30956 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECERICAL PERMITNO. 3 0 9 5 6
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
OWNER' : N CONTRACTOR'S NAM LIC NO NDC C/� ROL N
ARCHI CI BBR:�^ ��—LI I'lliA ADDRESS'. ❑ a�`�
CONTncc
PHONE BUILDING PERMIT INFO
Ad(D —s a -5-
,S-0 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I heabr soman mat 1 man herwl order porremonr of chanter 9(mmmeneing JOB DESCRIPTION
OOZ with SeaionJWO)af DivisionJof tbeBmircarxnd Rofcssions Cade,anal mylittnse is ` RESIDENTIAL,
full force and affect, PFRMTT ISSUANCE -- -
❑SFDWL ❑KITCHEN REMODEL
�U'hj UcaDents CW.ss LION APPLIANCES-RESIDENTIAL
W Doc Gmtnam ❑ADDITION El PLUMBING RE-PIPE
FOy ARCHITECTS DECLARATION ❑MULTLUNIT El STRUCTURAL
Z OrZ, 1 undustual ro plans shaMed ll usas Puhlic acutds PANELS MODIFICATION
OZ-- UPT0200AMP5 ❑INTERIOR CHIMNEY REPAIR
F.4°L t�i Liccmd Prof,ssimin 2111-IOW AMPa IMPROVEMENT
..I OWNER-BUILDER DECLARATION comer ON OVER I0f1(I AMPS � ❑BATH REMODELREPAIR [I DEMOLITION
C'ew Q 1 hetes.form on 1 1 ,emnpt from the Cmm�ct«s e:Any c taw for the
�a5 O d V following reason.(amino 70315,t,Business and ove,dlaiatrs Code Any city or county tura SIGNS ELECTRICAL y OIIiER
W WO F' which t ots m i a humin re construct,alcor,int torsi n perm rte,or repair any svuewm
pronusli,c. dface,.mar,1.the Oweppllumt torsion 10 filesignedpChatsem SPECIAh CIkCUIT/MISC.
piq, y thatheenni.nrcdffrsuent tothapmnsmit of their B-mtors Lmande taw(CCapter9
te. (�om he
exempt anfromeir and
of Dlvision3Mdweged co ipton Anyotu'Cak)of TEMPMElT_POLE INST. COMMERCIAL:
a q oC Seethao is exempt 0ny a and drc terms it the rs diel conniption 1.Any violation of ❑NEW BLDGIADDITION El DEMOLITION
i� aa• Sminn l03L5 by any epplicwt fwapermit whjccu ted apple<untwacivil penalty of POWER DEVICES 0TENANT ❑FOOD SERVICE
F,Z� nal moa thin five hunbed ddlm(f5W).
yy< I,as owrcrof mepropery,umy unpinyers wiN wager rev their aIle ammpnsetion. SWIMMING POOL ELECTRIC IMPROVEMENT
p.0 will do the winds,Anal the wuctme is cost imcnddor offered for over(Sao70ab4,Business - ❑OTHER
W3 and Pmfessiens Code:The Contract«s Licence Law docs not apply to an owner of19 OIITI,FIS-SWITCHES-FlSTORES
popery who builds or improves mcam soil who dos such work himself ar mmugM1
his own employees,pavidM that such improvements as not intended err offered for NEW RESIDENTIAL ELECTR SQ FT.
-
sal,If.howev«,the building or mmpnrvemem is sold withimava yearufromplmioa rhe SQEL FLUOR A EA 9 Q'FT.
owncr-WEdar will have the burden of Moving that he did rw build or intpmve r por- .
pace err sok.).
❑ th
coaua ruct as ower Of 1M1e pmlwny,em exclusively conceomis worm I¢emd convenors to T
e prnjat(Sao 9044.Business and Proferaoar CadeJ'11¢Contrmm'a lJ-
scLaw dues nm apply to an owtwrrof pmpery win buids a improves menton,ad QTY, PLUMBING PERMIT FEE
who rnnlmeG far such profess with a crnttactrn(a)licensed pursuant to the Contrvd«s
U.law' ' PERMIT ISSUANCE '
lam er
eaemyt under S . ,B&P C for oris mumu
(Owed ^- �, �- I ALT F.R-DRAIN&VENT-WATER(EA) -VALUATION
WORKER'SCOMPFNSATIONDECLARATI(IN BACK FLOW PROTECT.DEVICE1 a'
rn
Ihe"IF,affirm under Fchy of perjury am of the following dm re 0.
❑ 1 bye end will maintain a Cerlfwme of Conumno ul6 insum forw'orker'a Compeer- DRAINS-FLOOR,ROOF.AREA,CORD,
cation,as Provided for by Section 3700 of ted:labor Codo,for the perfonwnce of the STORIESr TYPE CONSTRUCTION
work fu which this pmmit is issud. FIXTURES-PER TRAP `
[-I1 have and will maintain worker's Compensate—Inwrenee.as required by Section
37W of the later Coder for the performance of the work for which this Permits issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
My Worker's Comtcnaation Inwmtwc career and Policy number cane OfT�Al_
APE
Cavlee PMicy No.: GAS-EA,SYSTEM-0V ER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(lids udim recd nal be rompleted if tbcpernit is fwmcM1uMred Johan(5100) r� D�SION^FRES
in Free.) GREASETRAP D)7 It �� (�^ 2D �I cerify mat in me pNmuncofthc work for which this pamm is Ir win,Tanen SEWER- ..II V .SANITARY=570 tRM'EAi7tU�.f� 1yIr.Z satien laws of California,DateWgTER FEATFA WNENTApplicant IfEy NOTICE.TO APPLICANT:If,after making this C«tlfieate of Exentrarm yea dmuWWATER SYSTF.MII'ItEATING
haome sub*(to tk WorkCs Compenramion provisions of Bae Lahr Cult,year must 11��frrhwim comply wim such provisions or this permit shall be damd revoked. WATER SHBl'CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAI{P �. nrya .S�TPRI U C) I hereby affirm Nv thea is zee bamormn lerdmgagency forthe perfao ov. eceipta
O wr for mm�mirep mal,ri «I(s«. an.c.c) L TI Q
U lenders N.
TOTAL.
IllI &I
a. Lrndcr'I Address 1
V) 1 certify met 1 have read all
city and coup and dime met do starve iws matin is BUILDING FEE ti
.y
Z sorsa.l agree id comply with ell city and county O mi-md ad stare lana rdvine m Q'IY MECHANICAL PERMIT FEE
U u .1boveng«nmuclinas h«ehyautlwnarcposemativu of thiwily to enterupon dw SEISMIC FEE t
rinse-(W t) poppy far indp,iont keep ee. PERMIT ISSUANCE
(We).gra s,rave,indemmfy and kith barrtdeu the City of C....I s against ELECTRIC PF:B
in
mr and es prop which may in any way ossa,egsiaa deiJ City ALTER OR ADD TO MUCH. Q
' nuqurnce Of the granting of thisprnnit. PLUMBING FEE l:7
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-LPOINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. AL FEE
Rj"]-I, AIR HANDLING UNIT(OVER l0,o0n LEND MECHANICTIONT
IIlnf // CONSfRUCIION TA%
Sigremrc of Ap ran��witar One EXHAUST FOOD(WIDUCT) HOUSING MITIGATION PE
HAZAI(WUS MATERIALS DISCLOSURE.
Will the sHoicvnt«boom building..port stone or handl,M1acvdous material HEATING UNIT(TO 100,1100 BTU)
as def nal by the Cupenioo Municipal Code.Chaffer 9.12 and the Health anal Safety
Code,Seemm 255321x)^. HEATING UNIT(OVER ILL BTU)
❑Ycr 0N ' VENTILATION FAN(SINGLE RFi 1. al'i PAID
Date R«eiffa
Will nd us apinvialssitio ti lama handing oocupm y A eas Airtrnt or Mums which BOILER-COMP LIFE OR 100.000 BTU)
erNt M1umduua air crnaminenu as def nal by dw Bey Arra Air t�uelity Alwagertwm
Dismricl^. TOTAL:
❑Ycr ON. BOILER-COMP(OVER 100.000 BTU)
I have read the havNoun mammals napuiamenu under Claper695 nfthe Cali- AIRCONDITIONER ISSUANCE DATE
fumes Hcahh&Safety Crile,Scctiora 25505,D533 and 8534.I understand that if the NEW RESIDENTIAL MF,CH. SQ.FL
building docs net cuoontly have a mmnt,that its my responsibility to toddy the twcupunt
of the seminarians worm to! m«Trirmiewarce.f.Cenifj , f agency.
ISSUED BY. v�Q
GP �i � (JSP'
Ox'ner Or euthurvcd agrnt �
OFFICE