30033 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY "
CITY OF CUPERTINO BUILDING-ELECTRICAL. - PERMIT NO.. 30033 0 O�3
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
IIUILUINC PROJECT IDBNI'IF'ICATIf1N
UILDo�iw S: —4QA '/✓" Y SANITARY NO. APPLICATION SUBMITTAL DATE
6-\.00,,6
W ER'S NAM''rot co � CONTRACTOR'S NAME: LIC NO: NICmv) �Ln
IRC CDENGIN' g _� LIC VT ItVD�LADDRESS: ElCORTACT.. FJryl PHONE:: BUILDING PERMIT INFO
�.�-•� t j 10(o6w ❑ Cansultan[FeesPaidbyApplicant(Initial) BrLx� ELECr PLUMB MECFi
/' 1� /frXI
LICENSED CONTRACTORS DECLARATIONQTY. ELECTRIC PERMIT FEE
OO wec1 hereby uffvm that um licemed under provisions of Chapter H(commencing LOB DESCRIPTION
Cith S 7000)of Div3 crane Business anons e.ancense PERMIT ISSUANCE Busid Professions Codd my license is RESIDENTIAL:
40 ision •'
a W r in full formalist effect. ❑A DWL [I KITCHEN REMODEL
QUU License Class Lice APPLIANCES-RESIDENTIAL,. ❑ADDITION, ❑PLUMBING RE-PIPE
rF 7Qy RWaI Dam
Contractor ,. .
F7>m
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT [I STRUCTURAL
O p y q I understand my plans shall he used m public records - CHIMNMODIFEY
TION
REPAIR' OZt-Q - UP3'02W AMPS -- [I INTERIOR ❑CHIMNEY REPAIR
,� W Licensed Nocakmd 201-IIMIDAMPS IMPROVEMENT
fY 66g' -�1 OWNER-BUILDER DECLARATION OVER HMAMPS ❑BATH REMODEL/REPAIR C3 DEMOLITION
< I hereby i ffum that 1 son exempt from the Contractor's License Law for the
Oy ❑OTHER
U following raom
(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
3 tL F which requires a permit to conswet,alter,improve,demolish,or repoir any samens.
prior to its issuance,also requires the applicant for such Permit o file o signed statement SPECIAL CIRCUDUMISC.
y
Net he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
�a�p0 (commencing with Section 7")of Division J of the Busimasand Professions Code)or TEMP. OR POLE INST. COMMERCIAL
dyx o 2" that he is exempt thercfmm and the basis fm Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^ Secpermit subjects by any applicant for a persubjects the applicant o a civil penalty of POWER DEVICES EITENANT ❑FOOD SERVICE
m not mate than five hundred dollvs($500).
[-Z T IMPROVEMENT
=Q wi I,mowncr and proscuctur myotimenees with wagesmtheiPlen 0,hl B sines, SWIMMING POOL ELECTRIC
W 3 G will dahewnrk,aodthcswc on isnot.License Lea,it forsale ID)44,Business []OTHER
and Professions Cade:The Contractors License do does not apply to nn owner of OUTLETS-SWITCHES-FIXTURES ��
p' hpropertyis own who Wilds or improves thereon,i and who improvements
such work himself m through
building
that such int e b are not intended trr offcmd for NEW RESIDENTIAL ELECTR SQ FT.
his awn employees,provided provem n
sale,If.however.the huilJing nr improvement is sold within um ycarofarmpldian,the SQ.FT.FLOOR AREA ySQ.f4.
owner-builder will have the burden of proving that he did not build or improve for put.
grs1 of aide
h
❑ us ownertutr of the property,a Business
cafessi ns with licensed mmctors m 3 1 ���--✓✓✓
commatheeaoaa(Sec.]04gwnerof and Professions Cnde:)Thescithereon. nd
naa Lawdts fer. applymts ithaofpactor whosedprds sant menisci Contnn.und QTY. PLUMBING PERMIT' FEC ..
who contracts for ouch projects with i commaar(a)licensed pursuant m the Cnntmctors
License Law. PERMIT ISSUANCE.
❑Iamexemptunder Sec. ,B&PCimitakrcason
ALTER-DRAIN&VENT-WATER IEA) [/�� VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affum under penalty of perjury one of the following declarations: VV
l have and will maintain a Certificate of Conacnt to self-insure for Workers Compete DRAINS-FLOOR,ROOF.AREA,COND. gTQR�S TYPECOSIMUCION
ration,IN provided far by Section 3700 of the Labor Code,for the performance of the
work for which this Permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
37M of the Labor Code.for the performance of are work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS dooOCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number etc:
Carri<c Policy No.: GAS-EA.SYSTEM-OVER 4 kDG
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASEANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section treed but W completed lithe permit is forone hundred dollars IS INH GREASETRAP
or lcasd PLANCHECK FEE a
Icenify tbm in the perfutmuncc of the work furwhich Nis Permit is issued,lshall SEWER-SANITARY-STORM EA.200 1T. O
ENERGY FEE
No employ any person in any manner so as m become subject to the Wurkerc Cnmpca.
0 Z. section Laws of Califonda.Dote _ WATER HEATER WNENT/ELECTR GRADING FEE
Applicant _
NOTICE TO APPLICANT:IL arm,making this Cenifeate of Exemption,you,should WATER SYSTEM[IREATING
aIN' become ounce,in the Workers Cum mansilinn provisions ol'the Lohor Code,you mull MELS FEE
W .ra fanhwith comply withwchp ovisins.or this permitsha]1 W deemed rcvukeJ. WATER SERVICE
Q
a' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U O work
affirin them li isaco (Sen.3n lending agency for pcdiurmance of - Date Recciptp
Ne work(or which this permit is issued(Sec.JB9],Civ.C.)
0 U Lender's Nome TOTAL;
U Leaders Address - TOTAL:
0. 1 certify that I have read this application and statethat the abuse m1mm nher is BUILDING FEE
CA correct.I agree to comply with all city and county ordinances and state laws relating In QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U Z, building construction,and hereby authorize representatives of this city to enter upon the L
above-mentioned property for inspection purposes. ` PERMIT ISSUANCE ELECTRIC RE(We)agree to save,indemnify and keep harmless the City of Caption.agrea
liabiliticajudgments,costs and expenses which may in any way accmeagainst said City IL AITERORADDTOMECH. PIA
` I � PLUMBING FEE
I.carrese,mora,of the granting fthis pemtit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CTO to."CFM)
MECHANICAL FEF.
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IgIXIO CFM) CONSTRUCTION TAX
Signature of Applicun A71musamr hate EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
IIAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupantstom or handle hnmNnus material HEATING UNIT(TO 100,000 BTU)M.us dcOnW by the Cupertino Municipal Code,Chapmr 9.12,and the Health and Safety
Cede,Section 25532(u)] I EATING UNIT(OVER I00.00D BTU)
J-1 Yes ❑No VENTILATION FAN(SINGLE RFSID) PAID Date Receipts
Will the applicant or furore building occupant use equipment or devices which HOLLER-COMP(3HP OR LEE,Of,U tlTUI
emit huardous ab comiummo a as defined by the Bay Area Air Quality Munagcmem
TOTAL:
District] BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑Nu
1 have read the hmurdons materials mluiremems under Chapter 6.95 of dm Cali AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code.Sections 25505.25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
Wilding doc i not currently have a tenunn that is is my responsibility to notifytheaecupmt
of the requirements which must be con prim m iamrce ofa Cenlfcate of Occupaasey.
Owner or authorized agent - Data ISSUED
OFFICE