30916 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. �0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJE,C'T IDIEWIPICAI'ION
916
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
iD 13 9 'is - C u e r� v\ o y1
OWNBRS.'AM@ O V PHONIC: ^ L CONTRA O`NAME: �G ia1/,G/A IC% NIC CONTROL#
V7I„ ITM RCHMENG EER: LIC NO: l VADDRESS V
Mo AI4.-LG tkFor a �rO ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSEDtat I am ONTRAC sed unORSder provisions
DECLARATION QTY ELECTRIC PERMIT FEE
thereby )(if Um Iumfine Bdunderprovisionsof Chapter 9(commencing JOB DESCRIPTION
HCZO with Section]000)of Division]of Ne Buxiness and l'ndessions Cnde.and my license is PERMIT ISSUANCE
Tullf me mW offer .S
�F.Uj License Lina--��I ❑SFD CHF.N REMOUEI.
NQS Omc Cnnntemr 1]ep dPPL1ANCIS-RI?SIDENTIAL
UITION UMBING RE-PIPE
ARCIIITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O y 7�- 1 understand my plans shall be used as public records t
OZ-, UP TO 200 AMPS CHIMNEY REP
1=4I: Licensed Profe,"inanl [I INTERIOR [:j CHIMNEY REPAIR
201-1000AMPS
� . IMPROVEMENT
�d dem I i exempt f DECLARATION OVER I(")AMPS^y�T of�Q 1 herehy vffinn shat 1 oro exempt from the Contractors License Low home ❑BATH RCMODEIIItEPAIR ❑DEMOLITION
a5O G FUr following reason.(Section 7031..5,Busbie_m and Pmfcssiuns Code:Any city or county SIGNS HLBC'fRICAL ❑OTHER
t❑L7 LL p ya which requires u permit to construct,aher,improve,demolish,or repair any structure
prior to its issuance,also caquircs Ueapplicartfar such Permitto file usigned,occurm SPECIAL CIRCUIT/MISC. WFU
y that he is licensed pursuant o the provisions of the Contractors license Law(Chaptere) p
aC) (commencing with Section TIP)of Division 3 ofthe Husiness and Professions Oahe),, TEMP.METER OR POLE INST, COMMERCIAL:
Q.y o tY That he is exempt Therefrom and The basis to he alleged exemption.Any violmin.of ❑NHW RI. / ITI�N LITIUN
iYfl Ir. Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DIiVICES 1 Q �JIt���+��
} not more Uen five hundred dollars(S500). ❑TENANT v 117IA®SERVICE
a0 ❑1,as owner ofthe property,or my employees with wagesastheir sole compen..tin., SWIMMINGPOOLELECTRIC IMPROVEMENT
sale(Sce.7044,Ifnsinese' ❑ CI1OTHF �7 U') n
and Profession,Code:The Connector's License Law does not apply to xnowner of OU' -TLCFS-SWITCHESIXTURES T �drtitTlN�—
a' property who builds or impart director,and who diva such work himself or through
his own employees,provided that such improvements are nm intended or offered for NEW RESIDENTI :LECI'R SQ FT.
sale.Jr.hnwever.The building or improvemcat is sold within one year ofecmpletinm Ue SQ.FT.FLOOR AREA $/SQ.FT.
ownsa,builder will have to burden of proving that he did not build(ir improve for par-
pose of sale.).
as
1,as owner of the property,am exclusively contracting with licensed contnerors m TOTAL: a
courtruct the project(Sec.7144,Business and Professions CaleJ'Hie Commena's Li-
rense Law doesn lim,i,toanownerad Property who huilda or hopowcs thcrron.mil QTY, PLUM G♦y IJ FEE
who contracts for such pmjecn with a counteracts)licensed premum to the Contmemrs
License
RMIT law. PEISSUANCI?
I am exempt under Sec. ,B&P C forthisrenmr
ALTER-DRAIN&VENT-WATER
Owner Due VALUATION
WORKER'S COMPENSATION DECLARATION BACK ROW PROTECT DEVICE
I hereby affirm under Penalty of perjury one of the following do imosions:
Ihaveand will meinminn Cenifica¢of Consent to self-insure liar Worker's Comas- DRAINS-FLOOR,ROOF,AREA,GOND,
ind in ,as provided for by Sectio M
3700 of The Labor Code,for The pmfanernce of The STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as acquired by Section yo
3701 ofthe Labor Code.for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM. INC.4 ourt. S OCC.GROUP APN
My Worke's CiyynnPenxalinn lm Knee carneTand Policy n mer p
Carrier:5*16 �..0 Policy Nu.: 7Sa�T GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATEOFEXEMPfIONFROMW RKERS'
COMPENSATION INSURANCE GREASPANDUSTRI.WASTE INTERCEPTOR
(This section need not he completed it the permit Is for one hundred dollars($HXI) BUILDING DIVISION FEES
nr less.) IGREASE TRAP,
PLANCIiI?CK FBP,
I renify that inthe seder..nceof...work for which this thepermitWisissuC.m nil SEWER-
. nutemploy any person in en manner so aambecome suh'e<uothe Wnrker%Com SANITARY-STORM EA.2f10IT.
Y 1 pen- ENERGY EEE
Z sution Laws of Califomiu.Dan
yO O Applicam WATER HEATER WIVENT/ELCCfR GRADING FEE
p,^ NOTICE TO APPLICANT.If,after making this Cenilicale of Exemption,you should WATRR SYSTEMzMHAT ING
a become subject to the Workees Compensation provisions of the Labor Code,you must SOILS FIiE
W forthwith comply with such provisions or this permit shall be deemed revoked. WATI7R SERVICE
d Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,IT. PAID
UO I herehyaffirs,thm there isocardamom.lending agency far the performvrcenf U Receipt#
fL the work for which this permit is issued(See,3097,Civ.C.)
O LcndeT's Name
endTOTAL:
r[�] Lers Address TOI'A I.: _
y 1 really rant I have nail this application and state that the above information is a BUILDING THE
hcorrectt i agree to comply with all city and county ordinances and state laws calming to QTY. MECHANICALPHRMIT FEE
U 7 building construction.and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
ahuvo-memioned pmporty for ftepexion purposes. PI?RM1'I'ISSUANCIi
(We)agrccroav
one.indemnify anJ keep harndcs+The GYM'Copeninn against - ELECTRIC FEE '
liabilities,judgments.cash and expenses which may irony wayrcoue against said City ALTER OR ADD TO onsMECH. - �e
in cequence of the grunting of this permit. PLUMBING ME
APPLICANTLlDERSTANDS AND WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT OD 10.000 CFM)
SOURryCC�EIREG ATIONS. 1 MECHANICAL ME
AIR HANDLING UNIT(OVER 10.00)CFM) CONSTRUCTIONTAX
Signature of Appicimp Conauctor (� o Imo— EXHAUST HOOD(W/DUCT)
HAZARDOUS S1ATERIALS DISCLOSURE? HOUSING MITIGATION FEE
Willthevpplicaut orfuthre building.ccopam sma,.,handle hvzardmisrushrisl HEATING UNIT(TO 1110,000 BTU)
as defined by the Cupst ino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)? HEATING UNIT(OVER HT),g1(1 U)
Yes C]No
VENT I LATION FAN(SINO tkL'$ID) PAID
Will Joe applicant or Form building occupant use Date Receipt#
an
leapp g p ea Air
Management
BOILER-COMPJH RIOB,W BTU -
Disticts us air connminants as dcfinN by due Bay Area Air Quality Menagcnvm ( )
Distrix? TOTAL:
❑Yes 71Nq BOILER-COMP )VER 100.000 BTU)
- I have read the hazardous hanrials AIR COND ONER• r IJATE
requimtrvms under Chvptcr 6.95 of Ue Cali-
fom a Health&Safety Code,Seen..,25505,25533 and 25534.1 understand that if the NEW .;IDENTIAI.MECH. SV.halIJlng doernm currently havev tenant,that itis my responsibilitym maltythe tacupamofthe namirements which must be met prior m Issuanceofa Ceni vale of G,cupancy. -Owner or authenzed agent UaTx TOTAL: ISSUEDY(;1CF
OFFICE