30518 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3 J<05
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5 11 VXV8
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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0SIPS NAME: PHONE: CONTRACTOR'S NAME: LICNQ
/V! A NIC CONTROL as
ARCHITECTIEtgGINEER: LIC NO: ADDRE. : ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
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Consultant Fees Pnitl by Applicant(Initial) BO ELECTU❑MB ME❑CH
�TI LICENSED CONTCRACfOWS DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
got. th Section]ulMp ufDivision3uf the eosins,,and Professions Cndeandmylimmusi, RESIDENTIAL: -
00 wr ERMIT ISSUANCE
� full tone and effect. ❑SFDWL ❑KRCHEN REMODEL
�UlE' License Class Lic.M - pppLlANCfiS-RESIDENTIAL ❑ADDITION ❑PLUMBING RF.PIPE
NF Z a Dore Convector _
ZOIno C ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT El STRUCTURAL
5 VV� 1 understand my plans,ball be used as public records MODIFICATION
O Z,:JUPT0 2110 AMPS
I•41�Oi1 Licensed Professional 301-I(IfN1AMP5 IMPROVEMENT
El INTERIOR ❑CHIMNEY REPAIR
.•..:11 OWNER-BUILDER DECLARATION
Q 1 hereby affirm thin 1'mn exempt from the Cnntmeturs License Law fur the OVER I"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
gyp(,O y U billowing reason.(Section 703 1.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
41✓as I"' which requires a permit to convect,alter,improve,demolish,or repair any swcwre
0 priorm its issuancanlsonst,ores the applicant forsuch permit Write a signed statement SPECIAL CIRCUUDMISC. - /
yHas he is licensed pursuant to the provisions ofrhe Contractors License Law(Chapter 9
00 (commencing with Section Mid)of Division 3 ufthe Business sou Professions Code)or TEMP.METER OR POLE INST. O COMMERCIAL, ,
0, e K that he is exempt themfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
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Section 7031.5 by any applicant lot ap ormit subjects the applicant m a civil penalty of POWER DEVICES
�m ❑TENANT ❑FOOD SERVICE
F y
and more than five hundred dollun(S50).
Q Las owmr of the m norm rola ces wise we yes as theirmle cam tion, SWIMMING POOL ELECTRIC IMPROVEMENT
❑ t Soy Ye P Y b Pensee
a C ll ddothssitax and the he Con a totimendedLaw,doesard aale(d,to 4a Boniness ❑OTHER
and Professium Code:The Connector's License low,does nm apply nr an owner of OUTLETS-SWITCHES-FIXTURES
6 3^ pmpeny who builds or improves thereon.and who does such work himself or through
his own c n,liimea,provided that such improvements are not intended or offered fW
or NEW RESIDENTIAL ELECfR SQ .
sale.IL however.Ne huildin6mimpmvemem is sold within one year of complaion,rhe SQ.FT.Ft000.AREA SISQ.FT.
owner-builder will have the burden of proving that he did not build nr irepruve for pur-
poscofaale.). "
fill
71primary,I.a%owner of the ppery,am exclusively contracting with licensed comments no
IOTA
construct the project(Sec.7044,Business and Promismiri Cialrj The Carimmu is Li.
cense law does not apply nr an owner of property who builds or improves thereon.and QTY, PLUMBING PERMIT FEE
who commas for such projects with s cnmmrtar(a)licensed pursuant W the Convector's
License Law. PERMII'ISSUANCE
❑ I am exempt under Sec. ,B&PCfar this rrnson
Owner Bate ALTER-DRAW&VENT-WATT: ) r VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
Fl DRAINS andwill maimeina CenifiwW of Cunsem mself-insure for Worker's Cumpcn- DRAINS-FLOOR,ROOF AREA,CONI. STORIES 'fYPB CONSTRUCTION
;37W
n,as provided for by Section 37M of the labor Cove.for he performance of the -
for which this strut is issued. FIXTURES-PER TRAP -
have and will maintain Workers Compensation Insurance,as required h ..Par
of the Lalwr Cuk.forthe performance oft he work bn{whie niiiusi'esuul. GAS-[A.SYSTEMd INC.601ITL OCC.GROUPWork 1C r anon aurones Ter and Puli number arc:cc Policy, GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE '(EMPI'ION F OM WORKERS' /: GREASMNDUSTRI,WASTE INTERCEPTOR
COMPENSATION INSB NCE i BUILDING DIVISION FEES
(TTis section need nm hecumpined if Nt permit ex tents(SI001 GREASETRAP
or fess.) PLANCHECK FEE
I eenif n <performance of the work(or which this permit is issucd,lshall gE•WER-SANITARY-STORM EA.2001T.
not ample y per n any/manna w a to hctnnlP� 'aeon the Worker#Compen- ENERGY FEE
0� ,mien sof Cal snmria. to = /. WATER HEATER WNENT/ELECIR GRADING FEB
yO Applicant r _
y NOTTCETOAPPLICANT.If.aRelemlan ihla erificmeof ,luau,you should WATERSYSTEMUREATING SO . EE
1--! became sim.W the Worker s Cumpen t 1m visions of the labor Code,you must
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forthwith comply with such provisions ur vit shall be decmedrevoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ:PT. PAID
U p kforw which
his
theuhere issued 11",1 len ding agency for We perfnrmunce of Da¢ Receipt as
� the work for which this permit is issued(Sec.7(19],Civ,CJ
17'r Lenders Name TOTAL:
4US1 Lenders Address TOTAL:
y . 1 certify that leve read this application and shim that the above information is BUILDING FEE
V] correct.l agree to comply with all city and county ordinances and shite laws mating w QTY, MECHANICAL PERMIT FEE
building convection,and hereby authorise representatives ofthis city m enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save.indemnify and keep harmless the City of Cupcnino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
Z111
equ ce mfthcgmrom of this permit. PLUMBING FEF.
PPLI .T UNDF i'DS AND WILD COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10,000 CPM)
MECHANICAL FCE
SOUR( •RFGUI I '
AER HANDLING UNIT(OVER 10,000 CFM) CONSTRUCDONTAX
Signamrco App wnJCnnt Date EXHAUST HOOD(WMUCT) I HOUSING MITIGATION FEE
HAZAR or MATERIALS DISCLOSURE
Will the...beonlor furore building usemara me,or handle tiara Brox material HEATING UNIT(TO 10,00 BTU)
as defined by the Cupci iae Municipal Code,Chapter 9.12,and the Heahh it Safety
Code,Section 8532(a)^ HEATING UNIT(OVER 10.000 BTU)
❑Yes Fl No VENTILATION FAN(SINGLE RESID) PAID
Date Ree p
Will the applicant or fxame building reeuppnt use equipment or devices w
mmy hich BOILER-COMP(3HP OR 10,00 BTU)
emir hantous air a unarms as defined by the Bay Area Air Quality Management
Disuim'!
[D Yes ❑No BOILER-COMP(OVER 10,000 BTU)
1 have read to hi m ilm,materials mquinaimus under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cade,Sections 8505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.
building does not currently have a tenant,mat it is my responsibility W notify the eventual
of the accountants which must be met prior m issuance of a Certificate of Occupancy
,
0Owner or awhrriimd agent - Date TOTAL: ISSUED BY:
OFFICE