30188 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES—USE BALL POINT PEN ONLY -
CITYOFCUPERTINO - .. • . ,J' ,- BUILDING-ELECTRICAL p d PERMIT NO. VK0188
3 q oQ
5 BUILDING DIVISION l APPLICATION/PERMIT PLUMBING-MECHANICAL
�J/-$� {�J g�I BUILDING PROJECT IDENTIFICATION ^
BU�N�Or. EV /J'V f .,..
e+• SANITARY NO. APPLICATION SUBMITTAL DATE
C %0t0 V/�w CI rLC� Gu PC2Ti�rl O � �
OWF7�L.S pM� PHO B_D 0O fRACNAME:
N/C CONTROLa,
'A HI /ENOL EER:' �" - 3LIC N0: �-� ���- ���..�. Q. . ( ❑ p1 ��_ •
CONTACT. '- '. - - � qw ����� BUILDING PERMIT INFO
�O�J I ❑ Consultant Fees Paid by Applicant ELECT a PLUMB'A MECH
Y(/ LVE .❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY f ELECTRIC"PERM IT FEE -
I hereby affirm that 1 am licanI under provisions of Chapter 9(commencing JOB DESCRIPTION'
�QZ ith Suhon]000)ofD" ' 3 fere Busi- nd Professors Ciuleandmylicense is -
Fa Ver full force and cff Jam/ �j PERMIT ISSUANCE WL DENIIAL
El KITCHEN REMODEL
QF U U License Clay Llc.W / •••7 - -
WGG UateCnnlrucmi APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
L. 17 0
Dan ARCHITECTS D LARATION s ❑MULTI-UNLT'� ❑STRUCTURAL
I un d Ian all d ublic recoMa PANELS
Z O n Y - MODIFICATION
OZ'-O - - UPT02IX1AMp5 '• ❑INTERIOR C1 CHIMNEY REPAIR
� Loensed Prof o a AMP
i;." - 201-IOMAMPS - IMPROVEMENT- +
IR,
OWNER BUILDER CLARATION 1100 S ❑BATH REMODEUREPA [IDEMOLITION
yy 1 rely affirm that I am exempt fromm the Contractors License Law for the OVER 1
p(3 d F 'following reason (Section](131 5,Business and Professions Cade Any otty ar county SIGNS ELECTRICAL v v❑OTHER
unit alt pme which requires a permit to t i r improve diminish, p an,.wcture
h.] prior to its'issuance,alsomquires the pp1 and for such Permit to file a signed.tatement SPECIAL CIRCUIT/MIsc
} tet he is liversadp 10 he pooisims ofihe Contractors License L (Chprer9
q0 (commencing witSection 7000)ofDivision 3 of the Business andP [ Code)or • THMP METER OR POLE INST. COMMERCIAL:
Ihut he is exempt theratiournu d me has s for the alleged ascouplim.A y1 tion of NEW BLDG/ADDITION' 0 DEMOLITION,
aC {c
Section 7031.5 by y applicant for Permit subjects the applicant t c 1 mN p nsay id POWER DEVICES 0 TENANT �FOOD SERVICE
{u nal oref h dreddelWra($5(q) IMPROVEMENT
.
60 ❑'Ia ere of me popery,or my employees with wages as their le compensation,• SWIMMING POOL.ELECTRIC
will do the work,and the amoure is not intended orefferod fors I (Sec 7044 Business 'E]OTHER
" and Professionals Code The Cannes ors License Law does not apply to an owner of OUTLETS-,SWITCHES MXT ES
propeny who bo Ids or improves thereon,and who does such tinhimself or trough — -
' his own employees,provided that such improvements are not intsonded'oi offered for NEW RESIDENTIAL ELECTR SQ FT
safe.If,however the building or improvement is sold winter are'a a'ofbemplehon,the SQ.FT.FLOOR'AREAP) .$/SQ.FII
owner-builder will have the burden of proving tat he did not build or improve for Aur-• 'L
pose of estener - - 5 1996
❑ 1.as owner of the propeny,+am exclusively contracting wit licensed contractors to T -SEP- constmct n p Jui(Su 9044 Busntese end Professions Code)The Conmecror s Li- r
cense Law does not apply to an owner of propeny who builds m improves tenon,end QTY, PLUMBING PERM E t -
whden[riers for such projects with'a cmumatoredlcensed pcommne the Confessor's ,fF �'�� ,,tidYCfil1ik41
.,.t License Law. PERMIT ISSUANCE
0 I am exempt uMei Sec. ,B&P C for this reason
Owner Data
ALTER-DRAIN le VENT-WATER(EA) 1 i VALUATION -
WORKER'SCOMPENSATION DECLARATION ^ BACK FLOW PROTECT.DEVICE s'
I hereby affirm under penally of perjury one of the following declarations:" u
Kr
and will maintain a Certificate of Consent self-insure for Workers Compeer-' DRAINS-FLOOR;ROOF,AREA,GQND. STORIES' TYPE CONSTRUCTION,
set n,as provided for by Section 37W of the Labor Code,far the performance of to - _
work for which this pemdi is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section a
3700efne Lahor Crde,teethe performance of the work for which this permit is issued GASB EA.SYSTEM-]INC.4 GO METS -
My �u1 yIy' OCC.GROUP APN
Carrier.
Com< Policy No. WO snu'7" GAS-.EA.SYSTEM-OVER'4(EA) - 1' •i,'I
ER 1 AT OFE PITON PRO - +
COMPENSATION INSURANCE GREASF/INDUSTRL WASTE INTERCEPIORs BUILDING UIVISI 'FRES
or lass.) is.ectonneed not be completed lfte pefmftis foeoae hundred dollars($10(d) GREASE TRAP
1 nifythat inthe perfimmuceofthe•wofkfor which this permitisissued,Idall PLANCHECKFEE Q'
not employ any Person in an manner so as to become subject o the Workers Com SEWER-SANITARY-STORM EA.200 FT.
P Y Y pen- - ENERGY FEE
,7s sution l.uws of California.Data
0 - ,., WATER HEATER WNENT/ELECTR - -
O Applicant 'GRADING PEE
y' NOTICE TO APPLICANT If after makingCompensation
this C provisions
sof Labor lode,you
WATER SYSTEM?REATING
become salted to the Workers Compensat o p visions of n Labor Code,you mustSOILS FEE
WFr forthwith comply wnh such provisions err Ili p 't hall bed d ked, WATER SERVICE
1 CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMW I SQ ET. PAID"
I hereby affirm that them is acoustmctmn lending agency for the perfarearomid _ Date Receipt M'
W
the work for which this puma is Issued(Sec 3097Civ C) + _
TOTAL
Lender s No,W Lenders Address / •- sTOTpL: •
R1 I candy that I havevde th s application and scam that the above informationFE
is s_ - BUILDING E �•,:
to sumac[I agree m comply with all city and county endurances d state I relating to QTy.. MECHANICAL PERMIT FEE,
V_`z building construction,Find hereby authorize representatives of this city to enter upon the SEISMIC FEE ' d
above-mentioned property for inspection purposes. PERMIT ISSUANCE. _ f
(We)agree costive.indemnify and keep harmless to City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in anyway norms against said City,
onsequence of the granting of this pem+it.`" ALTER OR ADD TO MECH. PLUMBING FE - s -
APPLIC NDERSTA SAND WA COMPLY WITH ALL NON-POINT AIR HANDLING UNIT DO 10,(100 CFM)
SOUR RELATION /� _ - MECHANICA FEE s x
AIR HANDLING UNIT(OVER 90,000 CFM)
CONSTRUCTI ETAS
Sign am"FP....... onuacor' Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MI GATION FEE
Will theapplicantorfooe building oampiumsmmor handle h'azardiummaterial HEATING UNIT(TO 100,000 BTU) - -
as defined by the Cupertino Municipal Code„Chapter 9.12,and the Health and Safety '
Code.Section 25532(¢)] ' i HEAeas
TING UNIT(OVER 100,000 BTU) i)
+ ❑Y []Nos sxssx
VENTILATION FAN(SINGLE RESIU' PAID
�1r Will ere applicant or future building receptor use equipment devices which - Date✓ Rimi k r
craft instance., coeramnrnt as defined by the Bay Area Air Quality Management BOILER-COME(3HP OR Iffli”BTU)
Drstnd]
Fl Yes ❑NO
BOILER-COME(OVER 100,000 BTU) •
- . a:..
I have mall the hazardous materialsrequirementsAIR CONDITIONER. ISSUANCE AT
,2553and 2 �Chapter rstand Put
Call- -'
forma Healer&Safety Code,Semmes 8505,26533 and 8534,I understand thm if the 4:
NEW RESIDENTIAL MECH. SQ.PI'.'
building does not conen0y have nfactor,tat it is my responsibility mmri(y to occupant,
- of ere requimmen¢which muss be,met prionoissu�nce ofe Certificate of Occupancy.' S' k�
Owner oreutmrizeJ agent - Date .TOTAL: ISSUEDBY1
F OFFICE