30759 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. 0L59^ res
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. -
BUILDING PROJECT IDENTIFICATION
f.DINGADDRISS: SANITARY NO. APPLICATION SUBMITTAL DATE
C> S S o c}' rS h-�—Ck 6 1r q 1
NER'S NAME: PHONE: C NTRACTOR'S NAME: r .LIC NO:
L 'Z C, Cr' L1 7 7SSo! NIC CONTROL#
�RCHYTECT/PNGINEHR: LIC NO: )DRESS:
CONTACT. Y)� PIH-ONE: BUILDING PERMIT INFO
.ti zh ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MECH
40 3'7-5---190
-�
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am[massed under pmvisinns of Chapter 9(commencing JOB DESCRIPTION
{Q{�aZ Ih Seetion7lN)0)nI DlvLvlonJ of tha llusircan and Profeulonn CUJe,and my liwnse is RESIDENTIAL:
FOO Wtfull force and efftt PERMIT ISSUANCE It
6VU. License Clas Lic.M -ate, 7-61 ❑SFUWL ITCHES REMODEL
�Qy Dao Convector APPLIANCES-RESIDENTIAL CIADDITION PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS -• ❑MULFFUNIT ❑STRUCTURAL
,Z O�Z 1 understand my plans shall be used republic re ods MODIFICATION
OZ— _ UP TO 200 AMPS ❑INTERIOR 11 CHIMNEY REPAIR
FSE' teemed Pmfesslonal 20I-1000AMPS IMPROVEMENT
Oat I am uUILDER DECLARATION
CommuON OVER["AMPS ATH REMOD"EPAIR D DEMOLITION
ss 6 I hereby.(Sect on I°m exempt from she Cssions Co License Law for the
9 y V following reams(Section 7 nscure Business and Professions Cale:Any city st roomy SIGNS ELECTRICAL OTHER
a 0�j poor
which requires n permit re conswcL aper,improve.demolish,or repair any structure
�O that h n its licensed
issuance,p rso requires the the applicantnof fay themch permit Lice seit Law(Chaps ant SPHCIAI.CIRCUIT/MISC.
} that ea is licensed purauvnt to the provisions 3 the Conwcmr'a License Law(Chapter 9
W O O (m(he is exempth Section 70 ad of basis for th @eB ed rote ry t Pmfessiuns Calc)or )GMP.METER OR POLE INST7 COMMERCIAL:
Sec he is exempt Therefrom and the basis for the is the exemption.Any violation of ❑NEW BLDG/ADDITION DEMOLITION
i� rY/•
not
mom
five
hny undred dollars D500mit subjttts the applicant ecivil penalty of POWER
OGVICEg
FZY' not more then five hundred dollen(SSq)). ❑TENANT Cl FOOD SERVICE
a I,
as owner ofda o normemployees with wa es as their role compensation, SWIMMING 1'001.ELECTRIC IMPROVEMENT
O ❑ pr so Y Y6 pens° ❑OTHER
II dothe work,vndthehe Contractors
tintendede Lawadsnota(Sec.7044, oryarm
{at)3 and Professions Cale:imp over heor'n License o do does not apply man owner of UTLEI'S-SWITCHES-FIXTURP.S
his
property who builds primped h thereon,and who does each work himself.1 through
his own however,
provided rpm such improvement me not intended or inland for NEW RESIDENTIAL.ELECfR SQ PI',
s:daIf,hnwevegthe vilthe hods of portent LsLthat sold he ithinone yevndammletfor,the S EA t, t/SQ.IT.
comer-builder will have the bodes of proving that he did not build or improve for per-
[j 1.assale). �l
1,as owner of the property,um exclusively contracting with licensed contractor i- JABS 6 REC IL
currency e La the es moa(Ser.oar Business and Professions Cade:)Thu Contractor's Li- ga
se Lawdasnotapply tnan with
a cofprnpeny whosedprsuanpmves Neeson.end QTY. PLUMBING PERMIT FEE
who wmmw.fur such pmJems with a enmmemr(s)IimumJ pursuant m the Cammmnrs C11Y Ur wrEH f INO
License Law.
❑I and exempt under Sec. ,Il&P C for this restos PERMIT ISSUANCE
Owner Date ALTER-DRAIN&VENT-WATER UN, VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby off.under penally of perjury ane of the following deelamtionn:
J [have and will Malaysian Cenilicate of Cousem to selbinsure forWairm's Comped- DRAINS-FLOOR,BOOP,AREA,COND. STORIES TYPE CONSTRUCTION
union.as provided th
for by Section 37W of the Labor Code,for e performance of the O
work for which this permit is issued. FIXTURM-PER TRAP
D 1 have and will mutein Worker's Cnmpenedion lose.,us required by Section
3700 of the Labor Calc,for the perfonnunceofthe work for which this permit is issued GAS-EA.SYS'I EM-I INC.4 OUTLETS a (Hal GROUP APN
My Work ,Caro et oboe In nee ca 'm and Policy number re:
mer, 5 Policy No I GAS-EA,SYSIEM-OVER4(EA)
CERTHICATE OV E) ;MPIION FROM WORKERS'
COMPENSATION INSURANCE GRHASFANDUSTRI,WASTE INTERCEPTOR
(This section need not be cumpleted iDhe permit is formi.hundred dollars 100) BUIL. [ SION FT:E.S
or less.)(no TRAP PLANCHECK FE
I certify that in theperform°nwol'the work for which this permit is issued,[shall SEWER-SANITARY-STORM PA.200 PI'.
not employ any person in any manner sn vs m hec7tio xuhjcct m the Wnrkem Contpem ENERGY .
0 z smioc Laws of California.Date WATER HEATER WNENTRiLECfR
12 Applicant GRADING
I,,, NOTICE TO APPLICANT.ILaftermaking this Certificate of Esemption.you should WATER SYSTEMITREATING
ai become subject m the W'orker's Compensation provisions of He Labor Code,you must SOILS 1 ?E
fomhwim,mr,ly old,such provisions or this permit shall be des,n.ed revoked. WATER SEUj RVICE
(� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI.MO. SQ.FT. PAID
I hereby affirmtha0construction hem is a coction lending agency for Ne performance of -k
Reeding
. �P the work for which this Permit is issued(See 9097,Civ.CJ
Lender's Name TOTAL:
WLe el,Address
F(y` 4y [certify that 1 have 1 Ni.applicedon enol sues thm the above infumutiun is BUILDING •E —w
0 V] correct.I agree m comply with all city and county ordinances and state lnwsrcletag to QTY. MECHANICALPF.RMIT FEE
V z buildingconsuuchon,and hereby authorize representatives ofthis city to enter upon the SEISMIC E
above-mentioned p openy for inapemien pmpoma' PERMIT ISSUANCE
We)agree to save,indemnifyaw
and keep hless the City of Crpenino againr ELECfR[C FEE
liabilities,judgeri and expenses which may i n anyway accrue uguinst said Ci ty ALTER OR ADD TO MF.CfI. O -/A
in consequence of the granting of this permit. PLUMBING FEE V
APPLICANT UNDERSTANDS AND WILL C) PLY WITH At.].NON-POINT AIR HANDLING UNIT(TO 10,00 CPM) MECHANICAL FEE
SOURCE REGULATIONS,Y/
AIR HANDLING UNIT(GVHR 10/00 CPM) CONSTRUCTION TAX
/ Signas�pplicant(Ccura Date HXIIAUSTHOOD(W/DUCT)
HARKADOUS MATF.RIAIS DISCLOSURE HOUSING MITIGATION FE
Will the applicant or future building acupent store or handle hexadous mmeriel IMATING UNIT(TO 100,000 BTU)
as defined by the Crimmins,Municipal Cale,Chapter 9.12,and the[]cul in and Safety
Cade,Section 255320)? HEATING UNIT(OVER 100,000 BTU)
DYes C]No
VENTILATION PAN(SINGLE RISID) PAID
Will the applicant or Rome h°iiding ercup°nt car vyripmeat or devices which Date Receipt p
mit hemdom air recommends as defined by the Bay Area Air Quality hlunagcurem, BOILER-COMP OHP OR 100,0110 BTU)
Dinrict, TOTAL:
[D Yes ONo BOILER-COST(OVER 100,000 BTU)
I have real the hnemnos material p AIR CONDITIONER ISSUANCE DATE
mquirernema under Chapter h95 of the Cali- -
firm.Health&Surety Code,Sections 2.5505,25533 and 25534 1 understand unit if the NEW RESIDENTIAL MECH. SQ.F-L
buildingdoes not currently have a recant,that it is my responsibility m notify theuttuped
of the tequimmems which must he met prior to issuance of a Certificate of Occu,ney.
Owner m amhmised agent Dam
ISSUED BY:
OFFICE
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