30952 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING"ELECTRICAL PERMITNO. 0
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PR J CT IDENTIFICATION
952
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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s _ OWNER'S NAME: PHONE: ON RA DR'S NA LIC NO: N/C CONTROL#
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CONTMCc PHONE: 13UILDING PERMIT INFO
7/ ,S-36 ❑ Consultant Fees Paid by Applicant(Initial) BLDG uaic PLUMB MUCH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRICPERMIT FETE El E)1 hereby a03rn that 1 nor licensed ander provisions of chapter 9(eommanaing JO DESCRIPTION
WOO with Section 700Bo( ie
Divisn 3.Ohc Businewmal Professions CW,...d my license is RE_SIDENTIA
I,W O in full marcn and effect. PERMIT ISSUANCE �
� License Class Lir.# WL ❑KITCHEN REMODEL
b—Z Date Cremona, APPLIANCES-RESIDENTIAL. ITION ❑PLUMBING REJ'IPE
ARCHITECTS DECLARATION PANELS
p.pm ❑MULTI-UNIT ❑STRUCfURAL
Z Z v�Z 1 undersmntl my plans shall be u.uJ as public reroNs - MODIFICATION
OZ- UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
�a+� nscd Professional 201.1000AMPS IMPROVEMENT
a� OWNER ammildR.DECLARATION OVER HIDOAMPS O BATH REMODEUREPAIR ❑DEMOLITION'
ppx,,C W FQ I hereby affirm that 1 1. exempt from the Contractor's Licence Law forme
W aSN 703 BusinessmWoev,dsioas Cade:Any city nr county SIGNS ELECTRICAL. ❑OTHER
LLl Is. which regoizvs a pennil to conswct,alter.iinpmvq demolish,or repair any swcwze
t^0g prior to its issuance,also requires the applicant for such pennino file a signed statement SPECIAL CIRCUIT/
} that hoislicensed pursuuntm the provisions oftlm Convcrum,l,Iccnne Lam(Chapter') -
00 (commencing with Sectiun]IXVB of Division 3 urine Business and Professions Code)or 'I'EMA MET ER OR POI. INST, COMMERCIAL:
ti{i,a�• that he is exempt therefrom and the breis for the alleged exemption.Any violation of # C3 NEW BLDG/ADDITION ❑DEMOLITION
Ii+CI ti Section 703 IS by any applicfor a permit subjects the applicant to a civil proudly of POWER DEVICIiS
F-Z} not mom man five hundred dollars(5500). ,TENANT El FOOD SERVICE
ant
F, 0 01,as owner ofthe property.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMFdN
W
swill Jnthework,andtheswCureator,LiverJo Low dJs mapplyto6a, ovor o ❑OT�Rs
L 3 and dothe ,,,k Code The emnueaot i tendeu Law does nm apply n,on owner of OUTLETS-SWETCtIES-FlXTURF_S
L property who builds nr improves Nercon,and who does such work himself or through
his own employees,provided that such improvements ecru not intended or offered for NEW RI:SIDCNH IAL 17LECTR SQ Irl',
sale.if.however the building or improvement is sold within one year of completion,she SQ RAREA ,ti $/SQ.E3'.
mer-builder will have the burden of proving that he did not build or improve for par-
Pose of#ale.).
❑1,m own r of the property,am exclusively contracting with licensed contractors to JJv
.Inert thu project(Sec.7(146,Business and Professions Cale:)The Conlmomr's Li-
se Law does not apply man.voe,orpropeny who builds or improves tic reon.end QTY PLUMBING PERMIT FEE ��`•
whoconvects forsuch projects wireaemarso nts)licensed pro uantmthe Coemcmrs
Licensr Law. .4
❑ I am exempt under Sec. ,B&P C In,thismason PERMIT ISSUANCE
Owner Date ALTER-DRAIN&V. ATER(EA), VALUATION
WORKER'S COMPENSATION DECLARATION. BACK FLOW PROUT D ��1s
Ihereby afire:under penaay of perjury one.fine following declarations: �� Wa
❑Ihaveand will maintain aCcrtificam.fCImImd mIcIpucle for W�uxACamper. DRAINS-FLOOR,ROOF,ARBA,
sada.,as provided for by Section Out of the Labor Code,for the pedimnance of the STORIES 'TYPE CONSTRUCTION
work far which this pared,is issued. FIXTURES-PER TRAP
0 1 have and will nmintion W..on,Compensation In.mmnW,as required by Scnd.n
3701o1fthe Labor Code for performance of the walk for which this permit is issued GAS-130.SYSTEM-I INC.roue- OCC.GROUP APE
My Workers Comppm_gnysu � 11'oldy ry;Yn I ¢�: A yaw
Cartier. -avli7I (tO �Z GAS-CA.SYSTEM OVIik4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
(This wIlmeneed.,,(heromplcted if he permit i,r one hundred dollars IS I did BUILDING DIVISION RBS
or le".) GREASE TRAP
PIANCHECK FEE
leanifythat' the arfo rant Ithew fp vInch this permit is issued,I shall
not em lay on SEWER-SANITARY-STOkM EA.200 FT. ENERGY FBI.
P y pe• n i en ant cast Lv ubJect m the Workers'Compon-
2 satinnLawsnfCi
z O Applicant a WATER HEATER WNfiNT/ELECTR GRADING FEE
(4 NO3'ICE M P11 Ar4t.1f.aTwrmaking'lEisCeNiC)Calec)fF.Xemplion.y(iushouid WATER SY$'TEM/1'NEAI'ING
abecome subject to the Worker's Compensation provisions of the Labor CMe,you must SOILS FEE
Ltf forthwith comply with such provisions or this pcnnit shall be deemed revoke, WATER SERVICE
Q
r47 z
CONSTRUCTION cONmlion IGAGF.NCY NEW RESIDENTIAL I'LMB. SQ.ET. PAID
UQ Ihcrehy affirm thnuMrO isoanaswction lending agency tonne perf.nnunceaf Dam Receipt#
H. - me work for which this pewit is issued(Sea 3097,Cie C)
C) Landed.Name TOTAL:
W Lenders Address TOTAL.
1 renify that 1 have read Nis application and sem that the 0hnvc information isBUILDING PCC
h conduct l agree to comply with all city and county ordin0nces and state laws relating m QTY, MECHANICAL PERMIT FEE
U buildimge.nsnaction,and erebyauthnrizempres tntives of this city to enter upon the SEISMIC FER
alma.. .....edp" y mimpectionpurpn
(We)agree mnifyanJke anal s City of Cupcnin.again't PERMIT ISSUANCE ELECTR IC FEE
1i0hilhour,jmlgm u,, is t dux n may' ay accrue agmansaid City ALTER OR ADD TO M'"CH.
consequence fah ting. is PLUMBING PLUMBING FEE
APPLICANT N i TAN 'ANI ILL ITHALI. N" INT AIR HANDLING UNIT(TO 10,00(f)CFM)
SON CE RI I MECHANICAL FEE
AIR HANDLING UNITIOVER 10,001 CFM)
CONSTRUCTIONTAX
Signemre ofAPPlkanUConwmtf l5rue EXHAUST HOOD(W/DUCO HOUSING MITIGATION PEE
j" HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 101,001 BTU)
at defined by Ne Cri,mra Municipal Code,Chapter 9.12,and the brain and Safety
Code,Section 25532(0)! HEATING UNIT(OVER 100,000 BTU)
0Yx, C1 No
VENTI LKDON FANS INGLE RESID) PAID Data Receipt Will the applicant or(more building occupant use equipment or devices which _
:mit haranlons air contaminants as defined by the Buy Area Air Quality Me end BOILER-COMP(JI IP OR 10,000 BTU)
District' TOTAL. IWI
r
El Val C]No BOILER-COME(OVER 100,00 B TO)
1 have real the hazsNuus materials AIR CONDITIONER
m,11533 an under .1 and 6tand that Cali" - ISSUANCE DATE
bored#Health&Safety Code,Sections 25505,255JJ and 25534 1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building dues not cuwhich have a Tenant that o is m Ice opt
to notify thm¢xvpam _
of the taluirements which mutt be met prion.issuance of a Cenilicate of Occupancy.
Owner or authorized agent - Date TOTAL: ISSUED BY:
OFFICE