30871 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILIHNG-ELECI'RICA. PERMITNO, 3OH 1 71 1
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING•MECHANICAL J
' BUILDING PROJECT IDIiN'I'IFlCA' ION
ILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
WNER'S NAM PHONE: Co AACfOR'SN Mlj. -�( LIC NO:
/`NAM fi��A// NIC CONTROLtl
ARCHITECT/ENGINEER: LIC NO: I RESS: V ❑
/b
CONTACT. veoee: , BUILDING PERMIT INFO
❑ Consultant Fels Paid by Applicant(Initial) BLDG ELI:CT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Cap QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing 108 DESCRIPTION
1a1y ceZ with nasion]000)asf Divisimn3nrthe Business and Professions Code.and my license is RESIDENTIAL:
—00- In full farce and efkm. PfiRMIT ISSUANCE
F�UV License Cm� LieN ❑SFDWI, KITCHEN REMODEL
HGL Dam Cemmnor APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
AkCI31TEC1"S DECLARATION ❑MULTI-UNIT ❑STRUCfURAL
PANELS
p�E.Nm lunde�ynJ in p as hail b��y�s�sJaeyyu6llc rmmrds MODIFICATION
-//� /rd�/,cy UP TO 200 AMPS
�0 ❑INTERIOR ❑CHIMNEY REPAIR .
P an I.I,a Licensed fasvonu - 201.1000AMPS IMPROVEMENT
s OWNHR-BUILDER DECLARATION
Syd _
O 0.'2w� I hereby affirm that 1 tint exempt form the Conttnnur's License Law fur meOVER I WO AMPS ❑BATH REMODEUREPAIR EJ DEMOLITION
iq5 6 V following women.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 LL F' wh'mh regnires a penton to cnnatrucL alter,improve,demolish,or repair any structure
re
prior to its issuance,also requires thevpplicunt fimmch pemmilin l3leuxignedsmtanem SPGCIAL CIRCUIT/MISE,
} deahaslicensNpunuanna flismovisions of the Contractor.License Law(Chapter 9
TEND,00 (commencing with Section]O(10)of Divisinn3o(the Business vnd Pmfexsions Coalehx TEMMUCH OR POLE INST. COMMERCIAL:
0. n C that he is exempt therefrom and the boars for the alleged exemption.Any eLlminn of [I NEW BLDG/ADDITION ❑DEMOLITION
LL, Saturn 7031.5 by anyapplicunt fora pcnnit subjects the applicant ma civil p...Ity of POWER DEVICES
o!, not more than five hundred dollars($500), []TENANT ❑FOODSERVICE
6 I,asowner0f the norm locus with woes as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
G ❑ tintstr Y Yemp Y B ,assn CI OTHER
anddothe work,andtirestructure isnut emendede Law do far sale(Sec.9044,Business
and Professions Gale:The Contractors License law does not apply. an owner of OUTLI TS-SWITCHES-PIXY S
a'w hismotherlyown who builds or improves thereon,and who docs such work himself of through
his own owever,h ltuddi til that such improvemema are on emended or offered for NEW RESIDENTIAL ELECTR SQ
swear
bower will have
hu improvement iBut,h didil nneyearoi completion,the SQ.PP. L�QR AREA $ISQ.irT.
ownerbuilder will have the huNen of proving ohm he Jid not build or improve for sur- � P A ` �J
True ofsale.).
❑I,as owner or the property,am exeluxis cly contracting with licensed contractors to "TqL'. -
construct the project(Sm.7044,Business and Prol'esxlonm Crxlep The Contreclurtm Li-
m Law - APR 7 I{G{g sI�U
nw does napply to an owner of property who builds or improves thereon, Q'I'Y, PLUMBING PERMIT FEE
who contracts for such projects with a contortions)licensed pursuant n the Comment's
License[.it .
C)IamexemptunderSee. ,B&PCfordtisremmn PEkMITISSUANCE ITY Ur wrCHI"INU
OwnerALTER-DRAIN&VENT-WATER HDO VALUATION
Uvte - - w�
• WORKER'S COMPENSATION DECLARATION BACK FLOW PRO'I'ECI'.DEVICE ..J ;?VZ
1 hereby affimn under penalty of perjury one of the following declarations: �,J�•�
lhnve and will mvimvina Ccnifica¢of Consent to self-insure for Workers Compcn- DRAINS-FLOOR,ROOK AREA.COND. STORIES TYPO CONSTRUCTION
action,as provide far by Section 370X1 of the Labor Code,for the performance of the
wed:fnr which this pc nit is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as abiluired by Section
3700ofthc Labor Gale,fonhe partmernmea fthework l'orwhich this permit is issued. GAS-PA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worker' m e aliosunt, onrierand Policy numlyr/yTq -
Gmrier: Policy No.: /' GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF E(EMPTION FROM WORKERS'
COMPENSA'I ION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(7his section need not hecompleted iflhe prmit is fnnme hundred dnllara'($IfNq BUILDING DIVE PEHS
m less.) GRFASI3 TRAP PLANCHECK FEE
I certify thatin the performance of the work(nr which this permit is issued.)¢hall
SEW EIL-SANITARY-STORM EA.200 n'.
not employ any person in my manner in as to become subject m the Workers'Conifer- ENRRGY PEIi
QZ moult Laws of California.Dem WATER HENfER W/VEWIELECIR
z Applicant GRADING FEF.
pr NOTICE TO APo the Work If,after making this Certificatesoof Exemption,you should WgTT:R SYS'1'F3M?RL>A'IING
LQ , haeme subject y the Worker's Compensation isorhisprovisions of We labor Gale,you must SOIhS FEE
W forthwith comply with such provisions nr this permit shall he deemed revoked. WATER SERVICE
Q
CONS]RUCTION LENDING A a envy m NEW kES10F.N1'1AL PLMI3. SQ.Irf ,PAID
U0 work
whishmithet thereisaed(See ion lending agency fonhe pcRormancc of Dm eceipt#
� (~ the work for which this pcnnit is issued ISm.3047,Civ.CJ '
p U Lender's Name - - TOTAL:
Lenders Address TOTAL:
aa, I certify tba 1 have rad Ibis application and state tem the above information is BUII.DING
Ir VI corrcc0ingreemnempiy with all city and county ordinances vnd rime lows relining to QTY. MECHANICAL PERMIT FEE
C.)z building construction,and hereby autborlae represcmatives of this city to enter upon the SEISMIC FEE
above-ho mloned property for mr,cdiov purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way amme against said City ALTIiR OR ADD TO MECfI.
in ca seyuenc,of the granting of this permit. PLUMBING PE
APPLIC �k}T'UNDERSTANDS AN ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0(111 CFM)
SOURC, LGULAT NS �� MECHANICAI FEE
AIR HANDLING UNIT 10.000 CFM) CONSTRUCT NTAX
/
Sigrafthe ofAppliont/Comracmr Dam EXHAUST HOOT) W/DUCT) - HOUSINGM GATION FEE
/ HAZARDO MATERIALS DISCLOSURE.
Wlllthoapplicantor(uturebuilJinguccup.,dame ear handle hvardousncrathil HEATING UNI'I'(TO 100,000 BTM
as defined by the Cu,mro Municipal Code,Chopmr,9.12,ori the Health and Safety
Code,Section 25532(.)! HEATING UNIT(OVER 1001000 BTU)
❑Yes t F]No VENT I LATION PANS I NGLE R1331D) PAID
Uma sept#
Will rise applicantorfuture building by
B useea Air minor Marta which
emit huoNous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP OHP OR 100,000 RTU)
Districts TAL:
❑yes []No BOILIiR-COMP(OVER I(IO,IXNI I{'PU)
I have read the hamNous tnamrials requirements under Chapter 6.95.(the Cali- AIR CONDITIONER ISSUANCE DATE
front Health&She,Code,Sections 25505,2553.1 and 25534.1 tndersmnd that 11 the NEW RHSIDRNTIAL MECU SQ.ET.
building docs rot currently haven ume t,that it is my responsibility to notify the occupant
of the requirements which must Its met prior in issuance of a Certificate of Desolater.
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE