30680 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY /�Q
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 3 O 6 V O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL J `J
BUILDING PROJECT IDENTIFIC'A'TION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
s[3C0
OWNER'S NAME PHONE: CONTRAC FOR'S NAME: LIC NO,
Mt2.� ►-n(2-g -l.�L-eN 2S 2 41uS5 q,p�.-.S (o�syo� q NIC CONTROL
NCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
�04� rinw/C.e2�/.av{3 �uu
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MH
❑ ❑ ❑
LICENSED CONTRACTOR underSDECLARATION QTY ELECTRIC PERMIT FEE
1 hereby )).f that 1 am licensed wader provisions
..of Chapter Colter 9 mommenemg JOB DESCRIPTION
C 0'Z thll annad of DivivionJof the Nncina's unA Pmlesslnnp Caxlc,trod myliccn,c is RESIDENTIAL:
F_� L ane Cl...Jer�t. I'IiRMIT ISSUANCE
e—u Data Class C Lic.X �O a�64� ❑A D ITL ❑KITCHBN REMODIE
vFiQL Umc �Je'°yl��Cammcmr Tk�54 Qxy RQaI APPLIANCIi.S-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE
ARCHITECTS DECLARATION [I MULTI-UNIT ❑STRUCTURAL
ZoVIZ I understand my plans shall Be used as public records PANELS MODIFICATION
�
4 a— UP TO 200AMPS Zp ❑INTERIOR El CHIMNEY REPAIR
F W Licensed Professional2014000AMPS IMPROVEMENT
�y ; OWNER- BUILDER DECLARATION OVER IIIINIAMPS F1BATH REMODEL,REPAIR E3 DEMOLITION
6' 6 1 hereby affirm that I am exempt from the Commead's License Law for the
tl L U following reason(Section 7031.5.Business and Professions Cute:Any city or county SIGNS ELECTRICAL ❑OTHER
3 o Ha which acquires a permit to comtrun,alcor,improve,demolish.or repair any structure
CLLsnSYpy
m.] pnundus mouree.olsom marsthe.,,Memo ,t
forsuch pemrio file asignnlsmernem SPECIAL CIRCUIT/MISC.+YI p' that he 1,licensed puramnd to the provisions of the Contractors License Low(Chapter 9
u1�G0� that
with Sonion7")of Division 3 of the Business and Professions Care)or THNURNIMIlIt OR POLI:INST COMMERCIAL
T :
a c o at he is exempt therefrom and the basis for me alleged exemption. C3 Any violation of ❑NEW BLDG/ADDITION DEMOLITION
4•
Section by any applicant for aperadit subjects the applicant to a civil penalty of POWER DEVICES
- ❑IMPROV ❑FOOD SERVICE
our moa than five hundred dollars(SS(Np.
- IMPROVEMENT
=6 0 Lasuwncrk.the prapcny, remyetinten ep wllhwredf reale tale compensation, SWIMMING POOL ELECTRIC
will don a work.and ahc he Contractor's
not s License,
,Low dos salepply(See to n owner
os ❑OTHER
L 3 m and ors,who
Cade:The over hens Liccnu Law Jens not apply s if owner of OUTLETS-$WITCHIS-FlXTURES
his own who baled,or sided!that
thereon,and who Joss such work himself or through
Min own employees,building that pooh improvcare nm intended m offered for NEW RESIDENTIAL ELECT! SQ IT. .C'a
wle.ILhoweva.the building orimprom
veem is sold
old wiNinone year ofcomplction,the SQ.FT'. O R1REA S/SQ.IcI'.
caner-builder will have the burden of carrying that he did not build or improve for put-
p
apeafale.l. MAY13 w
I,asowner of Neproperty,am exclusively sof..i.ng with licensed .in......n to 'IAL'
conswca Nc pmjal(Sec.]M4,Business and Pmfcssionz Codc:)The Contractors Li.
cense Law does not apply to an owner of property who builds or improves themon,and QTY.. PLUMBING PERMIT F Equy 0/;
who contracts lin such projects with a contractors)licensed pursuant to he Conwmor's MI' V Jetu
Lirenu Law. PERMIT ISSUANCE �I��NO
❑1 am exempt under Sec. ,B&P C for this..,an
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner TIIC
WORKER nder Penalty
DECLARATION BACK FLOW PROTECT.DEVICE
I band will maintain
ai under penalty of Perjury,one of the fallowing Jeclarnlmm:
�Ihave
pro,idl main mi nationComatose,700ofConsent toLabor
Code, otfor Workers Compcn- DRAINS-PLOOR,N(X)HAREA.GOND. STORIES TYPE.CONSTRUCf10N
ration,os provided for by Section PINI of the Lobar Code,for the lerhvntunee of the
r which this licrmit is issued. Il%TURLS-PER'IRAI'
w rl have and will maintain Workers Compensation Insumrtce,as required by Section
37Mofthe LaMSCode.for the performance ofthe work for which this permit is issual. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP AYN
My WorkS� Compo Imumnax cu trod Policy qy
Cartier:C.:P�ny �� mac l'nlicy Nu.:C ��14m 1(e�J- GAS-EA.SYSTEM-OVF:R4(EA)
CERTIFICATE OF COMPENSATION
INN FROM WORKERS' GREASE/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FF.15
(This section need not Becompleted if she permit is for one hundred dollars(Sled) GREASE'1'RAP
or Ims.) PLANCIIGCK PF:f?
Icenify Nat in Neperforrnanceofine work lot which this Permit ipisaed.l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manners,as to become abject to Ne Workers Compen- ENERGY FEE
ZZ stion Lawsaf California.Data WATER HEATER WNENTMLECTR
2 Aplllcatr GRADING FEE
NOTICE TO APPLICANT:If.after makes,this CenificOm of Exemption,you should WATER SYSTEM?RENYING
I^ ; Become abject to the Workers Compensation provision,of the Labor Code,you must SOILS FEE
Wforthwith rurally with such provisions m Nis perunitshdl he deemed revoked. WATER SERVICE
Q
as CONSTRUCTION LENDING AGENCY NEW RISIUGN'1'IAI.I'LMB. SQ.PT PAID
.`7. Z Date ReceiplX
V p work
by which
ahthisffirran at themschti issued(Sec.30 len ding agency for Ne performance of
F thewmk for which this leanit is issued(Sec.3119].Civ.C.)
w I<ndcr's Name TOTAL:
Q Lenders Andres, IYUAL BUILDING PEG
I certify that I have mad dr,application and sante that the above infuanaron is
,F. Vatcnnect.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V Z building cnmardeiae,dmA herebymolormempre,cools,ofthis city manor upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgmems,costs and expenses which may in any way accrue against said City ALTERORADDTOMECH. PLUMBING FEE
in asequence of the granting of this pcmtit.
147W-
APPLICAN UNDERSTANDS AND WILL COMPLY Wl'fH ALL NON-POINT AIR HANDLING UNIT(TO I0,000 CFM)
MECHANICAL Plili
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER In"CRM) CONSTRUCTION TAX
Signamm of Applican/Corder,n Date F:%HAUS"r HOOD(W/DUCT) to""ll. G HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE Q
Will the applicant or future building uacupatuawreor handle hazardous macrfid [ HEATING UNIT CFO 100.000 BTU) pX
as derided by the Cupertino Municipal Code,Chapter 9,12,and are Health and Safety
Code.Sadao 2553200! HEATING UNIT(OVER 100.000 BTU) .
C]Yes No PAID
VENTILATION FAN(SINGLE R[.SID) Dam Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(711P OR I(Ml,(NIO PTU)
mit hazardous air coni nninants an defined by the Bay Amu Air Quality Management TOTAL:
Untactl BOILER-COMP(OVER INUAM B'ru)
❑ye, ❑No
I have read the bvaaJoa,materials requimmums under Chapter 6,95 of Ne Cult- AIR CONDITIONER ISSUANCE DATE
fonts Heull & 'sty Car,Sections 25505,2.5533 it 25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ.CL
building a rreonly have a terms.and it is my responsibility to notify the monition
afore at n 'ch bemaprimmi"oancenfa .rfi Occupancy.
Owner ora cont 1 DateIOTA ISSUED Ii Y:
OFFICE