefrwages as lale(Se .r sole 0,14,Buannar.siness SWIMMING POOL ELECTRIC
SBL 1.. will do late work.ands:The isnotLicense
Law
es rot apply
Business []OTHER
i 3 m and Professions Code:The sthereon,
herContractors License Law does not apply to if owner of OUTLETS-SWITCHES-FI%TU '
property who builds or improves thsuch i and who does such work himself or through
his own cnnplor.the provided intsuchmentis sold ware nmiewof comofferedpletion.
Tic NEW RESIDENTIAL.ELECfR 5 -
mle,lf,howeveoth cvethngorimprovementithathe ithinone ycvbfrompletianlhc SV.FT.FLOOR AREA) - $ISQ.FT.
osuct-tamider will have the buNcn a(prving thm he did not buil)or improve for poli-
[] 1,a,sulc.).
i,ps owner of the(Sm.
.Business
s and Professions with I The C ntracttorss i- TOTAi.. JUL 2 4 1996
construct the project(Sec.o an Business and Professions Code:)The Contractors nd
cense Lawdoes not apply man with
arofpmpeny who
sedQorimprothe Contra,orJ QTY. PLUMBING PERMIT PEE p
whoa,Lacm for such projects with vamtrndor(s)licenced pursuant to the Contractor's E1TY Uf UW L— II INO
C] Ism Law. ! PERMIT ISSUANCii
lam exempt under Sea ,B&PCfor this reason
Owner Dam ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROITCf.DEVICE
I hereby official under penalty of Perjury one of the following declarations:
•❑I have and will maintain a Certificate of Conserv to self-insure for Worker's Comp,n- DRAINS-FLOOR,ROOF,AREA,COND. STORIES 'TYPE CONSTRUCTION
nation,as provided for by Section 3900 of the Labor Cade.for the jrerfonwnce of the
work for which this fail is issued. FIXTURES-PER TRAP
C] 1 have and will maintain Worker's Compenm oro Insurance,as required by Section -
37Ww the Labor Code,for the performancrof the work for oHvhlhlspemtit is issued, GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
MY Workers Com ctsatinn in c -Bier nd Polity nuinhr 'r-
Canicr.} CRTIfj TF.OPEXEMY ION FROM WONT WO tK'@� GAS-EA.SYSTChLOVER41[A)
<l�`O•rCUhBCOMPENSATION INSURANCE GREASIVINDUSTRI.WASTE INTERCEYIDR
('fnT2cd nm be mr.,lned if the pqm,it is mei ne hundred dollars($1(o) BUILDING DIVISION PIifS
or less) GREASE TRAP PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued.I shall SEWER-SANITARY-STORM EA.gal FT.
" nal ainploy any pe,an in anymmn¢ u
sec uv es becion, imjeen the Worked Compen- ENERGY FEE
zZ cation Laws of California.Date WATER HEATERW'/VENT/ELECIR
Applicant GRADING IEE
y NOTICE TO APPLICANT:If,afmrmaking this Certificate of Exemption,you should WATER SYSTEM/TREATING
become object 1. he Worked,Cnn, lion sinal of the i.ahor Code, t SOILS PER
w p acts provi you roar r >'
foMwith comply with such provisions actinic pe,mil shall be deemed revokW. � WATER SERVICE
Q
7 Z - CONSTRUCTION LENDING AGENCY NEW RLSIDENTIAL PLMB, SQ.FT. PAID
U 0 I hereby iffrmthanhem is asmawnionlending agency for lwrform;mca of Date Receipt#
f-' the work for which this permit is issued(Sea3090.Civ.C.) -
Q U Lenders Name TOTAL:
Isnder s Address IOTA[
�' 1 1 ratify that I have read this application and ,are that the vrve in&nmmlon is BUILDING FEE
M
F lin comet.l agree mcompiy with all city and county ordinances anlwate laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby aummize representatives of this city m enter upon the SEISMIC FEE
a1mve-n,cmioned property for inspection purposes. . .
(We)agree it)save,indemnify and keep h:unless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
iiubdries,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in asequence of the granting of,his pcool. PLUMBING EEE 19�
APPLICANT UNDERSTANDS AK)WILL COMPLY WITH ALL NON-POINT AIRHANDLING UNITOO I0.00PCFMI
'R EGUf NS. MiiCHANICAL FEE
AIR HANDLING UNIT(OVER to."CFM)A 6A kr
CONSTRUCTION TAX
Signa f pp, o fm1u, Dan EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE -
' Willtheapplicem or furors building mairpawmineor handle hrzallous material HEATING UNIT(TO 100,068 BTU)
as defined by,he Cuponino Municipal Calc.Chapter 9.12,;rod the Health and Safely
Cade,Section 255321x1^ HEATING UNIT(OVER I(X)JXX)BTU)
❑Yea 0 N PAID
VENTILATION PAN(SINGLE RESID) Dat, Receipt#
Will the applicant or Lane building occupant use equipment or devices which -
emirhmarduusaircommitmentsasdefinedbvtheBayAreaAirQualityManagement BOILER-COMP(3HP OR 100,000 B IOf
OTAL:
District? - I O/
20
❑Yes Fl No BOILER-COMP(OVER Ilk."BTU)
I have read the bromadaus materials requirernems under Chapter 6.95 of tine Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 2554.1 understand the it the NEN'RESIDENTIAL MECH. SQ.PT.
building does not currently have a tenant,that it is my res,torobility to notify the occupant
,if da,r yuimments which must be ret pnnr m i...ance of a Ccnifirnm.10...pancy. -
Owner or authorized agenl - Dam I TOTAL: ISSUEDBY: eezfve�_
OFFICE