30903APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATIONMERMIT PLUMBING• MECHANICAL.
BUILDING PROJI?CF IDENTIFICATION
PERMITNO. 30903
ARTA.DING ADDRESS:
I0325 PLuM TP -EG LAf'f GvPERTzA/o CA`7S0/¢
SANITARY NO.
APPLICATION SUBMI"ITAL DATI
��.11,�^)
NER(;S NAME: kUMA^ ��9.'1�3�
1 A-155fr_il
CONTRACTOR'S NAME. LIC NO,
NIC
CONTROL #
ARCHITECT/ENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provision, of Chapter 9 (commencing
with Section 90001 of Division 3 ofthe Business and Professions Carlo, and myli.mse 11
in
in full farce and effect.
License Clash Lic.#
Date Convenor
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RF3IDFNTIAL:
❑SFDWL ❑ KITCHEN REMODEL
[]ADDITION ❑PLUMBING R&PIPE
C] MULTI -UNIT El STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
GS'1�
Ll BATH REMM2* RR 0DEMOL_ I_Tet,
❑OT}fER t ��(]1sr,r a f:,_—
APPLIANCES -RESIDENTIAL
ARCHITECTS DECLARATION
1 understand m„lmrsshall heusednspublic me ds
PANELS
UPTO 2IX1 AMPS
Licensed Profcaionel
OWNER -BUILDER DECLARATION
1 hmaxo .!firm that l am exempt from the Cantona/. License Law for the
whichirectu maxon. Business and Professions Cade:or Any city or county
which poor to itsissanpermitm,on.i the almaimprove. demolish, or repair anystructure
that hes! issuance, to res the
Law (Chapter 9
sofcant for CoM1pemsivoicensle aargued w(Chpter9
that menden with
pursuant to the of Division 3 the a Business nd Professions
(commencing with Smtinn 7”) of Division3of the Business and Professions Code)or
that he is exempt therefrom dad the adds for the alleged exemption. Any violation of
Secure 7031.5 by oay.pplicaat fora permit subjects the spplicand to. civil penaltyof
hot ...,ban f ve hundred dollars !SSW).
Ej1. as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended oroffered tattoo (Sec. 7144, Business
sad Prefessions Cmie: The Contractor's License Law does not apply to an owof
property who builds or improves thereon, Cad who does such work himself or thmugh
his own employees, provided that such improvements the not intended or offeeL for
sale. If, however. the building or improvement is sold within one year ofcompletion,the
owner -builder will have the burden of proving that he did not build or improve for put-
Paso of sale 7.
1, as owner of the property, am exclusively commning with licensed contra,.... to
omedwct the project (Sec. 7044, IR.,mes. and Profession. Code) The Commodes Li-
cense Law does not apply to an owncrof pro,any who builds or improves thereon,and
who contracts for such projects with acommc..rts) licensed pumuanua the Convectors
License Law.
❑lam cosec under Sec. ,B& P C for this mason
Owner Data
201-1000AMPS
OVER 1001IAMPS
SIGNS ELECTRICAL
SPECIALCIHCUITMISC.
TEMP. MLTIiN OR POLE ST.
❑ NEW BLDG/ADDMON ❑ DEMOLITION
❑TENANT ❑ FWD SERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING PC/.LECTRIC ,
OUTLETS1'rcRES-FIXTURES
-ner
NEW KABBINTIAL ELECIR OF
SQ. PRpL00RAREA VSQ.f ..
IRS] A
.4 -
11)
APR j
111-insj'tb
CITY IViv
Vi
V(f(+t.
VALUAT
TOTAL:
QTY PLUMBING PERMIT
PERMIT ISSUANCE.
ALTER - DRAIN & VENT - WATER (EA)
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following dealamtim s:
❑ I have and will maintain a Cerificam of Consenuo self-insum for Workers Cone ce.
sation, as provided for by Section 37W of the Labor Code, for the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Imurmme, as IN . d by Section
37M ofthe Labor Code. for the performance ofthe work for which this prmitistssued.
My Workers Compensation Insurance carrier and Policy number arc:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thin section need not le cnnnplcted if the pmnih hfnrono hwulnA Anllam ($IIXp
or les'.)PLANCHECK
I certify that in the performance ofthe work for which this permit is iaued, l shall
not employ any person in any manner sec as.. become subjectto the Workers Comper-
.firm Laws o(Caiiferem. Data
Applicant
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF AREA. CONTE.
STORIES
TYPE CONSTRUCTION
FIXTURES - PER TRAP
GAS - EA. SYSTEM-] INC. 4 OUTLETS
OCC. GROUP
APN
GAS - EA. SYSTEM-0VER 4(FA)
GREASERNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FOES
GRP.ASETRAP
FEE
SEWER -SANITARY -STORM EA. 200 FT.
ENERGY FEE
WATER HEATER W/VENT/ELRCTR
GRADING PEE
NOTICE TO APPLICANT: If. her making this Cenifcate of Maraption, you should
hm
mre snhject to the Worker's Compensation provisions of the Labor Cade, you mon
forthwith comply with such provisions or this permitshall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihembyafinothmtheei..comwctin. lendiag.gency for the padowarom of
the work for which this pemtit is i..uIII (Sec. 3W7, Civ, C.)
Lender's Name
WATER SYSTEM/TREATING
WATER SERVICE
SOILS FEE
PAID
Date Receipt#
NEW RESIDENTIAL PLMB. SQ. PR
TOTAL:
Lenders Address
TOTAL:
BUILDING FEE
1 certify that 1 have read this application and nate that the above information is
rtef.le,me m comply with .11 city Cad county ordinance and them law.miming..
building consavctime. and hemhy authorize representatives of this city con cat.. upon 0e
above-mentioned property for inspection purposes.
(We)agmeto save, indemnify and keep harmless the City of Cupenirr. against
liuhillties.judgmcnts, costs and expenses which may in unywayaccrue against said City
in asequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURC ULATIONX 1
QTY. MECHANICAL PERMIT FEE
SEISMIC ME
PERMIT ISSUANCE
ELGCTRIC I9?I?
ALTERORADDTOMECH.
PLUMBING FEE
AIR HANDLING UNIT(TO U).000 CFM)
MECNANICALFEE
AIR HANDLING UNIT (OVER M.000CFM)
CONSTRUCTION TAX
igmatum of pplicmnt/C vodorDm
I DOUS i'F IALS DISCLOSURE
Will the applicant or Future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, add the Health and Safety
Cade, Sectiom, 255320)?
❑Yes ❑No
l ants, building by the B use e. Air ehl it devices which
Will the applicant contaminants
emit hazardous air contaminants us defined by the Bay Area Air Quality Management
District'
E] Yes []No
I have read the hazardous materials
r5, 2i 533 a under Chapter hone of the Call.
Health at Safety Cale, Sections 25505, the[ e, any need 25534, I u amity,d that if the
buildingdoesnents which
have. m met prioress
it Ismyeeca'a Certificate of thessmupam
ofthe requirtmems which must he con prior ro ismunce n!. Cenifcnte of (kcupvncy.
EXHAUSTI 1001)(W/DUCT)
HOUSING MITIGATION IEP.
BEATING UNIT (TO UK%IIIO BTU)
HEATING UNIT (OVER I(NLIXk] O'f11)
PAID
Data Receipt#
VENTILATION PAN (SINGLE RESID)
BOILER -COMP (3HP OR 100,N)O BTU)
TOTAL:
BOILER - COMP (OVER IW.IXp BTU)
CONDITIONER IV
IF
ISSUANCE DATE
ISSUED BY: COW
-AIR
NEW RESIDVNI IAL MECH. SQ. IH'.
Owner or emhndzed agent Data
TOTAL:
OFFICE