30541 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 30541 0 5 4 1
BUILDING DIVISION APPLICATIONIFERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
e eco *"
j� ill's NAME: IC NO: NIC � CONTROL
CHIT"CI' iNGI LIC NO'. ti•' El
CONT CT: nONii: a� BUILDING PERMIT INFO
a r IG'L ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED N ACTO 'S DECLAITATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing LOB DESCRIPTION
000 with Section 700m f Division 3orthe Bminewmed Psursximns Cale,und nt license is RESIDENTIAL,
e)Op y PERMIT ISSUANCE '
�1ykk.. in full force and,Rut. ❑SFDWL FI KITCHEN REMODEL
FQ,Ut License Clens Lic.p ppp1.IANCliS-RESIDENTIAL []ADDITION El PLUMBING RF-PIPE
NQL Date Contractor _
F ARCHITECTS DECLARATION [I MULTI-UNIT ❑MODIFICATION
7 N PpNCIS
z O rn'4 1 undentwa my plans shall b,used as public records
OZ4, UPTO 2N)AMPS [I INTERIOR El CHIMNEY REPAIR
rt,,Ir.W Licenced Pnrfessional 201-IWOAMPS IMPROVEMENT
F••1 OWNER-BUILDER DECLARATION OVER I(Xlf1AMP5 El BATH REMODEUREPAIR ❑DEMOLITION
6 LIE 1 hereby infant that 1 in.exempt from the Commal.,'s License Law for the
y O a U following masao.(Section 7031.5,Business and Professimm Cale:Any city or county SIGNS ELECTRICAL []OTHER
which requires a permit to constmcL aheg improve,demolish,or repair any sauceme
.:m71 prior m its iswunce,also require,me applicmt farvuch penin to fle.o,orJ statement SPEC1ALCIRCUI'1'/MISC.
oq2,
tint that he is Iicenecd pursuam to the provisions of the Contractors License Law(Chaplain
wee QOO (commencing with Scetion 7000)of Division 3ofthe Business and Professions Code)or COMMERCIAL:
TEMP.METER OR POLE INST.
a y that he is exempt therefrom and the havis for the alleged exemption.Any violation of ❑ EW BLDGJADDITION ❑DEMOLITION
m SectionIIIIS by any applicant far ap��mit subjects the npplicannoacivil penalty of POWER DEVICES 1"(sl:_NpryT ❑FOOD SERVICE
F+ y not more than five hundred dollars MOIL TIIM—PROVEMENT
p Q ❑ Lnsowmatifthe property,or my employees with wages as their sole compensation. SWIMMING POOL(?LECTRIC
q—O wlldethework,andthe comment,is not intended oroliead forsale(Sec.`? 1.Business ❑OTHER
CW 3 and Profusions Code:The COntmaor's License Law does not apply to an owner of OUTLETS-SWITCHES-PI%TUR
p' property who builds or inmporms thereon,and who does such work himselfor through
his own employees,provided that such improvements are not amended or mffertJ for NEW RESIDENTIAL.ELECTR SQ
sale.If,however,the building or improvement is sold within oneysarfidampletinn,me SQ.FC FLOOR AREA SISQ.hT.
erbuilder wlll have the burden of proving that he did nal build or improve for pint-
pox of sale.). - \
❑1,as owner of the property,am exclusively commuting with licensed contractors to SEP 1p/ 1•I9
construct the protect(Sea.7044,Businass and Professions Cale:.....Crew.... l.i- 96
erns Law does not apply to an owner of proper,who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such pmjec'ts with a contmctonO licensed pursuant to the Contractors
License Lew. PERMIT ISSUANCE
❑1 um exempt under Sec. .B&P C for this..an
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE E�0M--
1 hereby affirm under penalty i f perjmy one of the following declarations:
,-]Ihave and will maintain a Cmifmcac Ol Consent resell'-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COED, STORIES TYPECONSTRUCTION
sation,as provided for by Scotian 3700 of the Labor Code,for the perfarmunce of the
work far which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Sectimt
3700ofthe 1',lOt the performance of Ne"fir lar which this Permit is issues. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP APN
My Worker'sC m Insurance careicr and Pnlicyp �e 'a y��
r Poliuy No. Oyu GAS-EA.SYSTEM-OVER 4(EA)
CER'1'IPICATEOF E%IiMIT10N PROM ORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR BU (VISION FEES
IThiasunlon need not beccmpletW mi
ifthc pert is forma,hundred dollurs 1$I Igp GR17ASETRAP -
arlessJ PLANCHECK �[
I cenify that in theperfm
ooere m be work for which this permit is issued,i shall SEWER-SANITARY-STORM EA.200 IT.
nut taint,any person Bt anymannef an to beconme subject to the Worketx'Compun- IN E*Y -
,Z sation laws of Callfomin.Dam WATER HEATER WNENDIELECTR
O Applicant kN
IA NOTICE TO APPLICANT:If, he,making this Cinificule of Exenptian,you chmdd WATER SYSTEMG BEATING
(" become subject to the Workers Compensation provisions of the labor Calc,you must E
Wfonbwith comply wilhxuch previsions or this permit shall he deemed revoked. WATER SERVICE
Q
5z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. ReceiptM
U 0 l herebyumrm that Nem is a connuumion leadim,,ency forte perfmmancc of
lT. (•-' he work for which this permit iv Lvsued(Sac.3097.Civ.C.)
0 Lender.Name TOTAL:
RUU LendeisAddress _ TOTAL: NG E
Its"' 1 certify that 1 have read this application and were that due above information is
rA correct.l agree to comply with all city and county ordinances and state laws relalingm QTY. MECHANICAL PERMIT FEC
L) z building construction,and hereby authouee representatives ofthis city to enter opium the FE
aMvcancntimna• city for inspection pmpuxs. PERMIT ISSUANCE
(We Tec wimlcmnifyandkeepht less the Cityof Cupcnino against ICF C
liabilities dgme scostsand xpenseswhich yi anyway starve against said City ALTER OR ADD TO MECH.
ancon. men the limn' of his permit. ING .E
APP CA' NO IV DS PT1 WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) NIC .FEE
SO RCE .GULA ,
4.0 Aills HANDLING UNIT(OVER 10,010 CFM) RUCT NTA%
$i App rtmmC ate E%IfAUST tI00D(W/DUCI') G MI' IGATION FEF.
HAZARDOU !RIALS DISCLOSURE
Will thbappliraimmimme bnnish.g ottupantsmremrhandlchazardouwmatcriul HEATINGUNITOO IW,B(IUBTU.
as defined by the Cupertino Municipal Code,Chapter 9.12,and he Health and Safety -
Code,Section 21532m)? HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RFSID) Dam Rmeipttl
ON '
Will the applicant or future building occupant use equipment or devices which
'mit luxurious air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) TOTA
Uistrict4 BOILER-COMP(OVER 100,01))B'TU) M
❑Yes El No
I have tend me hamrdous materials p AIR CONDITIONER
) regoirtmcnts under Cha ter 6.95 of me Cab- ISSUAN ATE
fomiu Ileahh&Safety Code.Stations 25505,25533 and 25534.1 understand that if the NEW RESID[WNTIAL MECH. SQ.FT.
building dna not currently have a tenant that it is my responsibility m notify the acufwat
of the mqulremems which most be met prior to manure of u Certificate of Occupancy.
Owner or authmized agent Data TOTAL: ISSUED BY:
OFFICE