31278 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 7^q
BUILDING DIVISION APPIACATIONMERMIT PLUMBING-MF,CHANICAI, 3127V/
BUILDING PRDJI?CT IDENTIFICATION
BUIL f ADDRBSS: /'�� SANITARY NO. APPLICATION SUBMITTAL DATE
TJ P LID Io4.6
A I'li(Nli: CON'I'RACTUR'S NAME; LIC NO. N/C CONTROL#
a.1E�� El ARCHITECT/RNGINEER: LIC ND'. ADD ESS:
CONTACT; p'BG1�E' _ BUILDING PERMIT INFO
N�N rMC7�f� (,ansul(unl Pees Paid by Applicant(Initial) BLDG ELECT UMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE ❑
1 hereby affirm that I ram licensed under provisions.f Chapter 9(commencing JOB DESCRIPTION
{MyOZ with Section 701 of Division 3o to Business unit Professions Calen m ,and mylicenmis PI?RMITISSUANCE RESIDENTIAL:
F i11 force end effect.
108 License Class Lic,# - 0SFDWL O KITCHEN REMODEL
FZly Dam Contractor APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
gy.�H ARCHITECTS DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL
z O y z 1 understood my plops shall be used as public mcorda _ MODIFICATION
0--4-0 UPT02MAMPS ❑INTERIOR C3 CHIMNEY REPAIR
AFint I�i Licensed Professional 20L1(XIOAMNS IMPROVEMENT
YS, OWNER-BUILDER DECLARATION
mqr tY 6 I hereby efficient'he,I am exempt from mn
the Coraoes License Lew for the OVER IOW AMPS ❑BATH REMODE EPA DEMO ITION
k3LV following reason.(Sarins 7031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
#a#
YY1l O�e which requires a Permit to construct,alcor,improve,demolish,or repair anre
y e m mate
Caw.] prior 10 its issmence,also requires Neepplicare for such permino file.signed swmem SPECIALCIRCUIT/MISC.
} thin he is licensed pursuant to the provisions ofrhe Contractors license Law(Chapter 9
81.-00 (commencing with Section Division 3 ratio,Business and Professions Cale)m TEMP.METER OR POLE INST. COMMERCIAIe
S a c�e that he is exempt merefrom and the basis for the alleged exemption.Any violminn M ❑NEW BLDG/ADDITION 0 DEMOLITION
Seen.703 L5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES
^w ❑TENANT ❑FOOD SERVICE
ore man five hundmd dollars(55001. IMPROVEMENT
^ZQ rasa.ownerofthe n,rann em to ceswith w.es as theircnle cum tion. SWIMMING POOLF.LF.CIRIC
WF Trope Y Y p Y g pcnsa
C will the work,C d e:no Com is to intended munched does not apply to an Business ❑OTHER
W and Professions who
Cale:The Contactor.License Law s such
not apply hi s if owner of OUTLLTS-SWITCIIFS-FIXTIIRFS
a 3 - his o
property who builds or improves thereon,and who does such wart himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELELTR SQ FT.
sale.If.however,the building or improvement is sold wimin one you ideompletion,the SW R 101996
$/SQ FT
er-builder will have the human ofproving that he did not build or improve for put. C�`V�71(H� ���t�
pose of ss)e). o
01.as owner of the property,am exclusively contracting with licensed contractors to TOTAL: Tia
ranswm the project(Sec.)UW,Business and Professions Cas)The Comanor's Li- CITY 1 Vf• LUr,t„I INV
cense Low does not ply m an owner of p y who builds or improves thereon,and QTY. PLUMB ING PERMIT FEE
who contracts pno cc
tCth (.)licensed pu uanU.the Caronetnr.
icense
❑ Iva axe or a ,Bffi PCfor this reason PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATER BiA) VALUATION
tuner Date
WORKER'SCO 'EN'SATION DECLARATION BACK FLOW PROTF.CI'.DEVICE
I hereby affirm under penalty of perjury one of to following dcelamtinns:
I have and will maintain a Certificate of Consent to self-insure for Worker's Comfort. DRAINS-FLOOR,NOOP,ARP C STORIES TYPE CONSTRUCTION
mai n,ac provided for by Section 3?W of the Labor Code,for the p,rbvmonc,of the
work for which this permit is issued. FIXTURES-PER TRAP i
0 1 have and will maintain Worker's Compensation Insurance,as rcquireJ by S ....n
3700ofthe Labor Cale,for the performance of the walk for which this Permit is issued GAS-EA.SYSTRM-I INC.4 OUTLETS
OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are: EA.SYSTRM-OVCR4 PA
Carrie, Pal icy Nn.; GAS- (. ) -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUS7RL WASTE INTERCEPTOR BUILDING DIVISION FEES
(Thissectimn need nm bccompleted iftbe permit is forme hnNreddollme I$III)) GREASBTRAP
or 1.x) PLANCHECK FEE
I certify that in the performance olthe work for which this perm0 is issued,l shall SEWER-SANITARY-STORM F.A.2W FT.
min employ any person in any manner sn os m become e.hject ,,the Wnrkcrx'Compcu- ENERGY FEE
O Z .anon Lows of California.Date WATER((RATER W/VEN'r/EIi3CTR
72 ApPlic:nn GRADING IEE
t'-1- I,J NOTICE TO APPLICANT.If,after making this Cenilicam of Exemption,you On ld WATER SYSI EMn RRA'1'ING a SOILS FEE become subject ,,the Worker'.Compensation Provisione of the Labor Code,you must
(11 forthwith comply with such Provisions or this permit shell he deemed revoked WATER SERVICE
Q
� zCONSTRUCTION LENDING AGENCY NEW NESII3ENTIALPLMN. 1UQ. PAID Dam r #.
I hereby affirm that there is a ed(Sm 30 lending agency for the perfannance nl'
me work for which this permit is issued(Sec.309?,Civ.C.) _
O U Lender's Name OTAL:
W Lenders Address L:
ly 1 codify that 1 have reed this application and..sam that the above informmion is BUILDING O
W7 marten.iagree to comply withal)city and county ordinances and state laws relating to QTY. MECIIANICALPERMIT FEE
G building construction,and hereby authorize mpresenmtive.ofmic city to enter upon the SEISMIC FEE It
above-mentioned property far inspection putpnecs. PERM IT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupeninn ugsimt ELECTRIC FEE /
liabilities,judgmens,crossed expumeswhichmoymany, waymcmeagoiriv said City ALTER OR ADD TO MUCH,
I.consequence of the gren,img of this permit. PLUMBING If
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO I0,00)CFM)
SOURCE REGULATIONS. MECHANICALF
AIR HANDLING ON]r(OVER III."CFM) CONSTRUCTION TA
Signature of Applican,fon,mnrar Dow EXHAUST HOOD OVIDUCT) CONSTRUCTION TAX
HAZARDOUS MATERIALS DISCLOSURE.
Will theepplicant or future building occupant store rehandle hazardous material HEATING UNIT CM IW."BTU)
az defined by the C.Netino Municipal Cale,Chapter 9.12,cal he Health and Safety
Cole.Section 25532m)? HEATING UNIT(OVER IBt,"BTU)
O Yes r-1 No PAID
VENTILATION PAN(SINGLE RESID)
Will the applicant or future building oceupm use equipment or devices which Dem Receipt#
it hacomsts air emounimme.as defined by Ne Bay Area Air Quo)ity,Mansg,ment BOILBR-COMPGHPOR IW,000BTU)
arstnno TOTAL
❑Yes ON. BOILER-COMP(OVER 1010.0011011 BTU)
I have read the hazardous materialsrtquirtmenu under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forms Health&Safety CMe,Smions 25505.25533 and!25534,1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
buildingdoes not currently have a tenant,that it is my responsibilRy to notify the meupvnt
of the requiremenu which must be met prior to issuance o!a Ceni6c.m dOccup:utcy.
Owner m aatherized agent Date TOTAL: ISSUED BY:
OFFICE
to - ro -yb
� � (,L,E,QEr/A To Secure,
k- P,-Of
. 2 �av-�, si y� f� p�r�,�-F G l>c�opo
a.�cl p�f c�lr�i ori .