30868 APPLICANTTO FILL'IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - -
CITY OF CUPERTINO "APPLICATION/PERMIT' BUILDING-ELECTRICAL PERMIT NO. 3 O �^8
BUILDING DIVISION PLUMBING..MECHANICAL. 3 Vh
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - -- - -SANITARY NO. 5 APPLICATION SUBMITTAL DATE
2Lor
2
t OWNER'S NAME. - ' PHONE:, CONTRACTOR'S NAME: . LIC NO:
fV LIM . T p
NIC '. CON TRILL#
RCHITECr/ENGINEER: • LIC NG: .. ADDRESS: 1zZa0 S(J(�'f0 eO—S V�L.� t tV
M 'a a
c$F}A�1Nc.1 FPICiJGo��c�l PH/pNI��PJ� ❑
Consultant Feegi Paid by Applicant(Initial) BLDG BUIeLDCI PE
B
LUMNFO MECH
z ' o.
LICENSED CONTILA DECL 1201.1
ELECTRIC PERMIT FEE
1 Hereby amrm that I am ucersea under prnvi.1 . el ter 9 mo ,intros 70B DESCRIPTION
Bo�1az wimsprtmn 9a)o)ofniviaion3enne enamesa and Pr nae.dna Imenaeia
FSC wiOSin full forceundeffed. - n RMIT ISSUANCE '
�UZU License has Lick . e WE [3 KITCHEN REMODEL
Huu Date Commcmr PLIANCES-RESIDENT - ADDITION El PLUMBING RE-PIPE
'Do, ARCHITECTS DE 0 NELS MULTI-UNIT -EISTRUCUKAL
Z p N 7a 1 understand my,li ns shall be used asp is nidi MODIFICATION
OZ—Q - 'a. 'I'O 00 P ', EJ INTERIOR C1 CHIMNEY REPAIR
a7 Licensed Professional 0 IMPROVEMENT
OWNER-BUILD RDEC ION 1 0 5a�^� I hereby affirmChar 1am eempt rein Contractor's License Law frthe B TH REMODF,{/REPAIR D DEMOLITION
Y" following reason.(Section 0031.5.Business and PeePossios Code:Any city of countyIGNS'EL'CTRI - HER P✓ w
which q " a permit 1 contract, h p demolish, e,t a y wcwre
Aron il a I y th ppl' t f .uch perm ll 1 d [mment
y - 6 SPECIAL,CIRCUIT/MISC.
y
Oat he'is licensedpursuant the p n. fC t r L (Chapter _ - -
0 (coin g th5 i 90IXp (p' � 3ofN 0 and Pr f"I sCarol or TEMP.METER OR PDLEINST
that h pr therefrom d theb f h ll exemption A y I t of 'VADDIt!
_ w
OLITION
FOOD SERVICE
Secn 70315 by any ipl tf permit objects theapplicantt Ipenalty of POWER DEVICES ANT sU!'�hrm thanf hundred d II (%500) M❑I as owner of the property, ye ploy it g .the I peneaton, SWIMMING POOL ELECTRIC PROVEMENT nvu _
jf
waldorhe work,and the structure is not intended or offeredf 1 (Sce.7044 Business OTHER
dna Prices ions Code The Certainties License Law docs not apply to an,owner of OUTLETS SWT rCHES-FIXTURES
property who builds or.homes.thereon,and who does such work himself or through
his own employees,provided that such Improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however,the building or improvement is sold within one yearoi'completiun,the SQ.FTFLOORAREA S/SQ.ET.
owner-builder11 have the burden of proving that hedid not h ld-rim,' efnpur-
insecticide.)
I as owner of the property am exclusively contracting with
n ' licensed contractors to
constructthe 7044 Business u d Profession,CoContractors Li-
cense Low doesnottapply t rte fprpinh hilitis improves thereon,
e n,dna
QTY, PLUM-
BING PERMIT FEE
who cnnwcn for sumprojects that wt OIlicensed t to the Contractor a
/
License Law - PERMIT ISSUANCN.
❑I am exempt under Sec ,B&P C Fargo'reason
ALTER-DRAIN&VENT-WATER IEA)
Owner Date AW#fl
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE 4
Ihereby
andwillaffirm under penaltyat perjury one of the following declarations _
❑Ihave and will maintainstion Ecme of the
Code,
thehlormeCompen- DRAINS-FLOOR,ROOF,AREA,COND, STORIE. TYP. ONSTRUCYION
�sd[lon,as,resided for by Section 371N1 of the Libor Code.for @o pal'nrmanw of the ..
ofor which this pemtit isissued FIXTURES-PERTRAP
w 1 have and will maintain Worker's Compensation insurance,as required by Section
3900 of the Labor Cede,for the
yperpforrmance of the work for which this
permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS. s OCC GROUP APN
My
Currier: �•11/N Onn� Pole'Noot end y�'�i_d���F�sG GAS-EA.SYSTEM-OVP.R4(BA)
CERTIFICATEOFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASDINDUSTRL WASTE INTERCEPTOR
(TTlssec0orneed nmhe completed if the permit is fnnmehnndred dellen($I(q) s ? BUILDING DIVISION FEES
- or less.) . CREASE TRAP PLANCHECK 'E r
Loy any thininthe any mananeco as
work for which this the Wrkers' Qmper- SEWER-SANITARY-STORMEA.20a TT.
not employ any r In any manner sin as m become snnlom m the Workers'Compen- ENERGY FEB
,� Appli Laws of California.tiifDote 1. -
�.
Applicant WAl'ER HEATER WNENT/F.LECTR
y PP GRADING PCC
' V] NOTICE TOsubject
w c ANT:Work If,after corking this Certificate o of Exemption,you should
..I WATER SYSTF,MITREATING
forthwith
comp y rbe Worker's Comp in this provisions of the Leber Code,you mum - SOILS FEE
forthwith comply with such provisions or this permh shall be deemed revoked. WgTER SERVICE -
�z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB.: SQ.FT. PAID
l hereby alarm that them is ncovswmion lwding agency forrhnperfermunceid Dare Recolpt#
L1 the work faro ich Oh,permit is issued(See.31)99,Civ.C.) _
' Q F Lender's Name ' I TOTAL'
lic
W Lenders Address _
Ps 1 certify the[1 hvvr read thl-s upplieation Hud stun that the those information is BUILDING PEE
.V1 cntectragreememnplywitha it and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
V"Z 'huildingosubmi a,aadh you merepresenlvrives ofthis citymenturpou the SEISMIC FEE
above-menti d frainspe ionparpmses' PERMIT ISSUANCE
(W a t e,Indent neand seen yinformless the City re Cnpenstsid Cit'' ELECTRIC IEE
liaeanseb go P. matic,e nseswhich may in any wry nceme against said City AITFRORADI)MMECH.
'
means be oft gmming rM1is pennir. - ' PLUMBING FEB
APP CA 11 ERSTA S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
50 LATIO 'MECHANICAL FEE
icJ .�\ AIR HANDLING UNIT(OVER 10,00)CFM)' CONSTR
pli2ant/Contruc... Dab EXHAUST HOOD(W/DUCT)" HOUSING MITIGATION FE
HAZARDOUS MATERIALS DISCLOSURE
Whig, applicant or future building ticcepant store or handle hrdardous material HEATING UNIT TO 100,000 BTU) t
as deft ed the Cupertino MunicipalCode.Chirpier 9.12,and the Health and Safety
- Coda ton 25532(v)'1 _ HEATING UNIT(OVER 10RO(s)BTU) -
❑Yes JflNo ..
= VENTILATION FAN(SINGLE RESID) - PAID
Will thea licant or fum he"air t use c ui mint or devices which Date Receipt#
pp goycpa y i p y g BOILER-COMP(3HPOR100,000BTU)
,.it hnzallous air c s as del red 6 the Ba Area Air Quality Marta einem -
Distin^ BOILER-COME(OVER IOQ000 D'TU) TOTAL:
El Ye In�]No. ,
.h Ih vea addition terms requirements under Chapter 6.95 of,me Call- AIR CONDITIONER_ ISSUANCE DATE c
Smoke I y Cod actions 25505,25533 and 25534.1 understand that if Ne NEW RESIDENTIAL MECH. SQ.PT.
buildivg lave a'count,that it is my responsibility to notify the occupant '
of rh enrs which must be met pima m isonerse old Cer'ifrcateot Occupant -
M.
1 nein uthori, at Date I TO ISSUED BY:
4 OFFICE '