30220 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 O 2 Z O
BUILDING PROJECT'IIIRNTIF'ICATION
Hf111.I31NG ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
. ZZ66o �o P ��-t��� c.uf`etLf1"0( C^ X16014 7
OWNER'S NAME: PHONE: CONTRACTOR'SNAME: LIC NO:
p W '1�01w1 $�31� NIC CONTROL
t N HITECf GINF:ER: IC NO: VI ADDRESS: 11 / tq Q
S �a 3 z2362 o cu eELt,(o A V J
CONTACT, PHONE
PHONE: BUILDING PERMIT INFO
���{oWu�!- f(LpyKy` Ile) _0101 ❑ Coulta
nsnt Fec9 Paid by Applicant(Initial) BLDG_ ELECT PLUMB MECH
LICENSEDCONTRACTOR'S DECLARATION y QTY FLECTRICPERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapmr 9(cammcncing JOB DESCRIPTION
yOI�Z with Section 70110)of Division 3 of the Business and Professions Cale,and my license is RESIDENTIAL'
F.WP in full farce and effect PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
�F.UzC1 License Class Lic.is pPPL1ANCliS-RESIDENTIAL
NQ Dam Conirutor ❑ADDITION ❑PLUMBING RE-PIPE
CCC6... ARCHITECTS DECLARATION ❑MULT6UNIT ❑STRUCTURAL
F� PANELS
Cp n z I understood my plans shall be used as public record: MODIFICATION
-I UPT0200AMPS
1-14 Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
44�,..1 OWNER-BUILDER DECLARATION 201-1000 AMPS IMPROVEMENT
y 6 1 hereby airrm Nat 1 am exempt from the Contractor's License Law for the OVER 1000AMPS [:]BATH RF.MODELIREPAIR�DEMOLITION
k C 6 U following mason.(Scctinn 7031.5,Business and Professions Cale:Any city m cmmly SIGNS ELECTRICAL ❑OTHER
41 W which requires a permit to construct,clam,improve,demolish,or repair any structure Q
��� pnnrtoios isauana,elm requires the applicvm for such perminn filen signed etatemem SPECIAL CIRCUITIMISC.
��Qf that he is licensed pursuant to the provisions of Ne Contractors License Law(Chapter 9
Oiq'DO (commencing with Section 7")of Division 3 ofthe Business and Professions Cade)or TEMP.METER OR POLE UST. COMMERCIAL:
d a c Y that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION [I DEMOLITION
n
�5CC u, ap
Section 7031.5 by any applicant fora p motiimbjeats,he applinnna n civil penalty of POWER DEVICES
u1= []TENANT ❑FOOD SERVICE
z nm more Nan five hundred dollars($5(N)1 IMPROVEMENT
F C Losawnerk,and Ile lwry,ar myempinyoav mothered
sole 044,8 Business
SWIMMING POOL.CLE IC El OTHER
rya will Pr one work,and e: he loureCont a for ins rileal License
Law
do fs not apply t oan owner
of
a 3 and Professions Cale:The over thereon,
License Law does not apply s if owner of OI/TLEfS-SWITCHES XT F
Property who builds or improves.aeon,and who does such work
te himself or through
his own employeese building ohm such impraveoldwithin
are not intended oft or oRered Ru NEW RESIOfiM'IAL EL
owalLhoweveuthescThe burden uivemcnt issolddid ntbuild or improve
SQ.FT.FLOOR ARBA LSQ.PT.
'es.of wilder will have the burden of proving that he did ria humid or improve far bur-
ryveofsdeJ. AUGq L�
❑ 1,as owner of the property,am exclusively convecting with licensed cmdow mi to /'1AX I��U
construct the project(Sec.7014,Business and Professions Csde:)The Contractor's Li.
cense Law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who cc nclown;for such projects with a cum uchods)licensed pursu in to Ne Contractors
License Law.
❑1 am exempt under Sec. ,B&P C far Nis reams PERMIT ISSUANCE L II'l UrVUI L I I IItltJ
Owner L- ALTER-DRAIN&VENT-WAI'HR(EA) VALUATION
Date
ONK ER'S CONI ;NSA'I ION DECLARADON BACK FLOW PROTECT.DEVICE
I hereby.afifirat under.enalty I'"jury one of the followingdedmmions:
L I have and will maintain a Certificate of Comentto self-insure fur Workers Comber. DRAINS-FLOOR,ROOF,AS FA.COND, STORIES TYPE CONSTRUCTION
sation,as provided for by Swim 37M of the Labor Cade,for the Performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ I hal and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code.for the performance of the work for which this permit is issued, GAS-EA.SYSTEM.)INC.4 OUTLETS OCC GROU APN
My Workers Compensation Insurance carrier and Policy number arc:
Cartier: Policy Na: GAS-EA.SYS'TL'M-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR B LDING DIVISION FEES
(This section recd nor becompleed if the pemtit is forone hundrtddollars($100) GREASETRAY
or less.) PLANCHECK FE 16 /_
I certify that in the Performance of the work forwnich this Permit is issued,Imail
SEWER-SANITARY-STORM EA.200 bT.
not employ any Pearn in any manner so m ns racoma subjem m the Wmketa'Camper- - ENERG
Z ,,it ion laws of Cul if ixnio.Date
0 Applicant WATER 11(iA'1'IiR WNPNT/ELECI'N DRADING{7
h NOTICE TO APPLICANT:If,after making this Cenificme of Exemption,you should WATER SYSTEMITREATINO
a ; become subject to the Worker's Compensation provisions of the Labor Cale,you must SOILS EE
fonhwith comply with such provisions or this Permit shall W domed invoked. WATER SERVICE
06
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL PAIL
U0 Thereby iflimrthatthere iso ecnmmaion leadingagemy for the performance of ate Receipt
w 1-r the work for which this permit is i ourd(Sec.3097,Cie C)
0 U Lender's Name TOTAL:
Lenders Address - TOTAL:
1 certify ohm 1 have read this application wd state Nat the move information is BUILDING EE �+
UJ cormn.Iagre.to comply with all city end county nrdinancm and mane laws relasingto QTY. MECHANICAL PERMIT FEE
U 7- building constmction.and hereby a dionee representatives of this city m Inner upon the SEISMIC PIP L CID
ahnve-mned emioproperty for inspection p. PERMIT PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC 'EE
inbilinies,judgments.costs and expenses which may in any way acerae against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit, PLUMBIN FEE
APPLICANT UNDERSTANDS AND WILLCOMPLY WITH ALL NON-POINT AIR HANDLING UNIT(O 10.000 CPM)
SOURCE REGULATIONS, MECHANIC
AIR HANDLING UNIT(OVER I0.000 CFM) CONSTRUCTION TAX
SignatureofApplicamUConvamor Date EXHAUST HOOD(WNUCT) HOUSING MITIGATION F.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oecupatstereart handle hazaalnus material HEATING UNIT(TO 10.(10(18TU)
m def red by the Cuter iso Municipal Cale,Chap¢r 9.12,and the Health and Safety
Cale,Section 25532I0'f HEATING UNIT(OVER IO.fN)(I BTU)
Oyes ❑No
VENTILATION PAN(SINGLE RESID) PAID
Date RceeipoX
Willheair contort fns a building by the
Baseequipmentor deviceswhich BOILER-COMP(3HPOR 1W,OIM)BTU)
emit nazaNnus air amaminana as Defined by the Bay Area Air Quality Management TOTAL:
Disvim7
❑Yes r7 No BOILER-COMP(OVER I00.00d Ii'I'll)
I have read the mandaus materials requimsanB under Chapmr 6.95 of Ne Cali- AIR CONDI'I HINER ISSUANCE DATE
forma Halt&Safety Code,Sections 25505.5533 and 25534.I understood had if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a amount.that it is my responsibility to notify Ne occu oat
of Ne requioemems which must be ma prim m issuance of u Cenificme of Oeeupamcy.
Owner oramhurized agent Date TOTAL: ISSUED BY:
OFFICE