30963 APPLICill FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY.OFCUPERTINO • : ,' BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 30963
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS, _ SANITARY NO. APPLICATION SUBMITTAL DATE
loolo cittRM&N RC> • �"`� M
OWNER'S NAME, PHONE: CONTRACTOR'S NAME: LIC NO: T 1
TO Ilr
NIC CONTROL R .
AR HITECT/EIJGINEER: LIC NO: ADDRESS: ❑
6 C rAL. S 3
CDNTALT./ PHONE: - BUILD C PERMIT INFO
�EZ/'t `t T 3,��P F1 Qt1'3 ❑ CDpgW/anl Fees Paid 6y Applicant BLDG . EL- E'CT PLUMB MF.CH
LICENSED CONTRA R'S DECLARATION 1wG QTY. ELECTRIC PERMIT FEB `sL'`{••••
O W,Z, 1 hereby from thin 1 ma licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Iy with Sectiom7000)of Division 3ofihe Buune....d Pmfeashma Cnde.mall licameie
WOO
r in full forte and effect. PERMIT ISSUANCE�F.,UZU License Class - Lic,N WL C KITCHEN REMODEL
NQ4 Date Commcmr - APPLIANCES-RESIDENTIAL'. - ADDITION C1 PLUMBING RE-PIPE
F.7os ARCHITECTS DECLARATION - ❑STRUCTURAL
Zpy 7a Iunderstand my plain,Shull he mattes publio moods PANF;LS CMULT6UNIT
O Z..Q UP Tn 2tX1AMPS MODIFICATION
F4 Licensed Professional El INTERIOR ❑CHIMNEY REPAIR
'Jy3' OWNER-BUILDER DECLARATION 201-I1100AMP5 IMPROVEMENT
WOW 1 hereby affirm that 1 am exempt from the Commctor's License Law for the" OVER 1000 AMPS _ C BATH REMODEL REPAIR C DEMOLITION
34U following reason.(Section 70315.Businessland Professions Cole:Any city or county SIGNS ELECTRICAL ❑OTHER
F. C[:-��i which requires a permit to consuua,alter,improve,demolish,or repair any swcture
prior to its i11timae.vlsorequiiaa theapplicimt for such pmmifto,fileaoIned smmment SPECI AL CIRCUIT)MISC.
C,•i<� that he is licensed pursoanl 10 the Provisions M mr
the Conloc 's License Law(Chnpler9
sR ,00 (commencing with Section LXp)of Division 3 of the Business and Professions Cock)or TEMP.METER OR POLE INST. COMMFR IA '
4p m y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
,aq rn Section 7031.5 byany applicant for a Permit.Subjects the applicant a civil penalty of POWER DEVICES ❑NEW SLUG/ADDITION El DEMOLITION
FF. Y not more than five hundred dollms(5500). []TENANT ❑FOOD SERVICE
QC1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the stmmuic is not im6clad oroffered frireale(Sec.7044,Business C OTHER
3 end Potassiums Cuda:The Crintmcmrs License Law does not vpply m an owner M OUTLETS-SWITCHES-FIXTURES
Prapeny,who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended cr offered for NEW RESIDENTIAL RLECTR SQ IT
Sale:If,however,the building or improvement is sold withtio
in one year ofcompien.the ,SQoFT.FLUOR LSQ.FT.
owner builder will have the burden of proving that he did not build or improve for pun
as owner of the property,am eulusively curtaining with licensed cnmmcmn to 2
nstnlet the project(Sec.7044.Business and Professiao Code:)The Contractors LI
-
LawdoesnotapplytoSoOwnerofpropartyy who builds-1 noproves the...0,and QTY PLUMBING PERMIT FEE �`Ly
who contracts for such projects with a commacmr(s)IicenwJ pursuant to the Cono-actnr's• \
License low. 1'
❑1 sonexempt under Sec. ,B&P reawPERMITISSUANCE'C for this d -
Own US ALTER-DRAIN&VENT-WATER(E,O VALUATION
WORKER'S COMPENSATION DECLARATION T�r�µ BACK FLAW PRtyfECE DEVICE -`
(] Iherebyeffirm under Penahy of perjury one of the following Jed...I.,: _ U t'
Ihave and will maintain a CertificntaofConsent m self-insman forworker's Catalina- DRAINS-FLOOR,ROOF AREA,COND.
smion,as Provided for by Section 37M of to labor Code,for the Performance of the STORI TYPE CONSTRUCTION
work for which this Permit is issued. FIXTURES-PER TRAP
C I have and will maintain Worker's Compensation Insurance,as retained by Section _
37M of the Later Code,for the performance,
the work for which this permit is issued. GAS-EA.SYSTEM-I INC.40UTLETS OCC.GROUP
My Workers ComPensntim Insumnce comer and Policy numhcr are: APN
Cartier: Policy No.: GAS-EA,SYSTEM-OVER 4IRA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASErINUUSTRL WASTE INTERCEPTOR -
(Thiasaetirinnced not be completed if he permit is for Onehmomedd.11MO SIah) I IN IVISIONFP.IS
or less.) GREASE TRAP
I certify that in the rfo.....Ithe work for which this PLANCHE FE r.
not employ an Permit is cd,ishull SEWER-SANITARY-STORM EA.200 Ff.
p y y person in any manner so as m heroine suhjun to the Workeri Cnmpcm ENERGY
Z
Applicant
I.S.of Celifiimie.Date WATER HEATER WNENT/ELECTR
0 Applicant - GRADING FEE
ay NOTICE TO'pPo the ANT.Work ra suer ranking this Certificate for Exemption,you should
; M1erome subject y it Worker para CompensationsProvisions of Ne Lobar Cole,you must WATER SYSTEMITREATING SOILS FEE
D�1at t.
forthwith comply with such provisions or this Permit shell be deemed rtwkN. WATER SERVICE
r7zCONSTRULTION LENDING AGENCY NEW RESIDENTIAL PLMB. - SQ.FT. PAID
L)0 I herebyafftrm that Nen,iso cnnstrradma lending agency fmthe perfxtram of Data eceiptM
E-t the work for which this permit is issued(Sec.3097,Civ.C.)
0 Lender's Nume
V landerx Address TOTAL:
I certify that 1 have read this o f,ticmbm and smm that the above information is BUILUIN FEE
V) cmrcct l agree m comply with all city and county ordinances and state laws relating tit QTY. MECHANICAL PERMIT PEE
Ll building conswctinn,and hen,byauNorio reprcsenmtives of Nis city to cmerupon the
SEISMI
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harvi the City of Cupertino against PERMIT ISSUANCE ELECTR -
Iiabilities,judgments,crisis and expenses which may in any way narrow against said City ALTER OR ADD TO MECH.
in consequence of the gaming of this permit. PLUMBING E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL •E
AIR HANDLING UNIT(OVER IR00gl CFM) CONSTRUCTION X
Signature of Applicum/Comructor - Data EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION ME
Will Neapplicanmr future building recupsom stare orhamdle hazardous mamdul HEATING UNIT(TO IOLOOR BTU) _
or,defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code.Section 25532(a)? HEATING UNIT(OVER 100,000BTU) %
❑Yes No x -
VENTILATION FAN(SINGLE RF.SID) PAID
IIIVVV
Will the applicant or future building occupant use equipment or devices which _ Data e' t
emit hcandous air contaminanu as defined by the Bay Arca Air Quality Management BOILER-COMPUHPOR 100,000BTU)
District? _ TOTAL:
❑Yee No BOILER-COM P(OVER 1100,0110 BTU)
I have read the hreadous nomiials requirements under Chapter 6.95 of the Codi- AIR CONDITIONER ISSUA
ford.Health&Safety Code,Sections 25505,25533 and 25534.1 undersand that if the
building does not currently havenmwn,Nat it is my responsibilitymnotfy the occupant NEW RESIDENTIAL MECH. SQ.FT. '
of the requiremema which must be met Prior to issuance of.Cennicam of Occupancy, -
Owneroauthrirrzed agent pate T
ISSUED BY:
OFFICE