30939 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 30939
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DE
3 AT-z
O ER;S NAME: PH NL': CO ACTOR'S NAME: LIC N0:
NIC CONTROL
�A CHI'1'EQ'l1iNGINHE LIC NO:
AgDRESS: • 4G a 4 �c ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MECH
❑ ❑ _ ❑
umENSEDCONTRACTOR's DECLARATION QTY. ELECTRIC PERMIT FEE
C C)Z 1 hereby 70 aft that 1 me the B ander provisions of chaplet 9¢ommenems JOB DESCRIPTION
wish Section](MI(I)ec Division l of the Rosiness anA Podesniom Code,and my license i. F
�O O PERMIT ISSUANCE R_SIDFNTIAI:
F-V F in full force and ellen. D SFDWL 0 KITCHEN REMODEL
V V License Clans Lia p APPLIANCIigRESIDENTIAL
F. i I)ae Commator — ❑ADDITIONLUMBING RE-PIPE
ARCHITECTS DECLARATION EhiULTLUNIT S
PANELSTRUCTURAL
O Z y Z I understand my plans shall be most as public recrd
os
O E
ATION
UP TO 200 AMPS INTERIOR CHIIMN
❑ OYR PAIR
1=�F'u; Licensed Professional 201-1000AMPS IMPROVEMENT
C W X j at amexemptOWNER-BUILDER front
me CoATION OVER]"AMPS D BATH REMOUEL/REPAIR O DEMOLITION
y u:6 I hereby all"arm that I am exempt Tato Ne Cunvuaor's License Law for the
i�3 a.u following raisin.(Section 7031.5,Business and Professions Code.Any city or county SIGNS EL[LTRICAL DOTHER
LL R y which rcPure,a permit to ammo ,aha,improve,demolish,or rcpalr any mructu¢
F"uco
prior to its issuance.also requires the applicant for such perniuo file a signed statement SPECIAL CIRCUITIMISC.
co
W ttprevisions that he is licensed pursuant the pvisions of the Cortactor's License Law(Chapter 9
0� (commencing with Section 700))of Division 3 of the Business and Professions Conic)or TEMP.METEROR POLE INST. COMMERCIAL:
a a p K that he is exempt therefrom and the basis for the alleged exemption.Any Ouhviun of D NEW BLDG/ADDITION D DEMOLITION
LL• Scninn7031.5 6y any applicant far apermil subject,the applicant loo civil Penalty of POWER DEV ICES
..y n more than five hundred dollars($500). []TENANT ❑FOODSERVICE
F.
I,as owner of the pe,ti employees with wages as their role coat IMPROVEMENT
ASO ❑ t ar y Ycntp y ,B.,irom. SWIMMING POOL ELECTRIC
CF ill do the work.and lheswcturc most oruffered latrine(Sec.](004,Booties OGTHER
13 and Professions Cale:The Contractors License Law docs not apply to an owner of OUTLET'S—SWITCHES—igXTURL•S
propeny who builds or+mproves thercnn,and who does such work himself or through -
his own employees,provided thin such imp...arm r,arc nm intended or offered for NEW RESIDEN'T'IAL ELECTR SQ FT.
sale.If,however.the building or improvement issind within one year ofcompletion,the SQ.FT.FLOOR AREA YSQ.FT.
awria,builder will have the burden of proving not he did not build or improve for pur-
pmc of sale.).
1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
consumer the project(Sec.]BTL Business and Professions Cede.)The Conmtaor's Li-
cerise Lave does not apply 1oanowner ofproperty who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such pmjcem with n contm usn')licensed pursuant to the Contmaor's
License law. PERMIT ISSUANCE O
0 I am exempt under Scc. .B&P C for this mason
Owner Date ALTER—DRAIN&VENT—WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROT Iii'.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑ (have and will mainmina Cenilicam ol'Cnnecm mseli-insure for Workers Compen- DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPECONSTRUCTION
scion,is Provided fur by Scones 3700 of the Lima Corr,for the pcif nrmuse of the
work for which this permit is issued. FIXTURES_PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
371X),`the labor Code.Nrthe perfamnerneof the wick liar which But,permit is issued GAS—EA.SYSTEM-I INCA OUTLETS UCC.GROUP APN
My WorYPeis Co penvtiun i"%imn ecrierand Policy nye y,
Camcr/'ae �yy— �'' Policy No, /t'�C/�JL•/ GAS—EA.SYSTEM OVER 4(EA)
co
I'110EfE%EMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
(phis section need not be completed if Tiepin it is h,rone hundred Jollurs 151(X)) BUILDING DIVISION FEES
or less.) GREASETRAP PLANCHECK FEE
I certify that in the performance of the work ler which this ammit is issued.)shall SEWER—SANITARY—STORM HA.200 FT.
not employ any Person in any manner so as to become subject to the Workecr Compery ENERGY FEE
� Z anion laws of California.Date WATER HEATER W/VENT/ELECTR
Z Applicant GRADING FEE
pJ NOTICE TO APPLICAM':If, marinading this Cenificam of Exempdmm,you should WATER SYSTEMiTh EATING
abecome suhjafto the Worker's Carmser ntion provisions of the Labor Coyle,you must SOILS FEE
forthwith comply withsuch Provisions or this permit shall be decmalrcvoked. WATER SERVICE
DZ CONSTRUCTION LENDING AGENCY NEW ftFSIDENTIALPLMB. SQ.FL PAID
V Q Thereby affmnhauhcre isaumstmctinn lending agency for the perfonnnnce of Dam R ei #
U. the work for which Nis permit in issued(Stt.3097.Civ.C.)
C) U Lender's Name TO'AL:
r Lender's Address TOTA
1 certify tm I have read this application and state that the above infernamon is BUILDING FEE
.F.o (4/J cores.l agree mcumply with all city and county ordinances and same laws miming to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby motorize representatives ofthis city Income upon Ne SEI.S.MICFEE
aM,vo-memionW propeny for impenion pnrpous' PERMIT ISSUANCP.
(WT)agate Ito sox.indemnify and keep harmless a Clay or,a gamin s against ELECTRIC FEE
liahiliticn,judgments,wsnwdof th 'x which may in any any nacos against said City AITEMORADDTOMECH.
' nscyucncc of the 6rmnting of lh' pemtil. PLUMBING FEE
APPLICANTUND. STAN D WI 1,COMPLY WITH ALL NON-POINT AIR HANDLINGUNIT(TO 10.000CFM)
SOURCE R' TIONS MECHANICAL FEE
L�•� AIR HANDLING UNIT(OVER 10,0M CFM)
CONSTRUCTIONTAX
Si o #pelican Co ems— Dale EXHAUST HOOD
(W/DUCT) HOUSING MITIGATION FEE
H BEGUN MATERIALS DISCLOSURE
Will the applicant or furore building no,upantibiae m handle horacdnun mutual HEATING UNIT(TO 100,000 BTU)
as defined by the Cuperinn Municipal Code Chapter 9.12,and the Health and Safety
Code.Section 25532m)! HEATING UNIT(OVER IMAM BTU)
O Yes ONm PAID
VENTILATION FAN(SINGLE RESID)
Will the applicant or futurebulding nacupaace equipment or which
Date Receipt#
minmai,emitaminams as Jchned byhe poy Area Air Quality Maradement BOILER—COMP(3HP OR IfX,fp BTU)
District'
TOTAL'
❑Yes No BOILER—COMI'(OVEH 1110.0110 BTU(
I have mnd the ham ardoun materials myulmmems under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
borons Health&Safety Cade,Sections 25505.25533 and 25534.1 understand Nm if the NEW RESIDENT IAL MECIL SQ.CL
does 1. 9
building ds not currently have a nem.that it is my responsibility mainly Nemenpant (_{. C_
of the requimmems which muss bemetpsfor to ofn Cenulaim of Occupancy. ( s
Owner or summion agent Date TOTAL: ISSUED BY:
OFFICE