30813 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 30813
BUILDING PROJECT IDENTIFICATION
RUILDINGADDRESS: II T 1 SANITARY NO. APPLICATION SUBMITTAL DATI
-+653 Mock gloj"ibiE br . Cu ertItiIa
OWNER'S AME: (p``�_T7 14Ak_ �f PHONE: CONE ACTOR'S NAME: LIC NO:
J N TI N/C CONl'ROL#
RCHITEC/FNGINEER: LIC NO ADDRESS: ❑
CONfAC'1': ooJJkk.�\1 PHONE: �s -E BUILDING PERMIT INFO
W 1 �NQ NRPIR!} �40`-)��" ✓ T�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
z Ihereby afion that 1 ant licensed ander Pmvision,i Chapter 9(commencing JOB DESCRIPTION
its Section II%p)dDivision 3ofthe Business and Professions Cale,and my license is p RESIDENTIAL:
wo, in full force and effect. PERMIT ISSUANCE .J •� ❑SFDWL ❑KITCHEN REMODEL
QUU License Class Lic.a APPLIANCES-RESIDENTIAL ❑AUDITION D PLUMBING RE,PIPE
y G iM Date Contmemr
ARCHITECTS DIiCLARATION ❑MULTIUNIT DSTRUCTURAL
Z O N y PANELS MODIFICATION
rnz 1andersum tar pram shooused as public CLARrecords �/
oz- UP
UP TO 200 AMPS IMINTERIOR []CHIMNEY REPAIR
F�FW Licenced Professional 201ml QUTAMPS IMPROVEMENT
E'C a', OWNER-BUILDER DECLARATION OVER I050AMPS ORATE REMODE F AIR���ITION
a 1 hereby (Sect Item 1 1. a%unlit from the Carl mnnr's :An,c Law for the FI/ 5
xLx C U following reason.(Sutton]oJ LS,Business and Professions Cade:Any city or nwntY SIGNS ELECTRICAL. ❑OTHER
W 3 C,y which regains.permit b construct.alter,improve,demolish,or repair any swcure �(� -a—
o- =off prior to its issuance.also requires the applicant lot such permit to file a signed stmemem SPECIAL CIRCUD'IMISC.
} that he is licensed Pursu.m to the previsions ofthe Commcsm's License Law(Chapur9
�no (enmmemeln,with Semina 9(XX))nfDivision.1ofthe Ranne,.nd Prnks.inneCee),r TEMP.METER OR POLE INS .
a d c C Item he is exempt therefrom and the busts for the alleged exemption.Any violation of D NEW RLDG/ADDITION DDEOLITION
�H
Section 7031 S by any applicant for a permit subjects the applicanrEN ❑
to a civil Penally of POWER DEVICES OTANT FOODSERVICE
not more Ibav live handled dollars($5M).
F Z} - IMPROVEMENT
C]1.as own,,.f the pmpenR or my employees with wages as theirsole aompenmtion. SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended or offered for sale(See.]Mi,BusinessDOTTER
u'-m end Pmfax,mm,Cee:lbs Contractors License Law does not apply to an owner of OUTI.I.FS-SWITCHES-171 1.
L 3 For,,who builds or improves,hemm,and who docs such work himself or tbmugh
his own empinyen,provide that sada improvememc ore not intended m offered liter NEW RESIDENTIAL ELF CfR
side.If.however,the building,,improvement is sold withinum ye.rofcompletion,the SQ.FT FLOOR AREA $/SQ.IT.
owner-huilder will have the burden of proving that he did nal build or improve for put-
ry),e of sated. F-31 O 1,as ownerofte parat.m exclusively enamling with licensed contractors b TOTAL: R O `-'ly 0icon Incl Ob pnajca(Seo.9014,Business and Professions,1l 1'",a Cnnnars I -se Law does not apply loan owner ofmpeny who builds or improveslhcreon.and QTY. PLUMBING PERMIT EE
who contracts for such projects with a eommebr(e)licensed pursuant to the Contractors
License law. PERMIT ISSUANCE
O l am exempt under Sm. .B A,P C for this reason
ALTER-DRAIN k VENT-WATER(EA) VALUATION
Owner Dole Dv
0,0
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE, �1 herehy affimh under penalty al'perjury one of the following weelaraie., 00I/n
��
•O I have and will maintain a Certificate of Consent bvelf-imme for Workers Camper- DRAINS-FLUOR,ROOF.AREA,GOND. STORIES TYPE CONSTRUCTION
s ition.its provided for by Section 3910 of the Labor Code,for the performance of the
work for which this Permit is issued. FIXTURES-PERI RAI'
O I have and will maintain Workers Compensation Insurance.as required by Section
3700 ofthe LoborCWe,l'ontee perf,rmanceofthe walk for which this permit it issued, GAS-F.A.SYSTEM-1 INC.4 OUTLEI:S OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Curler: Policy No.: GAS-EA.SYSTEM OVER 4 H1O
CERTIFICATE OF EXEMPT ION FROM WORKFRS'
COMPENSATION INSURANCE GREASMNDUSTRLWASTE I.Y1'ERCHM11
BUILDING DIVISION FEES
('Phis aainn tad not M1c completed if the Permit is lin one hundred dollars(E I00) GREASE TRAP
or less.) PLANCHECK ITE 2 O
Ioyer,that ionto any....a.rformance....waktmwdjea ,heWopermit uiss'Cara r-all SEWER-SANITARY-STORM 1iA.2fN1 FT.
our employ any pawn in any manner sn as m hrnmc suhjm,.,he Worked Compen. ENI[RGY PEE P A I' D
O Z satiom Laws of C.lifnmia.Data WATER HEATER WNENT/ELF.CTR GRADING HEz O Applicant
N NOTICE TO APPLICANT.If.afrer making this Cenificaa of Exemption,you should WATER SYSTENVTREATING SOUS FEEI'D❑[I'D
I--' become xuhjecuo the Worker's Compensation provisions of the Labor Calc,you as,,
forthwith comply with such provisions or this permit shall be dermal revoked. WATER SERVICE JAN 24
Q
•2 CONSI'RUC'I'ION LEND]NO AGENCY NEW RESIDENTIAL.PLMB. SQ,PC PAID s I NO
U zIhereby affirm that them is a c,nmmction lending agency for the Performance of D. , Ra o
(•" the work for whichthis permit is issued(Ser.30)],Civ.CJ
4. Isnder's Name TOTAL:
V Lander',Address TOTAL:
�s liv cantly,M1m 1 have rcaA this npPlicatiun and stab that the above infamtation is BUILDING FEE Q e
0 correct.l agree toemoply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
LJ Z building conswction,and hereby aath,nze representatives of this city to emrtrupnn the SEISMIC FEE cot
aW e-nuationeJ property for impeaion Purpose. PERMIT ISSUANCE
(We)agree to save,indemnify amt keep traders the City of Caliendo,.,.east
ELECTRIC PET.
liahi litia ral"ncnn,un,cand releases which miry in any any ac.a against sold City AI TER OR A DO TO MECIL
PLUMBING FEE
in conaspemat fine granting of this Permit.
APPLICANT UNDERSTANDS A D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICALFEE
SOURCE REGULATION:
1, ILj �a� AIR HANDLING UNIT(OVER 10.IKK)CFM) CONSTRUCTION TAX
Signamreof AMfirm uanmctor I 7 aerie/ EXHAUST HOOD I W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or labor building occupant store or handle handouts material HEATING UNIT(1'01(X)p00 BTU)
as define by,he Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Sael 25532(ao IHEATINO UNIT(OVER 100,410 BTU)
❑No PAID
VENTILATION PAN(SINGLE RFSIU) Dam Receip,M
Will,be applicant or future building occupant use equipment or devices which
emit he od us at'emiuminums.s defined by,he Bay Area Air Quality Management BOILER-COMP(3HP OR IlX1,IXq BTU) TOTAL:
UisVicf� BOILER-COMP(OVER 100,1X1(1 BTU)
Yea ONn
�7 i.
]have road the hawrdous materials is under Cha Rr 6,95 of the Coli- AIRCONDLTIONER ISS ANCE DATE
quire P.
karma Health&Safay Cade.S aaa 25 5,25533 a�25531.1 understand that if the NF.W RESIDENTIAL MECH. SQ.FT.
building Jnrsnm,uamnlly huvevmnv set itunry resrymsTility mnotify the<ccupam
of thesena is
us}Aae a priorto issoance of a CeniRcum f�ccupar
O ramhovW I Dat TOTAL: ISSUED BY:
OFFICE