30626 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT N030626
. 'a O /N^
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL J( Il'J�L YV�
BUILDING PROJECT IDENTIFICATION
BUIIAINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATF
me - Bl-vi) uPEC'TOR:S �v L1,4q-a�-96
OW ER:SNAMP' NGX P ONE: COM' NAME: LIC NO:
t R Lfg, s 11 NIC CONTROL
IT[CT?NGINEER: - L 'NO: I ADDRESS:
U ❑ (ywT,r14
C CONTACTV
^/t(r5L e-(.✓///�U IQ'JY(YIS HON(.. S-./0, BUILDING PGR LUT INFO
❑ Consultant Fees Paid 6y Applicant(Initial) B� FLEECY PLUMB MECH
6A.A a 08-8/0/ w�5�k ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ]OB DESCRIPTION
1 hereby off,.then I am licensed under provisions or Chapter 9(commencing
Oa"Z
�00 with Section 7000).f Division Sof the Buainesxand Professions CMe.suit m license is
r PERMIT ISSUANCE RESIDENTIAL:
in full force and effect.
'aUF License Class Lick CSFDWL � ED KITCHEN REMODEL
F.Zµ� pate Curacao, APPLIANCES-RESIDENTIAL ❑ADDITION C PLUMBING RF,PIPE
ARCHITECTS DECLARATION [I MULTI-UNIT ❑STRUCTURAL
Z O
>G I understand my plans shall M1sed az rouPANELS e upublic.,,ad, MODIFICATION
OZ-O UPTO 200AMPS [I INTERIOR [I CHIMNEY REPAIR
ggLicensed Professional OWNER-BUILDER DECLARATION ml-HOIAMPS IMPROVEMENT
3
6 1 hereby aRrm that I em exempt from he Gtmracmr'e License Law for the OVER Ig0AMP5 [:J BAT"REMODEI/REPAIR C1 DEMOLITION
06C2 following reason.(Section 7031.5,Business and Professions Code:Any city or county, SIGNS ELEMRICAL COTHER
which requires u permit to cnmwn,enter,improve,demolish,or repair any structure
pHer m its isxunnee,alsorequires theappli.al mrsuch pemtit an fileasignedstaemem SPECIAL CIRCUITIMISC.
y thaheislicensedpursaan11.me provisions ofthe Commeam.Law..la. Chuarr9
00 (commencing with Scctinr7l)(I(Iloflivision 3 of1he Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
ayx c oC met he is exempt therefrom and the basis for the alleged exemption.Any violation of (2 NEW BLDGIADDITION C DEMOLITION
Way Section 7031.5 by any applicant for o p:mtir uahjrcts the applicant o a civil penalty of POWER DEVICES []TENANT El FOOD SERVICE
zQ or mare than five hundred dollars($50(7.
� has owner of the norm to cos with wu nmlhcir sole cnm nsation, SWIMMING POOL ELECTRIC IMPROVEMENT
SxO ❑ me sir r rot in r g i, ❑OTHER �^�
,t�isyE will dutMwons and me diodone is not Liensoro(w doesarot apply tonin,Business ✓V1���
and Professions Code:The Convenor's License law docs ern apply 6'3 owner of OUTLETS-SWITCHES-FIXTURES r property who builds or improves thereon,and who does such work himselfif or through
his we employees,pnrvided that such improvements are rem n iyear ,J or offered for
NEW RESIDENTIAL ELECTR SQ FT.
sale.If, willow hav bidding burden
f Powint issoldhe didin,build ofcmmpleltomme eCQ.hT.SL AREA LSQ.IrI'.
owner-builder will have the burden of proving thus he did no,
build or improve tmr par- K•
you of aslant.
co s,as owner of me prapeny.am exclusively mesand cantrodins with licensed cnntmctnrs to FEB 1 2 RECD
construct the project(Sec.TOW,Business and professions Code:)The Commdor'x Li- ,
cense Law does not apply to an owner of property who builds,er improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a coronations)licensed pumuanuo me Contractor's les. ar
1
License law. PERMIT ISSUANCE I•}�1 f 0- UUI'LHNNO
1 am exempt under Sec. ,B&P C for this reason
OwnerDam ALTER-DRAIN&VENT ATS (EAJ VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECp DE
1 herthy offirm under por alt,of perjury one tit the fellnwing declarations:.
t]I haveund will nminwnoCenilicamof Consenunsclf-inxurc for Worker's Competr DRAINS-FLOOR,ROOF,AREA.COND'.' - STORIES TYPECONSTRUCION
sation,as Provided for by Section 370],of the labor Calc,for the performance of the -
workforwhichthispermltisissued. FIXTURES-PERTRAP /
1 have vad will maintain Workers Compensation Insurance,ns required by Seainr
37Mofthe Lebo Code,fortheperfommnceofthe work forwhich thispermitis issued. GAS-EA.SYSTEM-IING.4OUT T OCC.GROUP APN
My Worker's Compensation Imvrance carrier and Policy min lter arc:
Carrie,. Policy No.: GAS-EA.SYSTEM-OVER J(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF.ASFJINDUSTRI.WASTE INTERCEPIVDR
(This swtioa need 11,11 twevor meed ifthe parrot,is forme,hundred Jollnrs($Rah BUILDING (VISION FEES
or leis) GREASETRAP - PLANCHECKF r+
1 certify mat in the performcore of the work for which this permit is issued,l shall
not employ any Person in any m 1 manner se as become subject to the Workeri Com SEWER-SANITARY-$TORN EA. FT.
Z sation laws of California.Date pen- ENERGY FE
z O Applicant WATER HEATER WNENTAiLECfit
GRADING
NOTICE TO APPLICAN E If,after making mix Certificate of Cx,oraimn.you should WATER SYSTEM/TRFATING
a , become subject to the Wmerf,C,1mpemntion prnvisimis of the Labor Code,you must SOILS FEE
{LI forthwith comply with such provisions or this permit shall Fe deemed revoked WATER SERVICE
d Q
CONSTRUCTION LENDING dinga NCV NEW RESIDENTIAL PLMB. SQ.FT. PAID
V0I for whantroth,mitt i isaed(See 30 lending agency for flue performanceof m Receipt Y
'he work far which this permit is issue)(Sec.309],Civ.CJ
O Lender's Name TOTAL:
{Ufa Lender's Address TOTAL:
1 certify that I have read this application and stow that the above information is M— HOUSINGMETIGATIO
UILDING 1> E —
Vii correct L agree m comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT
V building construction,and hereby stalactite representatives ofthis city m enter upon the EISMICF e
alone-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against LECTRI FEE
liabilities,judgencnts,costs and expenses which may many way accede against said City ALTERORADDTOMECH. LUMB( PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT(TO 10,1100 CFM) ECHA CALFEE
SOURCE REGULATIONS.
AIR I HANDLING UNIT(OVER 10,010 CFM) ONSTR . IONTAXSignaurem'ApplionUContracmr Dam EXHAUST HOOD(Wd1UCT EE
HAZARDOUS MATERIALS DISCLOSURE
Will me applicant or future building occupant store or handle haradous material I(EATING UNIT(TO 100,IKK1 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and me Realm and Safety
Coda n25532m)? HFTING UNIT(OVER 100,000 BTU)
es 0 N
VT:NTILAOON FAN(SINGLE RF.SID) PAID
Will the applicant or future building necupum use equipment or devices which Dae Ecce pr'k
emit harardous air contaminants as d,fi tied by lha'lh,Area Air Quality Management - BOILER-COME(RIP OR 100."BTU)
District? IOTA
i �Ycs ,C No - BOILER-COMP(OVER I00,000 BTU) -
I have real me haandois materials requirements under Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 undersand mut if me NEW RESIDENTIAL MECII. SQ,ET.
huildingdoesnmentlyhuveatetum.thatitismyse,msihility to notify the occupant
of equimmen ich rot t he met ono issuance of u Canaw of(c v y.
Owner or riral,gem C�' O( Date TOTAL: ISSUED BY.
'OFFICE