30985 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN,ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING s MECHANICAL - 30985,
BUILDING PROJECT IDENTIFICATION
BUILDN�DRESSi SANITARY NO. A-P^P/LLICATION SUBMITPALDATE
yr Umfr
OWNER S NAME: - PHONE:
S N/C CONTROL#
.,ARCHITECT/ENGINEER: LIC NO:
I,/Y9p S ,O , ,IVN•AVLAVO "V6` ZA ❑
CONTACT: PHONE: o 'BUILDING PERMIT INFO
•❑ Consultant Fees Paid by Applicant(Initial) BLDGLECT PLUMB Saint
El El 1:1
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 herchy amirm that I ado liaenaed ander provisions o[Clmper 9(eodomoncing JOB DESCRIPTION
00 with Section 9000loflamocn 3oftha Bnsiness and Professions Code,vnd toIicem.ii,
f-,acr in full fnrceandeffed. y PERMIT ISSUANCE RESIDENTIAL:'
�UU License Clara, Lia.# - CSFDWL C KITCHEN REMODEL
Nd,a Dam Contractor APPLIANCES-RESIDENTIAL. ❑ADDITION C PLUMBING RE-PIPE
ARCHITECT'S DECLARATION- PANEI.S-
6.7y - MULTI-UNIT OMOD119 ATIO
RAL
Zpy� PnnJerstnnd my pleas shvli be used as public recoils 0 MODII'ICATION
Oka ❑
UPT0200 AMPS
r ❑INTERIOR CHIMNEY REPAIR
he 'Q Licensed Pefidaddnal 201-1000AMPS - IMPROVEMENT
OWNER-BUILDERDECLARATION C OVER I"AMPS Q 1 hereby affirm that 1 am exempt from the Contractor's License Law for the C BATH REMODEUREPAIR C DEMOLITION
7ry5, p.U fallowing reason.(Section 7031.5,Business and Professions Code:Any city or coumy SIGNS ELECTRICAL C OTHER
a131:•F which requires a Permit m construct,chat,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant far such Permit to file a signed statement -
ta SPECIAL CIRCU117MISC, '
y
thin he licensedwith pursuant the previsions of Contractors omac Law(Chapter Codter9
� A a
(commutator,em with Barroom
9W d e t...for f rit ss v ha Profession,Ctd n or TEMP.METER OR POLE INST. COMMERCIAL
L c y that he pt mercf n a d the ba:is f the _ xen pt Any 'oration of E:1 NEW BLDG/ADDITION O DEMOLITION
ed Section 7031"5 by any appawart for.permit object, it ppli t to.<v'1 penalty of POWER DEVICES
y, not more than five hundred dollars($500)" - C TENANT C FOOD SERVICE
H d I,as owner of the norm cm to eea with wv es es their sale cora cnsmion. SWIMMING POOL ELECTRIC IMPROVEMENT'
� C ProPe Y Y P Y g P
'll do the work,and the staid re Isiah intended oroffesed for sale(Sea 7044,Business COFFEE
LL1"•� and Professions Cade:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES .f
property who builds or improves thereon,and who does such work himself or through
his own employees,pmvded that such irepFrvements dm not intended x offered for NEW RESIDENTIAL ELECfR SQ FT. -
crELIf,however,the building or imp rovemer,iesold within oneyamcfeurdectiomthe - SQ.IT.FLOOR AR[ p 1 $ISQ,UP
owner-builder will base the buden of prIdiom oving that he build or improve for par- W
pose of sale.).
I,as ownerof the mercury,nm exclusively Imamading with licfetsed ca madom to TO onlE8
stect the projettec
(S .7044,Business and Professions Code:)The Contractor's In- I'' I I1
cruise Law doe,ma.pply to anownerafpnpeny who builds odmpowes the.eon,and QTY. PLUMBING PERMIT FEE - !'� i7 (�
who contracts far such projects with a eomu
raer.,(,)licensed pursuant theC,mmw,tT, C17Y L
License Law. PERMIT ISSUANCE41 -s
❑ 1 vat exempt under Sec. B&P C for this reason -NO
Owner Date - - ALTER-DRAIN&VENT-WATER(TOO v - VALUATION t
' WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE '
1 hereby affirm ander penalty of perjury one of the following declarations
C lhnveaal will maintain aCenifenmofConsem toself-insorc for Wilkes Compan- DRAINS-FLOOR,ROOF,AREA,CON..
soman,has rich provided for uSection 3700 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
wo
r or whthis permin t is issued. FIXTURES-PER TRAP
1 have secs will maintain Workers Commensation lusurance,as re0nired by Semina "
Ill of the Labor Code.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.40UTLETS - OCC.GROUP ARK
My Worker's(Atrt�t�n alns..ad,,carriwund Policy u -
Carrier: CiiV Policy No.: r ^ AS-EA.SYSTEM OVER 4 RA)
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(Em"oetion need mplemd if the permit is fomne hundred Jollvrs(8100) OREASETRAP
'O le".) '
PLANCHECK PEE
Icervi alio the nee of e w fi aWeak rs'C mwe_ -
nm empl any person in yo'u �eWnrkern'CoIshall
mpeo- SEWER-SANITARY-STORM EA.2(1(1 FT. ENERGY FEE '
QZ sauna L wsof CuIifor U WATER HEATER WNENTIELF.CTR
Q
ApplicantGRADING FEE
NOTICE TO AT :If,after docking this Cenificam of Exeralnou,you should WATER SYSTEMITREATING
become mind the Worker',Compensation previsions III the Latah Code,yeti must SOILS FEE " -
forthwitha y with such provisions or this punct shall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION
munism LENDING AGENCY NEW RESIDENTIAL PLMH. SQ,PT. PAID
V l for
rwhichirm that there isace (Seeti0lending agency fiance performance of - Use Receipt#
�, t+ the work[or which this permit is issued(Sec 3097,Civ,CJ -
0 !'i .Tenches Name - TOTAL:
LeodatAddress " TOTAL:
I -
Iy anify that I have read this application and state that the above information is BUILDING NEC
cn7 correct l agreem comply with all city and county odinancesand state laws relating to QTY MECHANICAL PERMIT FEE
UG hiildingconstondimandhereby ecu SEISMICFEE
above-ment....adp,.pmy ,I'm Zee,
PERMIT ISSUANCE
(We)agree to ,indemnify it keep e s the City' of Cupertino against ELECTRIC PEE
1 ahiIIa,"ad s,ecrosande, se,-w ' may' a against said City ALTER OR ADD TO MECH. PLUMBING FEE
in e ofares,aining thivp it. '
APPnh ANT UNDERST WILL MPLY 14ALLN0 -POI AIR HANDLING UNIT(TO 10,000 CPM)
S( RCE REGULATT MECHANICAL FEF.
C
- r AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signature of V nnlmdor Ila EXHAUST FOOD(W/DUCT) HOUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE:
the applicant or future hadding oecupant,ton,or handle hamrdous ramenai HEATING UNIT(TO 100,000 BTU) •
as de ed by the Cupenina Municipal Cade Chumter 9.12,and the Health and Safety
Code,Section 25532(n)? HEATING UNIT(OVER 110,000 BTU)
❑Yes o PAID
VENTILATION PAN(SINGLE RESID)' Umr Receipt#
Will the applic or fmure building occupant use equipment or device which' BOILER-COMP(3HP OR 100,000 BTU)
emit hazardous air a taminants vs defined by the Bay Area Air Qmdity Management
4,District? TOTAL:
. E]Yes o BOILER-COMP(OVER 100,000 BTU)
Ihavereadthe In nous ramal.,requirements under Chapter 6.95 of the Cali- 'AIR CONDITIONER ISSUANCE DA
From Health&Safet oda,Sections 25505,25533 and 25534.Iundersand that If the NCW RBSIDBNTIAI.MECH. SQ.PI'.
buhding does not currently haven tenant,that it is my responsibility m no0fy the occupant _
of the reuirements which must be met polar to issuance of e C nific to of 0ocupancy. ,
Owner or bothonzed agum Data TOTAL: ISSUED BY: ^
OFFICE'