30281 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 30281
BUILDING PROJECT IDENTIFICATION -
ILDING DDRFSS: - - - SANITARY NO, APPLICAd ION SUBMITTAL DATE
NRIi'S�YIj�� �! PHONE:,, ) •�y Cfo 'S
LIC rvo:
^S• a/4/ 8 NIC LUN I,tOLq
ARCIT C`DENGINEER: LIC NO: ADD ESS: U �� S C� ❑
Co�✓NTACT: �UUr`JJ��D'�+� ✓ PHONE: - S BUILDING PERMIT INFO
G�fiiG�G GuNr(1/�Yo �p ❑ Consultant Fees Paid by Applicant(Initial) BLDG EL_ ECC PLU jB MECH
LICENSED CONTRACTOR'S DECLARATI 'ZW QTY. ELECTRIC PERMIT FEE
I hereby affirm Nat 1 am IicenxJ under provisions of Chap 9(commencing JOB DESCRIPTION
O�Z with Section 7000)of Division 3 ofthe Business and fessions Code,a m license is
I y PERMIT ISSUANCE RESIDENTIAL,
W 1.full force I
�F.VV Liccuse Cln Lic.p ❑SFDWf. ❑KITCHEN REMODEL
N<S Date Cnmructnr APPLIANCES-RESIDENTIAL. ❑ADDITION El PLUMBING RE-PIPE
I„ RCHITECFS DECLA ION PANELS -' El MULTI-UNIT ❑STRUCTURAL.
Z C n Z I understand my plans shall be used as public records MODIFICATION
-CZ—O UPTO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
cueid Promaximnel - 201-IIX)AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION VER HardAMPS .❑BATH RHMODEI/REPAIR 0DEMOLITION
aY
LC K 6 1 hereby affirm Nat I am exempt fns
from the Curtrai Licee Law for the
ad a 4 V following reason.(Section 7031.5.Business and Professions Code:Any city or county SI ELECTRICAL C OTHER
which reclaims a'reairm consumer,ahoy Lnprove,dumol iib,oi-on air any aimnnrc'
prior to its issuance,also requires the applicant for such p mast to file a signed narement SPECIA IRCUIT/MISC.
f y shot he is licereal moment o the provismns of the Committee,License law(Chapmr9
04 <O (commencing with Section 70())of Division Sof the Business and Professions Code)or TEMP.MITA OR POLE INST. COMMERCIAL'
0. Co C
that he is exempt therefrom and he hmis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
y Section 70313 by any applicant for a xmor subjects the applicant m a civil penalty yr POWER DEVICE. CTENANI' ❑FOOD SERVICE
r more than five hundred dnilars(8500)ZIMPROVEMENT Q
El ownerufthe property,or my employees with wages as their sole compensation, SWIMMING POOLE -CfRIC
will do the work,and the sbucure is not intended or offered manta(Sec.7044,Business OTHER
" and Profession,Code:The Contractor's License Law does not apply m nn owner of OUTLETS-SWITCHES- gXLURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided Nat such improvements are not intended or offered for NEW RESIDENTIAL ELECT SQ Irp.
_ sste.If,howevecthe building or improvement is sold within one year ofcompletiogthe SQ.14.FLOOR AR EA S/SQ.FT.
owner-builder will have the burden ofproving that he did not build or improve for put- AD pp a
ease of arde.). - Y
LJ 1.as owner of the property,am exclusively convecting with licensed contmemrs to TOTAL:
construct the project(Sec.7044,Business and Professions Code:)Tne Contractors Li-
cense Law does not apply to an owner of property who huildv'or improves thereon,and QTY, R FEE JUL ���29 6
who cornets I'nr loch projects with v commanns)I Ivories[pat a mnno the Comrncions
License Law. PERMIT ISSUANCE. CJ V,(
C3 IamexemptmWerSee. ,B&PCfmrhi,mw air (iUl^'CJY 11!6(3
ALTS - VALUATION
Owner - Date b m
WORKER'S COMPL'NSATION DIECLARA'I'[ON SACK C�tY1pI
elm
I hereby aff under penalty of la jury one of rhe fallowing declarations:
C l have and will maintain a Cestifcme of Conserv to self-iasum for Workers Camper- DRAT A. NIf STORIES TYPE CONSTRUCTION
Ions-
arrive,as provided for by Section 37M of the Labor Cale,for the performance of the
work for which Nix permit is Issued. _ p1XTU
❑1 haveend will maintain Workers Compensation In.mtnnce,is m,.ircd by Section
37W of the labor Code,for the performance of Ne work for which this pemdt is issued. GAS- UJI.BrInt.
OCC.GROUP APSE
Worker's Compensation Insurance carrier and Policy number am: 1
Currier: Policy Nov.: GAS- .
- CERTIFLCATL OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - GREASPJLNDUSTRI. O BUILDING DIVISION POPS
lTltis section mad not be completed if the Permit is for one hundred dollars ISIW) GREAT-W
L rectify that in the porfomiance ofthe work for which this permit is issued,l shall i ANClIECK FEB
premto ersoninen runner sa nsmbccome aubaunnc�Workers'Com ,F.WNI 'ANITAY-.TO IA.
p y any p y t j pen- - ,
Z ---
Applicant
of California.Dam
�� Applicant WgTER GRAD G PCE
h NOTICE TO APPLICANT:If,after making this Certificate of Esentption,you should W/ BEATING
become subject to the Worker's Compcnaativn provisions of the Lubar Code,you must
forthwith comply with such previsions or dtis permit shalt then deemcl revoked. WATERSERVICE
0
�tR&S
CONSTRUCTION LENDING AGENCY NEW IDENTIAL PLMB. SQ.PT. PAID
� PF-s Z I hetehyufline that them is ucnnerartion lending agency fmthe perfmmor.of D Roeeiptq
the walk for which this permit is i...ed(Sri.301 Civ.C.)
O U lanlaea Name 'TOTAL:
Lender's Address TOTAL:
Iy Icertifythat L have read this npplienum.and state that the abase information is BUILDING FEE
I) correct.1 agree to comply with all city and county rolmotmes and score laws rclufingm QTY, MECIIANICALPERMrr FEE
V Z building constmcinn:and hereby authorize represenatives of Nis city roamer upon the SEISMIC FEE "
`t .hove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep haddess the City of Cupertino against PERMIT ISSUANCE. ELECTRIC FEE
thdriiries,judgnmms;cosrxund expenses which may in any way accrue against said City ALTER OR ADD TO MECH,.
in . qucnce-f the givming of Nis permit. PLUMBING FEE
PLT N 'VDEfo".
DS AND WILL COMPLY WITH AV,NON YOINT AIR HANDLING UNIT HO 10,000 CFM)
OUR( .0 1LAT :—a iyy�� MECHANICAL FEE
p/ AIR HANDLING UNIT[OVER I(l,1Nq CFM) CONSTRUMONTAX
reofA"Ph . nrr Date F.XHAUSTHOOD(W/DUCT) .HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building vacepent store or handle hazardous material HEATING UNIT GDO 100,00)BT HE
iu defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(.)? HEATING UNIT(OVER 100,000 B'fU)
CYcs CIN. PAID
VENTILATION FAN(SINGLE RES ED pate ReceiptM
` Will the applicant or future building occupant use equipment or devices which
1 emit hicundma air conmMnrnrs as defined by the Buy Arca Air Curia,M.m.ganent BOILER-COMP(3HP OR 100,100 BTU)
District' I
BOILER 100.000 BTU) TOTAL:
❑Yes No ' -
I have read the hamrdous materials requirements under Chaplet 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cede,Sections 255(15,25533 and 25534.1 understand Nat it the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant,that it is my responsif iliry 1p modify the occupant
of the restatements which must be reef prior to reminiscent.Certif nim of Occupancy. -
Owner or authorized agent are a TOTAL: ISSUED BY:
OFFICE