30614 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. a� 0 C
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. J U 4
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRMS: SANITARY NO. APPLICATION SUBMITTAL DATE
10201 N. De Anza Blvd. Cupertino.` *(The Jack Dymond Constructio CO.) /a��,p
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO: / - l
J.D. Const. Co. 64 915 NIC CONTROL#
\RCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
HO% ' P.O. Box 7430 Mt.VieV CA 9403
CONTACT: PHONE: BUILDING PERMIT INFO
Gil Hubbard 415-243-0555 ❑ Consultant Fees Paid by Applicant(Initial) BLDG FkECT PLUMB MECH
PAD _\PUIA, v -6031/ ' 1:1 ElLICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing OB DESCRIPTION
y�y11 a,Z with Section 7000)of Division J of the Business and Professions Code,and my license is RESIDENTIAI: _
FaWr in full forteandeffecn. ` PERMIT ISSUANCE ❑SFDWL x
QUU Licersse Class RI Lic.# 6499115 - El KITCHEN REMODEL
HzW Dam Cont.aor APPLIANCES—WISH)IIIAL ❑ADDITION El PLUMBING RE-PIPE
7y ARCIIffECTS DECL w OIIS . CO. PANELS C3 MULTI-UNIT
[]STRUCTURAL
1 understand my plans shall he used as public records MODIFICATION
oz-, UPTO 2N)AMPS ❑INTERIOR ❑CHIMNEY REPAIR'
�kF
Licensed Professi...I 201-1000AMPS IMPROVEMENT
OWNERtBUILOERDHCLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
1 hereby affirm that 1 1. exempt item the ContracmLicense Law for the
3 Bt, follownng rensnn(Secti.n 70JL5,Business and Profcasinnz Code:Any city or county SIGNS ELECTRICAL ❑OTHER
0a which re9uirea a permit on cmutmcn,Oct.improve,demolish,or repair any sfeucwrc
0.4 PH.".I.i.moue,alsu1e1iresthe applicam farsuchpemut m file.signed.amerrem SPECIAL CIRCUff/MISC. "
y that he islicensed purosmmonalumvisimisofthe Contractors License Law(Chapters
00 (commencingwiNSectim.7000)or Division 3 office Businessmd Professions Code)or TEMP,ME TER OR POLE INST. COMMERCIAL:
than he is exempt therenrom and the basis for the alleged exemption.Any violation of ❑NEW RLDG/ADDITION ❑DEMOLITION
x To Section 7031.5 by any applicant for a permit subjects the applicanuo a civil Penalty of POWER DEVICES �7 TENANT ❑FOODSERVICE
{O y not more Nen five hundred dalton($500). IMPROVEMENT
LLD 1,to owner ofihe property,or my employees with wages as their sole compensation, SWIMMING PoOI.ELECTRIC
Q will do the work.and theswcam,is not intended oronfered for.[a(ST 7044,Business '[I OTHER
and Professions Code:The Contractors License Law does not apply on an owner of OUTLETS—SWITCHES—FI%TURES
property who builds or improves aherton,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If.however the building or improvement is sold within one yearofcompleaion,the SQ. AREA
ervbuilder will hf saoe the burden of proving that he did at build or imp.ve for put /
posy ole.).
❑ Lu owner of the propeny,am exclusively contracting with licensed contractors to
onsimet the project(Sec.7044,Business and Professions Code:)The Contractor's Li- �p 1 p z
cense low does not apply to on owner of pmpeoy who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a confessionals)licensed Torsion,no0o Comec.rs x
License Law. PERMIT ISSUANCE
❑I em exempt under Sec. ,B&P C for this reason
Owner Date W U
ALTER—DRAIN&VENT—WATER IEA) p pVfLUION
WO RKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE yy ,`
I hereby anion under penalty of perjury one of the fallowing deelam !y tianic G J`: V
❑I have and will maintain a Cent dine ofC.menu.self-insure for Worker's Compea- DRAINS—FLOOR,ROOF,AREA,COND. 1 'I PB CONSTRUCTIONcation,as provided for by Section 37M of the Labor Code,for the performance or the
work for which This permit is issued. FI%TURPS—PER TRAP V BPAINIf ,Lf,
❑1 have and will maintain Worker's Compensation Insurance,as required by Section on
3700of Ne Labor Code,for tic pefoomer.utthe work for which this permit is issued. OAS—EA.SYSTEM.I INC. OUTLETS .O OU APN
My Work{' pensaOun Insurance carrier Policy
Policy ryypp.y ir. - -
Carrier. +'+'^s Policy Na: GD41121901 GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPIINDUSTRL WASTE INTERCEPTOR
(This section need not becompleted done permit is for one hmndreddollers T$100) BUILD IVI ON FEES
or less.) GREASE.TRAP PLANCHECK THE[ to
I certify that ire the performance fthe work far which Nis permit is issued.I shall SEWER—SANITARY—STORM EA.2W FT.
.of employ any person in any manner sou to beconm subject.the Workers'Compen- ENERGY FEE
Z sadva Laws offulifumit.Date WATER HGTI3R WNBNT/ELECR eV
OO Applicant GRADI
L'Zi ,r, NOTICE TO APPLICANT:If,after making ibis Cenificate of Exemption,you should WATER SYSTEMaREATING
F' FY
become subject to fie Workers Compensation provisions of the Lulwr Code,you must SOILS
r. forthwith comply with such provisions or this permit shall be,deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.PT. PAID
V Q Ihertby affirm that there isac.nflmcnion lending agency for the performance of am Receipt#
the work for which this permit is issued(See.30197,Civ.C.)
0 F-'
O Lender's Name � TOTAL:
U Lender's Address TOTAL:
Wy 1 certify that I have Had this application and ata¢that the amwc information is BUILDIN 1
V1 correct.1 agree to comply withell city and county ordinances and state Taws missing to QTY. MECHANICAL PERMIT FFE
V bulldingemsuucnion,and hertbya.hmlee tepreserouvesafthis city eco entervgm the SEISMIC FEE
above-mentioned property for inspection purposes.
(We)ag. save,indemnify and keep m
p hedese the City of Cupenim against PERMIT ISSUANCE ELECTRIC FEE
U,
liabilities,judgments,costs and expenses which may in any way seems,against said City ALTER OR ADD TO MECH,
in consequence of the granfng of this permit. PLUMBING FEE
APPL T UNDER TANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT To 10,0(10 CFM) FE
SOI C ECU1LATI 5. MECHANICAL E
9 , 10—t- AI R HANDLING UNIT(OVER 10,000 CFM) CONSTRUCr1ONTAX
Sigm.te of pelican //l Dam EXHAUST HOOD(W/DUCE) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store catenate harsNous material HEATING UNIT(TO 100,000 HITT)
as defined by the Caliendo.Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255326a)7 - HEATING UNIT(OVER 100,000 BTU)
0YesnNo VENTILATION FAN(SINGLE RPSID). PAID.
Dara Receipt#
Willthe applicant or future building occupants use equipment m devices which #OILER—COMP(JHP OR I00,OIMl BTU)
mit hamrdous air contaminants u defined by the Ray Amo Air Quality Management TOTAL:
District? BOILER—COMP(OVER 100,000 BTU)
❑Yes Rom
- I have Had the barurdous materials requirements under Chapter 6,95 of The Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECIL SQ.Im
building does not currently have a annual,that it is my mspmsibility to notify the Occupant '
of the requirements which must he met prior to issuance of a Certificate of Occupancy. ,
Owner or uwhonmd agent Data TOTAL: ISSUED BY:
OFFICE