30216 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL ,PERMIT NO. 30216
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL' ' -
ti BUILDING PROJECT IDENTIFICATION
BUILDINGADDRF,SS: s SANITARY NO'. APPLICATION SUBMITTAL DATE
OWNER'SN ME: s PHONE: �/- /( CONTR Cfq\i'gfNAM` 1�LIC/p�'0 ,1 �
�— JLAO%if) 0-Al
I. D�V ✓" r KIpS-WY N/C - eI1\ CONTROI\LX
ARCHITECT/ENGINE'R:• LICNO: ADDRE : ❑ (Q11 /y/7
Y E
CONTACT.
PHONE: BUILDING PERMIT INFO
r�\ ���� ❑ Consultant Fees paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR DECLARATION QTY ELECTRIC PERMIT FEE 47_ I��ij
I hereby affirm that 1 am licensed under Provisions of Chapter 9(commencing JOB DESCRIPTION
WOZ with Sation700kdafDiviuon3m B sinessare Profce,iuns Code,mon license is
I0.-OO in full Totes and ) PERMIT ISSUANCE R T
141- ef� )WL ❑JAL-
KITCHEN REMODEL
G U U License Class Lie.X --
9zW Date Contractor APPLIANCES-RESIDENTIAL ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTIUNIT []STRUCTURAL
Z O rN I DOO understand my plans shall be used as public records PANELS MODIFICATION
OZ- UP TO 20OAMP5
F F`W Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
CYC; OWNER-BUILDER DECLARATION 201-IOW AMPS IMPROVEMENT
C Q I hereby affirm that 1 um exempt feta she Contractors License Law for the OVER IOW AMPS ❑BATH RF.MODEUREPAIR [I DEMOLITION
c,,<
U following teas...(Section 7031.5.Bu iness and Professions Code:Any city m mumy SIGNS ELECTRICAL C3OT'HBR
LL m which requires a permit to construct,alto,.improve,demolish,nr.,.it any fracture
NO; prior to its issuance,also requires the applicant for such pcmiuotile a.signed statement SPECIAL CIRCUIT/MISC.
Fly that he is licensed pursuant o the provisions of the Convenors License Law(Chapter 9
(commencing with Section 70O)of Division 3of the Business and Professions Codm)or TEMP.METER OR POLE INST. - COMMERCIAL:
d 0.chat he is exempt therefrom and the basis for the alleged exemption.Any violation of [INEW RLDG/ADDITION ElDEMOLITION
XI ff Section 7031.5 by any applicant for a permit subjcd%the applicant o a civil penalty of POWER DEVICES
ul"o ❑TENANT ❑FOOD SERVICE,
nm mme than five hundreddollars($500). -
9SD El Las owner of the proper,, y splay 'IIwages as theirpension. SWIMMING POOL ELECTRIC IMPROVEMENT
ka will do thework.mol the.t t ":nlmr• led If J hnrl (Sc tuu9194,Bv ❑0'THER
W IWw aadProfessions CJ ❑ C( fouror,1. Law 1 : apIplyt uowner of OUTLETS-SWITCHES-FIXTURES
0'3r property who builds or approves Ihereon,
and who does.suh k h' If or through
his own employu_v,It..sood Nm...hlalpmvemente are not intended or olfcrod far NEW RESIDENTIAL ELECI'R SQ FT,
sale.If,however,the building or improvement is sold within one yeurofcomplcdon,Ne SQ.IT.FLOOR AREA $/SQ.FT
rte bile 'lIM1 e h burden fp gIM1'tI JJ h IJ p I per t 3` 2
pose - I ) - f((}T\TVI\
❑ 1.as ownerf the"pent I IY contracting with licensed ut act : n T
construct the pociect S 7044 Business d Professions Cade:)The Contractor's Li-
cause Law does hot apply to an owner ol p Arty who builds or improves theren and QTY. PLUMBING PERMIT FEE L
whocommew for suchprojects with a contras gs)Icensed Initiation 1the C vxnas
License L PERMIT ISSUANCE �!
❑ I am exempt under Sec re
B&P C lot this ason
OO Date ALTER-DRAIN&VE WAT,R IEA) A t VALUATION
�`wner WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.WCE � 1 167(01-1-�X��
1 hereby affirm under Penalty of Perjury one of she following declarations: `
❑I have and will maintain a Certificate of Consenuo self-insum for W'orker's Compen- DRAINS,-FLOG ,R .AR ND. T IF TYPE CONSTRUCTION
setion,as provided for by Section 37M of the Labor Code,for she performance of she A U U �41996
work for which this permit is issued. FIXTURES-P TRA
0 1 have and will maintain Worker's Compensaion Insurance,as requiral by Section
37M of the labor Code.for the performance afthe work for which this permit is issmcd. G)S-ANST nAC.4 OUTLETS kAI I IOCC:GROUP:t11Hs. - APN
My Worker's Compton a on lienee earner and Policy number art:
Cartier: Policy No, -EA. T M-OVER 4BEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .A U TRL WASTE INTERCEPTOR
BUILDING IVISION FEES
(This section need not be completed ifthe Permit is fgone hundred dollors(SIM) GREASETRAP
or It I PLANCHECK ITS LOU
E/X
I certify that in the performance ofshe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any Person in any manner so as to become subject o the Wmkeri Compen- ENERGY PEE
ZZ ..tion Lawsof California.Date WATER HEATER WNENTMLECTR
Applicant GRADING FEE
NOTICE TO APPLICANT IL after making Nis Caron iena of Exemption,you should WATER SYSTEMTREATING SOILS FEE
> become subject to the Worker's Compensation provisions of the labor Code,you muss
forthwith comply withsuch provisions or this permit shall be deemed revoked. WATER SERVICE ,
0.
UO
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.IT, PAID Dote Recei X
1 hereby ich thi thauhon is a ed((See 3g lending agency lin she performance(if
she work for which this permit is issued(Sec.3!X17,Civ.CJ 1
C) U Lender's Name _ TAC:
Lend Addra1
Pi h certify that I hmad tI Ipl 1ion tand state that thMeal aeon is. BUILDING FEE y
CZ) care's I g l000mpy ilh.II ity d ty Iunce,a 1 state r-aclula,m QTY MECHANICAL PERM IT FEE O
) Z building mtmuon andhrmynthtraerepresentatives tr h 'city enter upon the SEISMICIEH t
shove-mentioned pmporty fur mP.,tiun purposes. PERMIT ISSUANCE
(We)agree to save,indcmnify:md keep haute.,,the City of Cupertino against K ELECTRIC Fill. ,
Iiabifi jdg ms,cros: d pnseswh' hn:ryinunywuy .giin.asaid Chy ALT ER OR ADD TO MECH. `
in y lithe gr t g fthis peons PLUMIIINOP t O
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AI R HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECfiANiCA. 'E ll
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUMONTAX
Signature of AppllcantlConranor - Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION TE
HAZARDOUS MATERIALS DISCLOSURE -
Will Ncapplicamm forum buildogneV....tsmoe or handle lecardous meenal HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)'l HEATING UNIT(OVER 100.000 BTU)
E]yes ❑Nu ` VENTILATION FAN(SINGLE RESHn PAID
Date Rcc'u'd
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by she Bay Area Air Quality Management BOILER-COMP QHP OR I00.000 BTU) TOTAL
DnMCC
100,000BOILER-COMP(OVER I00, 0 BTU)
❑Yes
I have and the meniscus materials requirements under Chapter 695 of she Cali- AIR CONDITIONER ISSUANCE DATE
Union Health&Safety Cade.Stations 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
buildingdces nm currently have a tenant Nat is tinny responsibility m notify Ne acupanr
mf the""unseen s which most be cost pour rt icmunce of a Certificate mOccupancy.
Owner or aushonud agent Date ISSUED BY.
OFFICE