30761 APPLICANTTO FILL IN.INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL DING-ELE(7PRICAI• PERMIT NO. 30761/.qJ.
BUILDING DIVISION - APPIACATION/PERMIT PLUMBING-MECHANICAL. (O7 6 1
BUILDING PROJECT IDENTIFICATION �J V
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
2_itvnAeL AhvN fkk L_)-} LA n
OWNER' NAME: PHONE: Z ONTRACfOR'S NAME: LLC NO:
�` NIC CONTROLp
kRCHrrEGT/EnINEM it LIC NO: ADDRESS ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
�.T vyy fJ CJ I J ❑ ❑ ❑
LICENSED CO T)R'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby alfrm that I am Baenud under provisions of Chapter 9(commencing JOB DESCRIPTION
QMZ mSection]01o)of Division3of the Business and Profeusiona Code,and my license is RESIDENTIAL,
0100 v PERMI'I'ISSUANCE RESIDENTIAL,
Section
❑SFDWL ❑KITCHEN REMODEL
�U�•j License Class Lic.M APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
LDate Contmcmr -
[1�..Pm ARCHITECTS DECLARATION PANELS ❑MULTLUNIT ❑STRUCTURAL
Z O,�Z 1 understand my plans shall be used as public recnNs MODIFICATION
oz—, UPT02MAMPS I C1 INTERIOR C3 CHIMNEY REPAIR
1.4 Licensed Professional - 201.1"AMPS IMPROVEMENT
ems+ Oat I..BUILDER DECLARATION be Contractor's
OVER INVAMPS - ❑BATH REMODE E ❑DEMOLITION
yFpx,C,Q I hereby afErm that 1 vat exempt from the Conducmr',.License Lew for the
WO�U followingre®oa.(Secuon]071.3,BusiaessvndProfeasioraGmde:Anyc�yarcounty SIGNS ELECTRICAL ❑OTHER �y
Ii1'31a, which mapdars a Permit to adiamon,niten improve,demolish,m repair any structure
try prior to its ismance,vlaccospores the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. )/
!!(} that he is licensed pursuant to the provisions of the Contmaors License Law(Chapter 9
apo (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.MITER OR POLE jNST. OMMER-IAL..
y yy that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
bl ed
Section 7031.5 by any a,,Iicam fora permitmbijects theapplicnnt to.civilpe..try of POWER DEVICES ❑TENANT ❑FOOD SERVICE
W of more than five hundred dollars(1500).
Fz6 has owner of the pmpnny,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT '
FD ❑OTHER
will do the work.and the structure is not intended oroffered for sale(Sm.7014,Business
W and Professions Code:The Cmindi ',License Law does nm lady to as owner of OUTLETS-SWITCHES-FIXTURES
4i a•� progeny who builds or improves tbeem,and who domes each .,it himself or through
his own employees,provided that such impnuvemen¢am not immrded or offered for NEW RESIDENTIAL ELECTR SQ Ity.
-
sale.If,however.the building or improvement is sold within one yearof completion,the - SQ. Af�A S/SQ.Fi.
owner-builder will have the burden of proving that he did not build or improve for par-
post i f..B.). A III
1.......f the property.am exclusively contracting with licensed contractors m rY OPEC,&
construct the project(Sec.]M4.Business and Professions Code:)The Contractor's Li- ICO
Genre Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE CI/?'vv'� _
whoconlrads for such projects with a contracri licensed pound to the Contractor's Vf LUr
fatal, Cly IIN(J
License l
lam exem442-701
t de Sec ,H&P C for this reason PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATER(PA) VALUATION
Owner Did
^OMR CO .NSATIONDECLARATION BACK FLOW PROTECT.DEVICE
1 hereby ufBrn undo ponvhy of perjury one of the following dwlamtions: -
❑I have road will maintainsCenif¢amof Consam to selLimme for Wmlaa,'s Carolina- DRAINS-FLOOR,RGOF,AREA.COND. STORIES TYPECONSTRUCTION
cation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which ria permit is issued. FIXTURES-PER TRAP
1 have end will motorman Winkles Compensation Ina name,as required by Section
3]0Di Labor Calc,fonhe perforaware of the work far whichthis permit is issued. GAS-EA.SYSI'P.M IINC.40UTLEfS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number ort:
Came,: Policy No, GAS-EA.SYS TEM.OVER 4(EA)
CERTIFICATE Or EXEMPTION PROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
(Ibis action need not be completed ifthe permit is for one hundred dollars(1100) GREASETRAP
or less.) PIANCNECK FEE
I certify that in the performance ofthe watk(orwhich this permit is issued,I shall SEWER-SANITARY-STORM EA.2010 FT.
not employ any Person in any manner so as to become subject o the Workera'Compen- ENERGY FEE
OZ arbor Lawsof California.Date WATER HEATER W/VENTBLECTR GRADING FEE
O Applicant
y NOTICE TO APPLICANT 11 after making this Certificate of Exemption,you should WATER SYSTE&TREATING
(" become subject to the Workefs Compensation provisions of the Labor Cade,you must SOILS FEE
forthwith comply with such provisions or this permit shall he decided revoked. WATER SERVICE '
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U CI Barclay affirm Nat there is a construction lending agency far the performance of Date ReceiPta
the work for which this permit is issued(Seo.3097,Civ.C.)
D. U Isnde",Name TOTAL:
TOTAL:
O la n
ime,
Address - _ BUILDING FEE
fiIrr 1 tardily read fy that 1 hthis application and start that the above information is
correct l agree to comply with all city and county ordinances and state laws mining to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authorize repreumatives of this city center upon Ne SEISMIC FEE
ti above-mentioned progeny for inspection pumpows. PERMIT ISSUANCE "
(We)agree to save,indemnify and keep historical the City of Cupeninn against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER ON ADD TO M ECH.
PLUMBING FEE
A APPLICANT
of the granting Sthis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0IX1 CFM) MECHANICAL ITiE
SOURCE REGULATIONS.
AIR HANDLING UNIT HOVE I0,000 CFM) CONSTRUCTION TAX
Signature of Applicam/Contmcmr Dae EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store manuals,hamodous material HEKfING UNIT(TO 100,01X)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale.Section 25532m)? HEATING UNIT(OVER 100,000 BTU)
❑Yes FIN. PAID
- VENTILATION FAN(SINGLE RESID) Date Receipt It
Will the oppticant or future building accupam use equipment or devices which• BOILER-COM)'OHP OR 100,001)BTU)emit hauurdous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
Dtmdn? BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No
I have read the hoatdausmamrials requirements under Chapter 6.95 maw Cali. AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cale,Sections 25505,25533 and 25534.I underatand that if the NEW RESIDENTIAL MECH. SQ.Fr.
building does urn curently have a moan,that itis my respnsihilf,mnatil,the nlapunt
of the requirements which must he met prior to issuance of a Certificate of Occupancy. Aulp
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE