31294 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO � BUILDING-ELECTRICAL - PERMIT NO. /� q /�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL J 1 L
94
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: /�S^ I �i _ - J l �cQ SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: _ 7 PHONE: 7_e ONTRA`CTOIR'SNAME: - O PLIC NO: NICCONTROL
Pe,�e. - Y� �.►� J
ARCHITECT/ENGINEEIL LIC ADDRESS:— ❑'
_
CONTACT: r Only PHONE: 7-A_V R BUILDING PERMIT V
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
L10EN D licensed
under
p DECLARATION QTY ELECTRIC PERMIT
I hereby an.Nes 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�d'Z with Section 7000)or Division 3 ofthe Business and Professions Cade.and my license is RESIDENTIAL:
a O_ PERMIT ISSUANCE
n full force and eff t.
�UF' License Clas Lim.If ❑STOW[ ❑KITCHEN REMODEL
h L Dme�Cantmcmr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE.
Tam ARCIIITECTSDECLARATION --PANELS El MULTI-UNIT ❑STRUCTURAL
MODIFICATION
O Z V)7J. 1 undersmnd my plans shall he used ns public mcnrda
UPT0200AMPS " L1 INTERIOR P`CHIMNEY REPAIR
LicenuJ Professional 201.1000AMPS IMPROVEMENT
a OWNER-BUILDERDECLARATION OVER IWOAMPS ❑BATH REMODED_REPAIR [IDEMOLITION
yy 11 1 hereby effum Nat 1 am exempt frommshe Convacmrs License Law far the
pg,ojr d O following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICALOTHER
Ya1l^O which requites a peroses a....It.alter,improve,demdish,or repair any structure 10
g��
m Enron,I.issuance.also requiresthe applicant fo.such permit fileasignedsu¢ment SPECIAL CIRCUR/MISC.
p. than he is licensed pussuanno the provisions ofthe Contrecmrs License Law(Chapter 9
00 (commencing with Scction 7")of Division 3 ofthe Business and Professions Code)or TEMP.METER OR PO SINS[ COMMERCIAL:
6 5 Not he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
V- Section 7031.5 by any applicant for a permit suocIn, he applicant to a civil Penalty of POWER DEVICE
m ❑TENANT ❑FOOD SERVICE
ZZZi
no'
mas than five thunddsnt l r my
IMP OVEMENT
p6 0 Louowner rawnuof the praperty..r my enspinyas with wages as their sole compensation, SWIMMING UL ELECTRIC ER
ill Pr Newark,anddee stromasin,tor s sense La does
apply to an covinesa
and Prnfexxinnn Code:The Contautsn's License law Jws not apply m an owner of OUTLET SWITCHES-FIXTURES 1
his o ny who builds ar improves thereon,send who does such work himself of through
his own employees,providd that such improvements old within vre not inanded or offered for NE ESIDENTIAL ELF.CIA SQ PT.
owneLhoxevegthe buil the burng en of Prmcm isat hediotbild or improve
pur- FT.Fl.00R ARCA SISQ.FT.
owncrbuildcr will have the burden of Proving that he did not build or improve for par-
pox of role).
❑ 1, a owner of the property.am exclusively contracting wide 1lcenxd .... rs m TOTAL:
fannmcl the prinations,n(Sec.76 ,Busineand Professionss Calc:)The Comrmmra
cense Law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE p
who contracts for such projects with a contmemtW rn
liceed pursuant m A
the Contractors
License Low. PERMIT ISSUANCE
1 um exempt under Sec. ,B&P C for this reason 01
Owner I Dam ALTER-DRAIN&VENT-WATER ILA) �x b vftol
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE y�I` Uf,t�•�1 /I yOa
have
and will maintain
ai under penaltyof ofConscueofthefollowin darker'sons Cs8
•�Ihave and will maintains tion 37M of Cotham,selfee,sure for Workers Compcm DRAINS-FLOOR.BOOP,AREA.COND. STORIES CONSTRUCTION
moon,as Provided for nu Section]700 of the labor Code,for Ne pefformantt of the
work rev which this omens issued. FIXTURES-PER TRAP
IP 1 have and will rods,far he W rs Compensation work
for hi az required by Section
AW ofk labor Code,fo,Nsurance Cance ofthPI for which this permit is issued, GAS-EA.SYSTEM-I INC.JOIITLETS OCC.GROUP APN
My Work C pensatian Insurance artier and Policy nu he are:
Carrier. i/•� Ca�1�Policy No.: A - JO If GAS-EA.SYSTBM-OVF:RJ(LA)
CERTIFI_ATY-0-COMPEN ATIfIN INSURANCE EMPTIONFROM
WORKERS' - j'')q GREASUINDUSTRL WASTE INT CEPTOR -
BUILDING DIVISION FEES
(Thissecticn need not becampsted iftlmpemdt is forum hundred dollar,H IIB)) OR TRAP
or less.) PLANCHECK PEI?
I certify Nut in the performance ofihe work for which Nis pemtin is issued.I shall SEWER-SANITARY-S RM EA.200 FT.
not employ any person in any manner so as to became subject o are Worker'Compere ENERGY FEE
0Z mti.n laws of California.Date WATER HEATER WN /ELECTR
Z Applicant GRADING FEE
pj NOTICE TO APPLICANT.If,after making this Cenificate of Exemption,you should WATER SYSTEATING
Isecame mbject to the Workers Campenmtion Emotions of the Inbar Code,you most P.M SOILS FEE
W r fonhwide comply withsuch provisions,,this penin shell be deemed revoked. WATER SER E
Q
CONSTRUCTION LENDING AGENCY NEW ENTIAI.PLMB. SQ.FT, PAID
V I hereby affirm thatthem is a construction lending agency for the perfurtnunce of Dore Rs pt
the work for which this permit is issued(Sec.3097,Civ.CJ
Lenders Name TOTAL:
hLf Lenders Address TOTAL:
I certify that I have reed this application and state that the above information is BUILDI F
L to correct.I agree to comply with all tiny and county ordinances and sum laws relating to QTY. MECHANICAL PERMIT FEE
U z building son swcoon,and hereby auth,rix representatives of Nis city roamer upmthe SEISMIC E
abavemenooaul property for inspection purposes. - PERMIT ISSUANCE(We)agree to save.indemnify sal keep hornless are City of Cupertino against ELECTRIC 'E
liabilitiea,judgments,cos¢mal expenses which may in any way accme against said City ALTER OR ADD TO MECH.
in consequence of the granting of Nis permit. PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CEM) MECHANICALFE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,0810 C CONSTRUCTIONTA
Signatureof Applicant/Commnar Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION 'EE
HAZARDOUS MATERIALS DISCLOSURE
Will theapi icant or future building occupant store.,handle m.nicusmme,inl HEATING UNIT(TO INDON)B 7
as d<0ned by the Cope ti.n Municipal Code,Chapter 9.12,and the Health and Swirly
Code,Seaton 25532(.)? HEATING UNIT(OVER 1 ,000 BTU)
C]Yet PN. VENTILATION PA Y6NGLE RESID) PAID
Will the a titan or future building t use mem or devices which Data Raeipt M
PP 8bytheen equip BOILER-CO (3HP OR 100,000 BTU)
t hazardous air conmminanrs ns defend by the Bey Area Air Quality Management TOTAL:
rxmct?
❑Yes Jallo II)BOILER OMP(OVER 10y"BT
I have read the bzardoui mmerinls requiremRents under Chapter 6.95 of the Cali. Al NDITIONER ISSUANCE DATE
liana Health&Safety Code,Sections 25505,25533 and 25530.I understand that if Ne EW RESIDENTIAL MECH, - SQ.FTb
building does not currently have a tenant.list it is my reaptmsibility to notify the wcupont
of the rtquirematx which m the It pr:or m issue a of to Certificate of To y.
Owner or mdhmimsdtigmrtt Uane TOTAL: I ISSUED BY:
OFFICE