30717 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO, 30717
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMiTITAL GATT
jOWN R'S NAA ': HONE: CONTRACTOR'SjlijNAME: TNL v LIC NO: ' I—
•, A5722 6 AiI NIC CONTROL ax
�IRCHITECGENGINEER: LIC NO: ADDRESS: ❑ .
COMfACf: PHONE: - BUILDING PERMIT INFO
yy�g ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
1] 1:1 Z/
LICINSED CONTRACTOR'S DECLARATI)N QTY ELECTRIC PERMIT FEE
I hcrchy from that 1 am licensed nide,provisions of Ch.Per 9(commencing JOB DESCRIPTION
aW0Z with Scmion'Al(XOof Division J oftbe Business and Pmmssi...Code,and my license is RESIDENTIAL:
E�-� in full farce and c( c, PERMIT ISSUANCE
L)F _� �s,3a9 ❑SFDWL Ll KITCHEN REMODEL
�ZUU License las.v ILt.#�•� APPLIANCES-RESIDENTIAL. [_1 ADDITION ❑PLUMBING RI PIPE
y6 i Gate Contra
ARCHLTF.CI'S DECLARATION PANELS ❑MULTI.UNIT ❑STRUCTURAI.
Z p m Z I understand my plans shall be used as recos MODIFICATION
py=- rs prdUP TO 2001 AMPS El INTERIOR [I CHIMNEY REPAIR
F 4tw Licensed Professional 201-1000AMPS IMPROVEMENT
^M�� OWNER-BUILDER B D the Col TFON OVER 1000AMPS ❑BATH REMODEUREPAIR (]DEMOLITION
Wm 1 heresy.(lino,hal 1 am exempt from the Contra Cu.r:An,r Law far,he
0. 0.U which ordinates
reason.(Section 703 S, i.alter.
and Pe.donors Cutin:Any city m achum SIGNS ELECTRICAL []OTHER
4.F' which rWuircr a permit m conswct,idler,improve,Jemmlish,nr repair any s,mewrc
E U`0 prior,o its issuanee,oko requirts,he.pplicant for Hoch pemtinolile6 signed sotnnem SPECIAL CIRCUFUMISC.
E�} NO
at he is licensed persmno me provisions ofthe ContractorLi
s cense Low(Chapter 9
===7 (lomirencing with Section 7001 Division Jofthe Busincomd Professions Cole)a, TEMP.SISTER OR POLE INST. COMMERCIAL'
G611 e C that he is excretal henchman and Ne basis for the alleged exemption.Any violation of 0 NEW BLIXS/ADDITION ❑DEMOLITION
�w Section 9031.5 by any applicant for a Email subjects the applicant to a civil penalty of POWER DEVICES
y t marc than live hundred dollars l$5110t TF OVEMENT FOODSERVICE
a0 ❑ Lasownecof lot prmpcny.nr my mnployces with wngexas'hall 1111c compensation. SWIM M INC,POOL ELECTRIC
CCN will do the work,and the swctum is not fronded or offered for wit(See 9044,Boviness HR
W m and Professions Code:The Convectors License Law docs no,apply m an owner of OUTLETS-SWITCHES-FIXTURES
pmoray who builds or improves mcrcnn,and who d...uch work himself or through
his own employees,provided that such improvements arc not intended or offered fm NEW RESIDENTIAL ELECfR 10TAL
sale.IL however.the building or improvement is sold within one year afcomplelion,the SQ.FT.FLOOR AREA SISQ.fen
nerbuilder will have the burden of proving that he did no,build or improve for pur-
pose assale.).
Fl 1,ru owner on e e Secpeny,air exclusively um,mdirg with -eee-em,m..i..in
i msvuct me project(Sec.9040.weer ofs rid Professions Co.,,p The Contractor's nd
cense Law does nor apply ots its aommictony who
sedEaor improves CommeorJ QTY. PLUMBING PERMIT PEE
who contracts for such projects with a ttmwceMs)licensed pursuant to Ne Convector's
License law PERMIT ISSUANCE
❑I am exempt under Scc. .B&P C for Nis reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dec
WORKER'SCOMPfi pemyoN DE Ce folio ON BACK FLOW PROTECT.DEVICE
I andwereby affiainamn a penahyof ofCoyanaofthcinsum for Worker's
Ca
❑(have aeavide maintain.on370D of heLmooCodenmmfor Workersce of
DRAINS-FLOOR.RIDGE.AREA,COND. STORIES TYPECONSTHUCf10N
cation.r provided for by Section P(XI up he lister Code,fir the performmee of the
1 far which this .i,is issued. FIXTURES-PF.R TRAP
❑1 have and will maintain Worker's compo..tion rkfar.e,as n,parr , Section
3900 ufthe LaMsr Code,for the pertommnce of,he work fir which thin pemmis lsmcJ, GAS-F.A.SYSTLM-I INC.JOUTLEfS OCC GROUP APN
My Workers Co nppnsaI m Insurance rd Policy n itilk- :
CarzieeZGl�l nrelitllcy to 4" �a�2- GAS-RA.SYSTEM-OVER 4(EA)
CERTIFICATEOP EXEMPGON FROM WORKERS' GREASFIINOUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need no,be completed ifthe permit is forona hundred dollars(SINd GREASETRAP
or less.) PLANCHECK FEE
Icertify that int he peRonnarce ofthe walk fee whichthis permit is issued,Isbell SEWER-SANffARY-STORM EA.200 FT.
ma employ any person in any manner m.,tit become subject m the Workers'Compete- ENERGY FEE
Z swim Lawsof C.dromia.Dam WATER I(HATER WNENT/ELECfR
Applicant GRADING FEE
NOTICE TO APPLICANT:If,ager making,hi.s Camfi.he rf Exemption.you should WATER SYSTIiM/IREATING
F ; bece subject Int the Workers Compensation provisions of the Lather Calc,you must SOILS TLE
om
WfoMwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
7 Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ,FT. PAID Date R.
,p
V Q Thereby affirm that there iso construction lending agency fir the performance ofes
l--t ,he work for which this permit is issued Su.409).Civ.C.)
u' h Lender's Name MAL'.
G Lenders Address TOTAL: RELECTRIC
LDING PEE
1 camiy Na,1 have mad this application and.sum that the move information in
F UJ correct.I agree in comply w4m all city and county ordinances andante laws mixing as QTY. MECHANICAL PERMIT
UZ building construction.and hembyauthoriac¢presenotivez of Nis city oentarupon the SMIC FEE
above-mentioned property for inspection puryasea PERMIT ISSUANCE
(We)agree interim.indemnify and keep harmless,he City of Cupertino.,.fust FEEirhihties.judgmems,so,l,and expenses which may foray wu,.emmag.instsridCity ALT ER OR ADD TO MECH.in consequence of the granting of this permiti MBING FF.E
APPLICA TUN "STANDS ND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.IXXI CFM) CHANICAL FEE
[G TIO' _15AIH HANDLING UNIT(OVER IU.IXIOCFM) NSTRUCf10N TAX
tg o ren pPlic nnvec,o � EXHAUSTHOODIW/DUCf) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wilhhe upplicnntror future building uccupnm sinrc nr hanAle hozurdous material HEATING UNG'(TO IW,(XX)BTU)
as defined by Ne Culemino Municipal Code,Chapter 9.12,aid the Ifeul,h and Safety
Code.Section 25532(u)9 HEATING UNI HOVER Baan%BTU) hp1,
p Vex ❑No Y1)D
VENTILATION FAN(SINGLE RISIU) Date RceciptM
Will the applicant or future building occupant use equipment or devices which
omit hazardous air contaminants as defined by he Bay Area Air Quality Management BOILER-COMP OHP OR 100.1100 BTU) I I TOTAL
OnocFl
E3 Yet, El No BOILER-COMP(OVER 100,000 BTU)
I have read the hazardous materials req arrear,under Chapel 6.95 of me Cali AIR Q)NDITTONIiR ISSUANCE DATE
fomi.Health&Safmy Code,Sma...25505,25533 and 25534,1 understood that if the NEW RESIDENTIAL MECH. SQ.ET. -7 _ T .,./
building does not currently have a tenern,that i,is my responsibility to notify me occupant L[� /
of me requirements which most M mel prior to issuance of a Cenifcate of Occupancy.
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE