30874 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I BUILDING-ELECTRICAL FERMI r No. Jl�S8 1/ 4
0 ^.a ,a
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUIL.OING PROJECT IDEMI'IFICATION
BUILDING ADDRESS:- - SANITARY NO. APPLICATIONSUBMITI'ALDATE
0555 . C>G _V I G LC �JA.
OWNER'S NAp1E: PHONE: CONTRACTOR'S NAMG: a LIC NO:
T LN I G LIO� NIC _ CONTROL If
4RCHITECDIiNGIN[ L LIC NO: ADDRESS: ❑ 1/yq_V(�`
G2ECX µOTO Al Ol LAfAYETTE
CONTACT: PHONE:' BUIIAING IaEHMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB Mr.CH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEC
1 hereby affirm that I am licensed under provisions of Chapter 9(e.mmencing JOB DESCRIPTION
Oaz with Smtion'RI001of Division 3.0he limistssand Pnmfessima Code,andm
E 00 y PERMIT ISSUANCE RESIDENTIAL
n fell e Chos
and cffat. license is
�U� Licens<Cas Lic.p ' ❑SFDWI. EI KITCHEN REMODEL
tFa Date Grant APPLIANCES—RESIDENTIAL
�� ❑ADDITION El PLUMBING RE PIPE
1_Om m ARCHITECPS DECLARATION PANELS ❑MULTLUNIT ❑STRUCTURAL.
z OP�Z 1 understand my pleas shall be used as Public records MODIFICATION
Oz
4, UP TO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
F4 Licensed Professional 201-1000AMPS
4 OWNER-BUILDER DECLARSHON IMPROVEMENT
�d U. 1 hereby affirm that I oat exempt from the Contractors License Law fur the OVER IOW AMPS
y' ¢ ❑BATH RF.MODHVREPAIR'�DEMOLITION
3 a u following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS F.LE CA ❑OTHER
LL which".I.,a permit to construct,alter,improve,demnE.h,in repair any suucmre
Fss"LL0 prion.its issuance.also requ nci.he applicant forsuch perming m
fleasigned smmem SPECIA C IISC.
sss�QE that he is licensed punwum m the provisions ofthe Contractor's License Law(Chapter 9
�G O (commencing with Section 7")(if Division 3 ofthe Business unit Professions Code)or TEMP.METNJ OR POLE INST. COMMERCIAL:
F y K that he is exempt Iherefmm and the basis for the alleged exemption.Any viohnion of ❑NEW BLDG/ADDITION DEMOLITION
iWC 4. Section 7031,5 by tiny applicum far u period subjecu @e applicant to a civil penalty of POWER DEVICES
re N
t more five hundred dollars(S500). ENANT FOOD SERVICE
l 01,as owner of the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC MPROVEMENT
will do the work,and Ne structure is not intended oroffered for sone(SmJBla,Business ❑OTHER
and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
6 3^ property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended gr afferent for NEW RESIDENTIAL ELECTR SQ Irl'.
sale.IL however,the building or improvement ksad withinooeyeaic'manpleJnn,the ' SQ,['r.FLOOR AREA $I$Q.Ir1'.
owner-builder will have die burden of Proving that he did not bulla or improve far Pur Lf-
pa c of'ale).
❑1,asownerof the preperry,am exclusively contracting with licensed convenors to TOTAL: PAID
construct use Project(Sm.TIYd,Business and Professions Code:)The Cunuannr's Li- W
cense Law does not apply to an owner of property who builds or improves thereon,an,[ QTY. PLUMBING PERMIT PEE ���
who cnmmcts for such projects with a contortions)IiccmcJ pursunm m the Contractors
License Law. 11111tM1'f ISSUANCE Aly
1 am exempt under Sec.' ',B&P C fonhis reason Iry
RECV
ALTER—DRAIN&VENT—WATER .
Owner Date t �1ek}f(1;ION
WORKER'S COMPENSATION DECLARATION BACK IT OW PROTECT.DEVI /`fie/Tf`f/d JIV76
1 hereby affirm under Penalty of perjury one come fallowing declarations: ,
❑(have and will mainwina Cenificum of Cnnsenunself-insure for Worker's Compen- DRAINS—FLOOR,ROOK AREA,GOND. STORIES TYPE CONSTRUCTION
satinSection
,as provided for by 3900 of the Labor Gale,for Nc pedoodinc,of the
w k for which Nis permit is issued, - FIXTURES—PERT
I have and will maintain Worker's Compensation Insurance,as required by Section
3 ofthe Latin Cele,for the performance ofthe work for which this Permit is issued. GAS—EA.SYSTEM-I INC.40I1TL OCC.GROUP APN
My Workers Car�arpenselio InsuTaTBc Ctmto.c(and Policy y
Cemeo17A yN1wMMGE aTep'Glpoliey No.:(90 Z GAS—EA.SYSTEALOVIiR4(FA)
CERTIFICATEOFE EMPTLONFROM WORKERS'
COMPENSATION INSURANCE GRFASEANDUS3'RL WASTE INTERCEPTOR
or less.)
(This section need not be completed if the pemmit Is R r mmc htmdreddollit s($10) GREASE TRAP BUILDING DIVISION FEES
PLANCHECK FEE 2 /�
(certify NminNrmycarmanmof Newark for which Nis the Workers
Ca shall SEWER—SANITARY—STORM EA.200 FI'.
net employ any pawn army manner ro ns m brume subject m the Workers'Camper- ENERGY FEE
,� Applicant
of California.aDam
O A licant WATER HEATER WNENT/ELECfR
PP GRADING FEE
ay NOTICE TO APPLICANT:If,alien ranking this C vision, a of [..bar Exemption,you situ til WATIiR SYSTF,M?HEATING
f;^ become object to Na Worker's i,un rte this provisions of Ido Labor Code,yon roust SOILS PEE ,
{la lti
forthwith comply with such provisions nr this permit shall he Jccmrd revoked WATER SERVICE
Q
U0 CONSTRUCTION NEW RESIDF.NTIALI'LMB. SQ.FT. PAID
U0 (for which
continue isaco (Ser.ion len ding agency Rmrthe Performance of Dare Receiptp
W H Lx work for which this permit is issued(Sec.3IMYl.Civ.CJ
Q U Lenders Name TOTAL:
W Lenders Address - 'I'O)'AL: O
Pa 1certify that 1 have read this a,ifincdon and slam that theabove informal ie BUILDING PEI(
y anrTy,
mt.1 agrcc t.comply with sll city and county ordinances and stow laws miming m QMECHANICAL PERMIT FI?li
U Z building constmnioa,and hereby satanic repasenmtivesof Non N
is city to emrnnPe SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree,.save,indemnify mad keep harmless the City.f Cu,ain.against ELECTRIC FEE
Iiabilides,judgmenm.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
consequencein of the granting of this Pcnnit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIN If ANGLING UNIT(TO 10,000 CPM)
SOURCE REG(31ATIONS. MECHANICAL.FEE
AIR HANDLING UNIT(OVER 10.0110 CFM) CONSTRUCIONTAX ,
Signature mApplicant/Contrecmr Date EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTI]) -
as defined by the Cupenlno Mmicipul Calc,Chapter 9,12,and he Health and Safety
Code,Section 25532(a)t HEATING UNIT(OVER 101,000 BTU)
Fl yes )6- VENTILATION FAN(SINGLE RESID) PAID
Will the air contaminants
future clefinng.ccue D use equipment Qu lilyor Management
which
Dam Receipt 0
mit hazardous air conmminants as Jcfncd by the Bay Arco Air Quality Management BOILER—COMP(3HP OR 100,000 BTU)
Disaivt4 'BOILER—COMP(OVER 100.000 BTU) TOTAL:
❑Yea �Nn
1 have rend the hazardous materials reuirements under Chvpmr 6.95 of Ne Cali- AIR CONDITIONER
q ISSUANCE.D
Tondo Health&Safny Code,Satins 255 ,25533 and 25534.I understand that if Nc NEW RESIDENTIAL Mr:CH. SQ.Fr.
building doestcurmntly haveam nv t, tit is my respomihiliry mnotify the gccupam
of titer in wdbmoa ono issuance nfu Ce ca of Occupancy.
Owneror out decd erg Data TOTAL: ISSUED HY.
OFFICE