30567 APPLICANT TO FILCIN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
a • 1 BUILIIINC.-ELECTRICAL. "• PERMITNO. O
CITYOF
GDVISIONO PLUMBING-MECHANICAL
BUILDING DIVISION APPLICATIONII'fiRMIT BUILDING PHQdEGI'IDErv'T'IFIGn1IQN
BUILDINGADDRESS: - SANITARY NO, APPLICATION SUBMI'EfAL DA'H
z1 s 4 o -Ar �;as . e 1 '19 6
OWNERS NAME: - PHONE CONTRACTOR'S NAME: LICNO�
14()A �9 St.`71C --ebfl NIC CONI kid.is
4Rr /ENGI EN: LIC NAlURC :
AYCLC3 ❑ .
is
CONTACT: pp PHONF: BUILDING PERMIT INFCT7,
Fl}aA� 11ppW I-1� r I_
I-c 4j% c)(0 — ❑ Consultant Fees Paid by Applicant(Initial)'! BLDG ELECT PLUMB MECH W
4-LIZO ❑ ❑ ❑
LICEam r CONtNACIQRg re ionsRf 00N QTY. ELECTRIC PERMIT FEE
1 herthy affirm Nat I am licensed under pnrviaions of Chapter 9(commencing JOB DESCRIPTION
GCz wimh Scaion]II00)of 0ivisinn3of the Business and Professions CnJe,ane mylicense is RESIDENTIAL:
00 PHRMI't ISSUANCE.
in lull force xnJ ell'ccl.
�U6j Licen ❑SfT)WL 11 KITCHEN REMODEL.
h i Dm s omr nor
APPLIANCES-RESIDENTIAL. ❑ADDITION (I PLUMBING RE-PIPF.
CHIT CC. EC El MULTI-UNIT El STRUCTURAL
II-. PANELS
CZ4- understand my shell) ed6 blit obs _ MODIFICATION
,p Zr3., UPT0200AMPSI ❑INTERIOR CHIMNEY REPAIR
�4 t� s mfcssio 201-1000AMPS - IMPROVEMENT e -
a th Ilan
asemDEN DEC LANAT N OVER I000AMPS,. ❑BATH REMODEIJREPAIR 0 DEMOLITION
4 erchy affirm the 1 am exnnpt Brom the Contrxemr's License Low for the
105, 6 U fo to ng rtmon.(Section]B3 L5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a Permit to cnnswcl,alter,improve,demolish,or repair any strvclnrc
p prinrm ns mssuance.also req rtes th app)'not fm such permit fl sill" t Ism"' SPECIAL CIRCUIT/MISC
2 } lathe sbcenudpursu nosh provisions of the Comracmr'L La Chance9
a'4
commencing with Sob 7000).f D .ran 3 ofle Business dP I .0 icor TEMP.MITER bPOLB INS'L'. COMMERCIAL f
that he s excmpl therefrom end the hmis fur the alleged exemption Any violation of ❑NEW BLDG/ADDI770N ❑DFMOLMON
x�a• Secmion]031.5 by any vppliuum hr a permit subjects th<aPPlicanun a civil Penalty of POWER W CE.S
H7 y ❑TENANT ❑FOODSERVICE
L. ,more than Ova hundred Jnllary(551111).
p' < Lusowncr of and
re norm etitoded m off. amrk,(Sce.cora sation, SWIMh LELECTRIC ' IMPROVEMENT
02G 6b❑Q ❑ P M Y Y P Y B pen a.
11 Jn Ne work,and the ewaure is not intended urtmHcred far sale ISce.]I1W,ftusiness ❑OTHER
.a and Professions Code:The Comment's License Law does not apply to an owner of OUI' -SWI -FI%TURES
.. factimy who builds or improves Rumors,and who dive,such work himself or through ,
his own employees,frovidal the such improvements are not imended or offend-for NEW RHSIDP.NTI li CTR SQ FP.
sale.If however.the building or improvement is sold within one year ofcompletionJhe - SQ.FEFLOORAREA LSQ.FT.
lamer-builder will have the home.of proving that he did not build of improve for par- x T.
po Iofsalc.h ^ '
I,is owner of the propeny,am exclusively contracting with licensed contractors to
TOTAL:
onbract the pmject(See 7104,Business and Professions Coda)'Ihe Computers U. ��� p ���+ ^
cense law does not apply to un owner of property who builds or improves Pattern,and QTY. PLUMBING PERMIT FEE ` ILS!' II
who camas for such pmjecu with a commissions)licensed pursuant it)the Contractors
License Law,- - '
PERMIT ISSUANCE
❑IumexemPt ,B&PCfonhisr<aon
0 / _ D �to, 1a� ALTER-DRAIN&VEM'-WAITR(EA)+ , VALUATION
'IWSRKER:4 COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
T hereby affirm under penalty of perjury one of the following dcdaramions: V �
[]IhavennJ will mulnmin aCenilicme df Gmsem medf-insure for Worker's Compel. DRAINS-FLOOR,ROOR AREA,COND,
sation,as provided for by Section 3700 of the Labor Cade,for e performance of the STORIES 'TYPE CONSTRUCTION
work for which this permit is issued IIXI'URE9-PER TRAP s
❑ 1 have and will an and.Worker's Compensation Inslumc,as requifW by Section
3700nfthe lalwr Cwth,fl-the Ismardemse of le work for whichthis permit is issued. GAS-EA.SYSTEM71 INC.4 OUTLLTS - OCC GROUP: - APN
My Workers Compensation Insurance carrier and Policy numbernre:
Cartier: Policy Na: GAS-EA.SYSTINIOVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRI!ASI%INDUS'I'RL WASTE INI'ENCEPTOR
(This section need..,he comps,lms]file permit is formhumarrddollan($100) BUILDING DIVISION FF S
m less.) GRHASE TRAP PLANCHECK FEE
Loy any Rod person
in my urmaor so as t become subject
uork far bjet to us Wakes'Cocapnt. SEWER-SANITARY-STORM EII.200 FT.
not employ any align in any manner rte as m become subjecno le Workers'Compete - ENERGY FEE
zZ amino laws of Califnmiu.Date WAI'ERlllLATERW/VENT/BLECfR
;2 Applicant ' ' - - GRADING FBI!
14 NOTICE TO APPLICANT.If.after making this Cerifcamof Exemption,you should WATER SYSTEM/IREATING
ahccom,aubjer,l the Work,,',Compcnntinn provision,of the Labor Code,you mast _ _ SOILS FEE - --
LL) forthwith comply with such provisions or this Permit shall be deemed revoked WATER SERVICE
z CONSI'RUCI ION LENDING AGENCY NEW RESIDENTIAI,PLMB., SQ.FI! PAID
Iherebyaffinn mhnuhert isacnmwmion lending agrncy for the pcRonnance of Date Receipt»
{ULI the work for which this permit is issued(Sec.3097,Civ.C.) -
0 U dander's Nam. TOTAL:
Leaders Address TOTAL:
I certify hat 1 have read this applicmiun and arae that le above iafommion is - BUILDING FET!
Z
<ortectiegree mcnmply with all city and munry oNinanas and sure laws relating to QTg MECILANICALPERMI9' FEE
Ua building commuction,and hereby outhedae representatives ofthis city in enter upon the SEISMIC FGE
above-menminn d property for inspection purposes. PERMIT ISSUANCE
(We)agree mo save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiabiliiies,judgmenec costs and expenses which may in anyway acave against said City ALTFRORADDTOMF.CIL
+ in conscqueresof the falling of this Permit. - PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,10X1 CFM)
SOURCE REGULATIONS. MECHANICAL ME )
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCIIONTAX
Signanre of APPlicmn/Gmweor Data , '- EXHAUSTHOOD(W/DUCf) HOUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE -
Will in.eppliciedorfuture building becupamnureorhandle haaommo.man ial HEAPING UNIT II'0100,1X11)ETU) -
as defined by the Cilamur,Municipal Code,Chapter 9.12,and the Beall tad Safety
Code,Section 25532(x)?, ,,. HEATING UNIT(OV ER 100,000 B•IM)
11 Via ❑No I• " ry VENTLA'I'[ON FAN(SINGLE RESID) PAID
Will,he applicum ter fvwre building acupnnl me equipment or Jevicep which
Data RoemIn X
mit huaudoms air contaminants as defined by the Bay Area Air Qualify Management BOILER-COMP(314P OR 100,0101 BTU)' '
TOTAL:
- District? -
❑Yes �No BOILER-COMP(OVER 110,000 BTU)
I have and the h usmmus materials
nmgi a under Chapter b.95 of lc
AIR CONDITIONER ISSUANCE DATE
forms &Safety Cale,Serons 25505,25533.,ad 255311 umdenand the dthe
NEW RESIDENTIN.MECIL "SQ.PI'.
builoc re silt moot s whit y hnve o term,tat it is my mapf.Ceriry I.ramify le occupant
ofl,•riquirtmems which must be mm pdonoissuence nfa Certificate nfOxuponry. s -
Damemauhonred agent- - Dame TOTAL: ISSUED DY:
r
OFFICE .,