30130 �wwry I IU HLL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF C'UPERTINO BUILDING-ELECTRICAL. PERMI'PNO.' 30130 ,
3O��O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. -
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
0Lbl QV-Q'LQ 131.E ' '
OWNER'S NAME: PH
�0.. ONE: CONTRACTOR'S NA LIC NO: NIC CONTROLN
�r
01111s.-bee 4RCHITECf/ENGINEER: GZ'`I O ADDRESS: El
or
CONUAA~CT`S PHONE:
r AUILOMC PERMIT INFO
v5 G► C�>,. #J 42-&-Za(V ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION -nt _-Ll7i'
QTY. ELECTRIC PERMIT FEE C�J(� �- /r�X_
1 hemby union th1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
CZp with Section 7000)ofDivision3 of Ne Business and Professions Code,and my license is
in full farce and effect. PERMIT ISSUANCE RESIDENTIAL:
W
License Class Lic.p ❑SFDWL ' [IKITCHEN REMODEL
� W Date Concrete, APPLIANCES-RESIDENTIAL 2.4 ❑ADDITION EI PLUMBING RE-PIPE
[[..pat ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z,p 7�. -I understand myp]ada shall teased.,public records PANELS MODIFICATION
0z QUP TO 200 AMPS
FJL-,{tJ Licensed professional ❑INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 2014000AMPS IMPROVEMENT
WW Q I hereby affvm that I um exempt foam the Comrnaols License Law for the OVER hast AMPS ❑BATH REMODEI/ PAIR [I DEMOLITION
3 LU. following reason.(Section 7031.5.Business and Professions Cade:Any city or county []OTHER
y which es o t m c mmoct,alter,balance,demolish,or re SIGNS ELECTRICAL
FG.W. f, rejoices perms p pain any trouncrt
2 m that he1lits censed piameregoiresthcuppifs.fdre such Contrau,6Liccensele file. Low
SPECIAL CIRCUIT/MISC.
L } that hers licensed pursu.m to the pmvisians of the Contmnurs License Luw(CM1apmr9
CC (commencing with Section 7")of Division 3 of the Bull ness and professions Code)or TEMP.METER OR POLE INST.
4 m that he is exempt therefrom end the basis for the allcgW eacan,ion.Any violation of W BLDG/ADDITION ❑DEMOLITION
,yy
"dill 7113 LS by any.ppli...I fora permit subjects daripplicuntto a civil penalty of POWER DEVICES ANT ❑FOODSERVICE
EJerly,
s-, } not more than five hundred dollars WO OL I.as owner of the propor my employees with wages as their Rude compensation, SWIMMING POOL ELECTRIC I - ROVF"MENT
sa� will do the work,odd the stmdum is not intended conffered forsale(Sec.7014,Business ❑OTHER
a 3 and Pmfessima,Code:The Convector's License Law does not apply tp an owner of OUTLETS-SWITCHES-FIXTURES
Property who builds or improves thereon,and who docs.such work himself or through
his awn employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL HLECTR SQ FT.
sale.IL however.the building or improvement is sold within one year of completion,the SQ.FT FLOOR AREA 5/SQ.ET.
ner-builder will have the burden of proving that he did not build or improve for put-
pose.(sale.).
❑I,as owner of the Seepro,cm,,70,L,B sin...andvely contracting with:)The C camracmrs Li-comtniact theprojectpplyton Businessandrtowhobuids or improves
m ro Convector's Li-legaJUN
2 Q 1996
who conwdaes not or Ruch apply ton hit ownerof whobuildsto the Contractor's QTY. PLUMBING PERMIT FEE L1IV O s,a,
who contracts for such pmjecu with a convaaor(s)license.)pursuant m the Cnnwcarzs
Licame Law, PERMIT I UANCE (il(y VY liUrCrf IIIVV
❑lam esemptunder .Sec. ,B&P C for this mason
Owner Dare A GRAIN&VENT-WATER IRA) VALUATION
WORKER'S COMPENSATION DECLARATION ACKFl PROTECT.DEVICE "2,9j
I hereby affirm under penalty of permit,one of the following deductions: 2,
❑I have and will maintain o Cenificam of Consencto self-insme for Worker's Comped- DRAINS-FZULP60F.AREA.GOND. STORIES TVPE CONSTRUCTION
aation,as pravided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURE. -PER TR
1 have and will maintain Worker's Compensution Insurance,as Required by Section
37W ofthe Lao,r Code.far the peruntance lithe work for which this permit is issued. CAS-EA..s•. .M-11 UTLRTS OCC.GROUP APN
My Worker's Compensation Insurance carrier add Policy number ere:
Carrico. Policy No.: GAS-EA.SYS E (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WAZE 1RCEPTOR
(This section need not becompleted Has,permit is Income hundred dollars($100) BUILDING DIVISION FEL,
or less.) GREASETRAP PLANCHECK FEE 2 �.
(certify that in the In,
of ihe s o,worktearewhich this the We rgera a coma.ll
ntionLmysay pcmcam any manner sn..v to M1erome subject the Warkers'Com _ SGWIiR-SANITARY-STORM EA,203 FT.
Z Applicant
of California.Data
pen ENERGY PF:E u
C WATER HEATER WNENT/ELLCTR
7 NOTICE - GRADING FEE
F7 NOTICE bj APPLICANT,IL atom making this Cenifcam of Excmptinn, ..should WATER SYSTEM/TREATING
abecome subject to the Worker's Compensation provisions of the Labor Code,you mull SOILS FEF.
W
forthwith comply with such provisions or this permit shall he JeensW invoked. WATER SERVICE
6r Q
Uz CONSem is a cIONLENDINGAGENCV NEW RESIUENTIALPLMB. SQ.1.7. PAID
U Q t,forw which
thi that iso issued
ct30 lending agency for the performance of 'Omc I
� the wank for which this pcnnit is issued(Sec.1097,Civ.CJULender,Name
Lemler's Addrtas -
�'0. 1 1 certify that l have rend this application and state Nm the above information is BUILDING FEE
% cored.l a gree to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
UZ building convection,and hereby uniform representatives oftmv city to enter upon the SEISMIC FEE
above-mentioned properly for inspersion purposes. ERMIT ISSUANCE
(We)ogre,ms save,indemnify and keep hornless the City of Cupertino against • ELECTRIC FEE O
lietilities,judgmcnm,costs and expenses which may in any way uttmeugainst said City ALTER OR ADD TO MECH.
in comer pledce of Ne granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,OW CFM)
SOURCE REGULATIONS. MECHANICAL FEE —
AIR HANDLING UNIT(OVER IO,B00CPM) CONSTRUCTION TAX
Signamrt of Applicant/Contmemo Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haa,dous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupees.Municipal Cale.Chapter 9,12,and the Health and Safety
Code.Section 25532(a)? HEATING UNIT(OVER Iftf,WB BTU)
❑Yes C]No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Will the air coma inmr future building occupantuse yAequipmentmdevices Manawhich BOILER-COMP OHP OR 100,000 BTU)
emit i't? air contaminants as defined by the Hey Area Air Quality Management
�DisWm1 TOTAL:
❑Nn BOILER-COMP(OVER 100,(1(1()BTU)
,
1 have mad me hudNom rsmterials rtq turnment under Chapter 6.95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
form. SafetyCode,he,S.monslSSOA is my rend2594.I understand mat if the NEW RESIDENTIAL MECH. SQ.FT.
building doesnots which have.,neat thuso ismyceof.Cflftyc andif, occupant
of the mquiremems which must be met prinrmissuance nfa Certificate oftkcuparry.
Ownefarauthonmd.gem Date ISSUED BY:
OFFICE