30894 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO. 38 9 p
0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3 S`MJ(,�
BUILIHNG PROJECT IDENTIFICATION
ILDINGADDRESS: v SANITARY NO. APPLICATION
NSSUBMITTAL
IDATE
/04I/ B rna 04VP- t✓IOC CA fro/`i
HER' E: VE i'HONE: CONTRACTORS NAME: LIC NO:
NIC CONTROLx
Ae
1RCHITECT/ENGINEER: LIC NO: ADDRESS7 :
oNTACT, PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby u'am Net I em licensed under provisions of Chapter 9(commencing
1 DESCRIPTION
Goo with Settion7000)af Diviaimn 3ofthe Business and Professions Cale,and my license is RESIDENTIAL
in full force end<ffea PERMIT ISSUANCE
W� ❑SFDWL El KITCHEN REMODEL U�U
yQULintner.Class Lic.p gppLIANCE,S-RESIDENTIAL.
y Date Contractor ❑ADDITION ❑PLUMBING RE-PIPE
g„py ARCHITECTS DECLARATION - ❑MULTI-UNIT ❑STRUCTURAL
Z 0-Z 1 uMmtattd my plans shall be used a public records MODIFICATION
CZ-^G UPTO200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
91-
Licensed Professional 201-IOW AMPS IMPROVEMENT
yy 6 •OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Cmancom',License Law for the OVENL__AMPS ❑BATH REMODEUI EPAIR C]DEMOLITION
p(34U following reaam,(Section]0315,Business and Professions Code:'Any city or county SIGNS ELECTRICAL - ❑OTHER
LLLL1l O high requires a Permitto construct,e1mr,improve,denmlisM1,or repair any structure 7•�/jl
�N Irior m its issuance,also requires the applicant for such permit to file esigned statement SPECIAL CIRCUIT/M ISC x-FII
ypy that he in licensed pursuant to the provisions of the Commeor's License Law(Chapter 9
GOC (commencing with Section]OW)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST.OMMFRCIA e
4{y y that he is exempt therefrom trod the basis for the olleged cou ption Any violation of
i� k• Sectinn]113 LS by any applicant for a permit subjects the applicant to a civil penalty ofPOWER DEVICPS ❑NEW BLDG/ADDITION ❑DEMOLITION
F.. } am mme than five hundred dollars($500), ❑TENANT ❑FOOD SERVICE
Q (]Las ownerof the property,or my employees with wagesistheir in compenmtior, SWIMMING POOL ELECTRIC IMPROVEMENT
will du the work.and the Inam,is nm intended oroffercd for sale(Sm.]IH4,Business - THER
3 and professions Cade:The Co teacmr's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
progeny who builds or improves 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 FT.
sale.If,however,the building mimprovement is sold within amyearofcompletion,O¢ SQ.FT.FPOWRB $/SQ.FT.
owtmr-builder will have the burden of pmvimg that he did nm Wildor improve for pur- PY
pose of sale.).
Q h as owner of the property,am exclusively conducting with licensed convector,to .TOTAL:
construct Ne pmjeet(Sec.](144,Business and Professions CMe:)The Committers U. PR .d 4 ���
cense Law does not apply to an owner ofpsonmy who buildsorimpmere
vestbon.and QTY. PLUMBING PERMIT FEE
who convects for such projects with a crearctot(s)licensed pmomm m the Contmnars `1
License LuPERMIT ISSUANCE tMl7NQ
1 am top under Sec. B&P C for this reason VUf
ALTER-DRAIN&VENT-WATER(BA)
n ❑ate �}+ VALUATION
W RKder. PENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under gena ty of Pe jury one of the following declarations: .7
I Internal will maintain a Cenificate of Consem to selbin,ima for Worker's Carmen- DRAINS-FIAOR,ROOF.AREA,GOND, STORIES TYPE CONSTRUCTION
lf�
on,as provided for by Section 3700 of the Labor Cale,far the performance of the
for which this permit is issued, FIXTURES-PER TRAP
I have and will maintain Worker's Compcnsmian Insurance,as required by Section
3700ofthe labor Cale,for the performance of the work for which do,Krmir is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP pPN
My WaAr
ee.Compensation Inumance cader and Policy nber umare:
Carrier. Policy No.: GAS-G.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OREASEANDUSTRL WASTE INTERCEPTOR N DIVISION FEES
Oris section need not becompleted ifthe permit is frrom hundred dollars GREASETRAP or less.) PLANCHEC 6
Loy any peso the peymannrof the work for subjech ct to
permit ises'Camped-hall SEWER-SANITARY-STORM HA.200 Fp.
not employ any person in my manner so as m become suhjcn m the Workers'Camped- ENERGY FE
OZ sation laws of California,Date WATER HF.A'1'IiE W/VENTMLECTR
Applicant GRADING
NOTICE TO APPLICANT:If,after making this Certificate mlExempabon,you should WATER SYSTEM,TRLATING
aFy become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
forthwith comply with such provisions or this permit shall he deemed revoked WATER SERVICE:
d
CONSTRUCTION LENDING AGENCY NEW RISIDENTIAL PCMB. SQ.FL PAID
(.10 • )hereby affirm theuhere isacoruwcdon lending agency forthe perfomance of Da Receipt#
IL the work for which this permit is issued(See 3007,Civ,C.)
QF' fenders Name TOTAL:
LJ finder's Address TOTAL: '
0. + I ccnify chat 1 have read this application and store that the above information is BUILDING O
(A conem.1.1.to comply with all city and countymdirances and state lows relating to QTY, MECHANICAL PERMIT FEE
IJ building convection,and hereby authoriu repusematives of this city to enter upon the SEISMIC Flif "
movcmentiuned property for inspection purposes.
(We)as.to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE LLECI-RIC E
liabilines,judgments.casts and expenses which may in any way accrue against said City ALTER OR ADD ib MECH.
in asequence of the granting of this permit PLUMBING
APPLICA UNDERSTANDS AND WILL C MPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0.10 CFM)
SDURC. .G LATIONS. ,I - MECHANICAL FEE
f� AIR HANDLING UNIT(OVER 10.000 CFM)
CONSTRUCTIONTAX
Signumr AWlicanpCondncror Data EXHAUST HOOD(WMUCI) HOUSING MITIGATION FEE
HAZARDOUS h RIALS DISCLOSURE
Will the applicant or future buil ing occupant store or handle hanrdous material HEATING UNIT(TO I W,000 BTU)
as defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
E]Yes C]N. VENTILATION FAN(SINGLE RESID) PAID
Will the applicant be future building occupant use equipment or devices which Date Receipt#
nut haumdoas air emntmnimarts as defined by the Bay Ara Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
isttict]•
❑Yes ElNo - BOILER-COMP(OVER I00,000 BTU)
I have read the hvundous materialsAIR CONDITIONER
requiremenu undo Chaplet 6.95 of the Cali- ISSUANCE DATE.
fomiv4, j
y Cotle,Sections 25505,25533 and 25534.1 undeboun l that if the NEW RESIDEN'TIAI.MECH. „SQ.FT.
huildiently have Ter t tat' is my respsmsibility mnotify the mcupant
thehich gyrus to mintm�e of a C. / �c myOwneagent Y Uv TOTAL: ISSUED BY:
OFFICE