30164 APPLICANT,TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT N0.'B 30164
ILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. %
BUILDING PROJECT IDENTIFICNrION
1o49i $
BUIL446D toya..rhE AvGa SANITARY NO. APPLICATION SUBMITTAL DATE
,lkWNfflVS NAME: PHONE: CO ACTOR'SN
LIC NO:
1 CRY! Qd tJ ` N/C CONTROL M
ARCHITECT/ENONEER: LIC NO: ADDRESS:
CONTACT, PHONE: p�p BUILDING PERMIT INFO
��AN AS Y-OM z.51 '4Z p p ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELEC PLUMP MEC
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT PEE /fY'-1(a``
1 hereby arum that I am licensed under provisions of Chapter 9(commencing - JOB DESCRIPTION
, 00 With
th Section 7")of Division Sof the Busineasand Professions Code,and my licenscis _
O in forramd effect.
y�UUrU License Clam Lic p PERMIT ISSUANCE
y 6 Dal Contractor FDWL C1 KITCHEN REMDDEI.
APPLIANCES-RESIDENTIAL CADDITION El PLUMBING RE-PIPE
F 7
not ARCHITECTS DECLARATION
Z O vv�p l understand my plans shall he used as public records PANELS C MULTI-UNIT C STRUCTURAL
O Z:4 UP TO 2M AMPS MODIFICATION
G o-111-1 Froo-NUMO 11 INTERIOR �C CHIMNEY REPAIR
LS` OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENTtj
O U I herehy M.thin I ore exempt from the Contractor's License Law for the OVER ItgB AMPS - C BATH REMODEL/REPAIR C DEMOLITION
3d following reasin.(Section 703 13,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
.LL.OW which requires a pronit m consvum,alter,improve,demolish,or repair any stmcmm A 11r
N prior m its"Immer,-Iso rrquims Ne apPRcanl for such mail to file aligned warmer, SPECIAL CIRCUIT/MISC. 1417 FA
y Net he is lianseJ purxuanno Ne provisions of the ContmcmJs License taw(Chapmr9
00 (commencing with Section 7")ef Division 3 of Ne Business add Professions Cale)or TEMP.METER OR POLE INST. COMMFR .IA u111•`i1(II[U
a y m ff Lha be is exempt therefrom and the basis rnr Ne alleged exemption.Any violation of
YX] y Section 7031.5 by any applicant for a Permit subjects the applicant to v civil penalty of POWER DEVICES ❑NEW BLDCJA6111T70N ❑DEMOLITION
Hot more than five hundred dollar, S500). C TENANT
F 7,y 1 ❑FOOD SERVICE
=p ❑Las owner of Nr pmpeny,or my employees wiN wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is not intended orolfered for sale(Sec.7044,Rtniness C OTHER
Gand Professions Cale:Thr Comment's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Property who builds or improves thereon,and who does such work himself or through
his awn 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 yemofrnmpletion,the SQ.FL FLOOR AREA $/SQ.ET.
owner-builder will have the burden of proving that he did not build or improve for pur-
f sale^). - ^
1XH
<raf he ped.(( .Bexdns andel,contracting with licensed Contractors
i.
conswct the project(Sec.]144,Business and Professions Cale:)The Commmor'x Li� '
c se Low doeam'tupplym an owner of property who huh Ids or improves thereon,add QTY, PLUMBING PERMIT FEE \
r who cam an forsuchP sets with u eontmnor(s)licensed puIL muenno the Comrucvrz's
Llcensr law.
❑ Ino exemptander Sec. ,B to Jlison't, PER
ISSUANCE
m , Date LTER-DRAIN&VENT-WATER(EA) VALUATION
ORKER'SCOMPENSATIONDECLARATION BACK FLOW PROTECT DEVICE
• I hereby affirm under penally ofpedury one of Ne following declinations:
❑I have and will maintain u CeNficamof Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF AREA,GOND.
senior,,as pmvidcs for by Section 3]00 of Ne labor Code,for the perfnmtance aflhe STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,sa required by Section
37M of Ne labor Code,for the pcAommnce ofthr,work for which ads permit is hours. GAS-EA.SYSTEM-1 INC.4OTLETS
My Worker's Compensation Imo ice carrier and Policy numM are: OCC.GROUP APN
Carrier. Policy NO.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE NDOSTRL WASTE INTERCEPTOR
or last
(This section near'not too,completed if Ne permit is fescue hundred dollars(II WGREASE TRAP
) tBdINGPIVESION FEES
Icenify that in the performance ofthe work for which this permit is issued,Lshall PLANCHET E �r
Z2 not employ any person in any manner so as to become subject to the Workidoc Comped- SEWER-SANITARY-STORM EA,2W PT.
Qavtion Law,of California.Dole - ENERGY r�
Z G Applicant WATER HEATER WNENT/ELECTR
GRADIN
NOTICE TO APPLICANT,If,otter making this Certificate of Exemption,yam shoals WATER SYSTEM?BEATING
h become subject m the Worker's Compensation provisions of the Lal+or Code,you mom SOILS FEE
fonhwilh comply with such provisions or this permit shall he deemed revoked, WATER SERVICE
0
z CONSTRUCTION LENDING AGENCY NF.WRESIDEN IALPLMB. SQ.FT PAID
U Q I hereby affirnuhotthem is aconswaian lending agency for the performance of Deta
{r. !� the work far which this permit is issued(Sec.3097,Civ.CJ
O U Lender's Name TOTAL:
y [>J Lender's Address TOTAL:
LL 1 certify that I have reed Nie application end state Not the above infommtion is BUILDING FEE 2 ��
h correct.I alter.ho comply with all city and county ordinances and sham laws rtivtingm Q
UZ building consometion,and hereby auNorim representatives of Ws TY. MECHANICAL PERMIT FEE city to enter upon the SEISMIC FEE Z qO
above-mentioned proper,for inspection purposes. PF.RMR ISSUANCE
(We)agree to as.,indemnify and r
keep harmless he City of CLpenino against ELECTRIC
Iiabilities,judgmems.eosts and cxpemeawhich may in any way accrue agvim.said City ALTERORADDTOMECH.
in consequence of the granting of this Permit. PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,"CFM)
SOURCE REGULATIONS. MECHANICAL
AIR HANDLING UNIT(OVER 14000 CFM) CONS TRIfCTI0 TAX
HAZARDOUS
Signature ofAppbcuUam EXHAUST HOOD OMMUCT)
A2ARDOUS MATERIALS DISCLOSURE HOUSING M ATION FEE
Will the Applicant or futurebuilding occupantsince Or handle lowishminmmrinl IIEATING UNIT(TO 100,00)BTU)
as de0nuf by the 32(d)?nn Municiryal C;wle,Chapter 9.12,and the Health and Safety
Code,SecOnn 25572(u7] IIEATING UNIT(OVER IW,IXp BTU)
❑Yes 7N
- VENTILATION PAN(SINGLE RBSID) PAID
JIM Will'he upplicam nr future building occupant use equipment or devices which Date Receipt
11H,eauNow air cnmeminents as definrd by the Bay Area Air Quality Management BOILER-COMP QHP OR 100,000 BTU)
ct1 - . TOTAL:
Fl You [2 No BOILER-COMP(OVER I OOJXG BTU)
1 have read the horalloux materials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER
farm-HeeIN&Safety Ctde,Sections 25505,25533 and 25534.I uMemtand Nat if Ne ISSUANCE DATE
.ftha daybsrems Which
oat poor
tn ismdem of.Catitcallatify,,namapant NEW RESIDENTIAL METH. SQ.FT.
of the regvirtmenu which must be met pion m issuatwwf a Cenificahe of s]ccupancy. '
Owner or euthomzed agem Dam TOTAL: ISSUED BY:
OFFICE