30649 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIIANICAL 3 0 6 4 9
BUILDING PROJECT'IDENTIFICATION
.U.DINGADDRfSS: SANITARY NO.]A�PPLICATIIONUBMIITCTTTAL DAt
ta11'ryEBNAME: /�k PH CONTRACTOR'S NAME: LIC NO: s'6
GSUY1/'' O '"Dle, NIC CONTROL#
ARCHITECPTE,GINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ Cr ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
Iiohereby 000)affirm mixomin I 3 licensed under pdPoA,, )visions f CJmr9«nmmemet, JOB DESCRIPTION
OWOO IXZ with Section 9fN10)uf Uivision3nf the Business and Professions Cnde,andm licenscis
11,w in full force and effect. y PERMIT ISSUANCE RESIDENTIAL
aUV License Class Lic.x ❑SFDWL [I KITCHEN REMODEL
yZW DateConvector APPLIANCES-RPSIDBNTIAL ❑ADDITION [I PLUMBING RE-PIPE
G ARCHITECTS DECLARATION PANELS
or,<S. MULTI-UNIT ❑STRUCI'UHAL
Z O'n Z I understand tat,Plans shall Nomad as#untie recent, MODIFICATION
OZ—, UPT02MAMP5 ❑INTERIOR ❑CHIMNEY REPAIR
1-4F'B1 Licensed Professional 2111-IgM1AMP5 IMPROVEMENT
IiNT
�S4 OWNER-BUILDERDECLARAT ION OVER "AMPS C Q 1 hereby affirm that 1 am exempt from the Contractors License Law far the Ll BATH RE.41Q 1/ \I DEMOLITION
K3 L Ct following reason.(Section 7031,5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER F k
mull W y which requires a permit,o conswct,alter,improve,demolish,nr,cpair any structure
prior to its issuance.also requires the applicant for such permit to file a signed statement SPECIALCIRCUIT/MISC.
MMC,
y that he is licensed punuan to the p,ovifion,mda,Conuemof's License Lw(Chapter 9
W C, (commencing with Section70oo)of Division 3 of the Basomro and Professions Code)or TEMP.METER OR POLE BEST COMMERCIAL
Q.a e R that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION DEMOLITION
W^y Section 7031. by any applicant for a permii.subjects the applicant m a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
1,,,Z�, not more than five hundred dollars($500).
yyQ ❑ I,as owner of the property.of my employees with wages as their so le compensaion, SWIMMING POOL ELECTRIC IMPROVEMENT
will it,,the wnrk,and limmoicmre is rent intended ornlfered knorle(Sac.)0de.Business ❑OTHER
and Professions Cole:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
properly who builds or improves thereon,and who does such work himself err though
his own employees,provided that such improvements are not intended mothered for NEW RESIDENTIAL ELECTR SQ t n
sale.ILhowever,the buildingor improvement i,sold within one year ofcompletion. he SQ.FTITY.OQRAREA S/SQ.FT.
crhadderwill havethe burden ofpmvingtnm hedid nal build orlmpmve fopur, {^ e O
E]1f side)
❑
I,as owner of the property,am exclusively contracting with licensed enntmctors to TOTAL.mnnnmt the pmjnt Ilea.7I94.6udncas rod nor n'ions Cndea l'hc Contractor',I.,- i
cama law dews not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE �S/,.rU - 3'An�
who contracts fon h projects with a comocmr(s)licensed punuentin the Comai --71 - h Oa7
License Law,
lam �� — 111- rcawm MII'ISSUANCE urC
OwnerDam ALTER-DRAIN&VENT-WATER(EA)
VALUA ON
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby arm,order#really of perp,y oe of he endowing dash radnm.:
❑I have and will maintain a Certificate of Consent oalf-insure for Workers Camper- DRAINS-FLOOR,RODE AREA,COND.
onion,as provided for by Section GOO of the labor Code,for Ne performance of the STORIES TYPH CONSTRUCfIO
work far which thio permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
37Wof,he labor Cede,for the perfnmtance afire work for which this permit is lswcd. GAS-EA.SYSTEM-I INC,4 OUTLETS
My APN
My Workers Compensation Insurance carrier and Policy number art:
Cartier: Policy Nov: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICA'I'H OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section need nn be completed ifthe permit is far nnc hundred dollars(SIOO) BUILDING DIVISION FERS
or Ices.) GREASE'I RAP
1 certify that in the performance o as t work fur vNixthNje this permit is inued,I ahvll PLANCHECK FEE
notemployLow any alifon in any manner so as to hecome.wbject to the Workers'Compem SEWER-SANITARY-STORM GA.200 FT.
,2 cation laws of California.Data
ENERGY FEE
� O Applicant WATER HEATER W/VCNT/ELEtTIt
Z GRADING FEE
h NOTICE TO nPo the Work If,after ranking this Cision,of
Exemption,you a must WATER SYSTEM/1'REATING
a ;
became subject m,the Workers pm Compensation provision of the Iuneu Code,you mea SOILS FEE
forthwith comply with such pmNsinnx ser this permit shall be dremeJ revoked. WA'TF;R SERVICE
0. Q
.`-3. z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
U Q Ihereby
ushich mthat Neto is acd(Sce.onlending agency for the perfonnnnce of Date NeceiptX
0 Ur. th adees for which Nis permit is la,ued(Sec.3197,Civ.C.)
Lenders Name
O U Tonder,Address TOTAL' AFEC
Fy I cenil,that 1 have read this application and,,ate that the above information is
h carrier l agree m comply with all city and roan, Ninancesand,titalowsmlatin m BUILDINGbuildm wetion.and bemn yn g QTY MECHANICAL PERMIT FEL'genas yamhmlrerposcs. ntives nfthis city wcnmrupon,M1e SEISMIC attove-mentionedpopes forimnifyan keephs. PERMIT ISSUANCE.(Wq agrtt to save,indemnify and keep,arml any w City of Cu onos idCity ELECTRIinconsaxmorcofarecoaxing Rhes esmit. may inany sayvecme against said City ALTER OR ADD TO MECH.in conseqence of Ne gmming of,his permiL PLUMBINAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CQ 10.000 CFM(SOURCE REGULATIONS. MECHAN
AIR HANDLING UNIT(OVER 10,000 CPM)
CONSTRUCTIONTAX
Signammof ApplicanUConuactor Dae EXHAUST HOOD I W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE ROUSING MITIGATION FEE
Will theapplicartt...future building occupantvoreor hunJl,hmardounalb,o.l HEATING UNIT(TO 101000 BTU)
a,defined by,he Cupertino Municipal Code.Chapter 9.12,and the Health and Safe,,
Cade,Sm,ion 25532(aV JWTOTAL:
NIT(OVER 100,000 BTU)
❑Yes 0N
N FAN(SINGLE RE.SID) PAID
Win,fie applicant or future building occupant use equipment or devices whichData Receipt x
emit halmho,cif comaminanrra,defined bythe Bay Area Air Quality Mana,mormMP OUT OR IOQO(10 BTU)
District? TOTAL'.
E]yes 0N COME I00.W0 BTU)
I have read the M1vashas matnials,ryulromem,under Chapter 6.95 mine Cali. IONER
Fame Health&Safety Code.Section 25505,25533 and 25534.1 m,dentand that if theISSUANCE DATE
building deemm curendy havezmnam.that it ism NTIAL MECH. SQ.FT.
y cesof,C nolic.notify the occupant
of Ne reyuimments which mea be net prior m issuance of a Cenilicaw of Dccupancy.
Owner or amounted agent DataTOTAL:
ISSUED BY:
OFFICE