30054 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES.USE BALL POINT PEN ONLY -/r�'
CITY OF CUPERTINO BUILDING.-ELECTRICAL PERMITNO. JQ O O 5 4
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION S U B MITTTAAL DAPI
O ER'S NAME: PHONE: CONTRACTOR'S NAME: // I.IC NO',
O 7—O Uy v I �U IY,Lf1f I NIC - COM'ROLR
�ARCHITECTIENGINEER: LIC NO, ADDRESS I ❑
d . ($o 2
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSEDtatIam ONTRd under$DECons of CON QTY ELECTRIC PERMIT FEE
1 hereby oafk Nat I am f,hc Bd underprovisionsPo roe of Chapter oa(commencing JOB DESCRIPTION
aZ with Swrecura0)nf DivisionJof Chef{usinessand Rofessinns Code,roadmy license is
00 in full force and effcc)). Qp PERMII'ISSI/ANCE RESIDENTIAL
�WU License Cla,s L� Lu.If ❑SFDWL ❑KI'fCHBN REMODEL.
Date�(�'—Cnntmctur APPLIANCI35-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
f-.7y CHITECI-S DECL A'I'10 PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z 012 K 1 understand my plans shall he used m public records MODIFICATION
O Z— UPT0 2M AMPS
F4 W Licensed Professional 201-1000AMPS
�d d OWNER-BUILDER DECLARATION IMPROVEMENT
6 1 hereby affirm that I am exempt from the Contractor's License Law for 0m OVER 1010 AMPS ❑BATH REMODEUR V AIR I]UE;M/nL�ITIO�'Vt
iW5 O y U following reason,(Simon,,7031.5,Business and Profession.,Code:Any city or amnly SIGNS HLEC'1RICAL ❑OTHER qA9 iL1 M,F, g - L
which requires a permit to construct.alter,improve,demolish,or repairany',.Care
N priormitsissram<.0lsnrequirestheapplicantforsuchpcmtiuofleasignu umeram SPECIAL CIRCUIT/MISC.
pursuant to the provisions oftheeBusimr'sxv ndProe law,Cartoer9
06,
(commencingatheisempth ember and t f basis for th Neeged exempt Professions Cale)ur TEMP.METER OR POLE INST. COMMERCIAL
6lL n oC that im is exempt therefrom and the basis far the allege)exemption.to Any violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION
,far am
live
harder!doll ,(Sys mit subjects theuPPlicummacivil penalty(if POWER DEVICES
z tmom mon Ove bandrea dollar,1%51X1). ❑TT:NANT El FOOD SERVICE
CO ❑I,as owner of the Property,or my employees with wages as their ode cmultmomion, SWIMMING POOL ELECTRIC IMPROVHh1ENT
will do the work,and the structure is not intended or offered for mle(Sec.]IW4,Business ❑OTHER
6 3$ and Professions Code:The Contmnoex License Lw does not apply to an owner of OUTLETS-SWITCHES-PIXTUREsi
property who builds or improves Hereon,and who does such work himself or through — —�K
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ IT.
sale.If,however,the building or improvement is sold within one yearefcompletion.the SQ.F'T�
FLOORAREA $ISQ.FT.
owner-builder will have the burden of proving Not he did not build or improve for par-
pnseofxala.),
C]1.as owner of the property,am exclusively contracting with licensed contractors to TOTAL: X
nswct me pnj44
ect(Sec.]0 ,Business and Profession,Cori The Cmarda es Li- �
cense Law dons not apply to an owner of Property who builds or improves tames,and QTY PLUMBING PERMIT FEE -
who contracts for such Projects with a contmcmKs)licensed pursuant o the Caricatures
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. ,B&PCforthis reason
Owner Uma
Al2ER-DRAIN&VEND-WATER(EA) f VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE '
I hereby affirm under Penalty of Perjury one of no following declarations:
I have and will maintain a Certificate of Comom,to self-insure for W'orkds ComPem DRAINS-FLOOR,ROOF.AREA,GOND. STORIES TYPECONSTRUCTION
stairs,as provided for by Section 3700 of the Labor Cale,for the performance of the
work for which this Permit is issued FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
_ 1 I ofthe Labor Code,for the perfornturicr afthe work for which this permit is issued, GAS-HA,SYSTEM-1 INC,4 OUTLETS J
OCC.GROUP
APN
My Worker,.Cy�'per _ion lniki$ur��anee wnterand Polip r�r�a�armera1�
Caricr:gS.I ('j0. Policy NoBL[,,`J�i�� GAS-BA.SYSTEM-OVER 4IEA)
��C��Ewpla 1a1FICA?? OP L'%EMPfION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
('this section need not be completed ifine Permit is for one hundred dollu s($I(XB BUILDING DIVISION IFGS
or less) GR[ASE TRAP
PLANCHECK FF:R
(certify hal rian in perany maarmnner
of Ne wok for which Nis pamth L,er,'(7l,lshall SEWER-SANI'T'ARY-S'IOItM EA.200 FT.
not employ any Califon in any manner sn us to hmomc suM1jat m the Workeri ContPcm ENERGY PER
Z
z cationnws of California.Date
O
Applicata WATCH HEATER W/VENT/ELECTR GRADING FEC
y NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATI7R SYSTEMOREATING
become subject o the Worker's Compensation provisions of the labor Code.you must SOILS PEE
Lkl fordwim comply with such provisions or this permit shall In deemed revoked. WATER SERVICE -
Q
CONSTRUCTION LENDING AGENCY .NEW RESIDENTIAL PLM({. SQ.Pf, PAID
UO Iher.1iftrm Natthere issued(Sev.30lending agency l'nrthe performance of Date ReceiptM
IL F. the workfor whichthispemdt is issued(Sec.309].Civ,CJ
O U Lender's Name TOTAL:
ftJ Lxhdces Add.. c
I carify Not I have read his application and state mat the above automation is TOTAL: /Q BUILDING FEE
IAA correct.l agree to comply with all city and county ordinances said state laws misting to QTY. MECHANICAL PERMIT FEE
r U � building conoruainn,and hereh,out irerepmsentativcarf Nis city m enter nponme S17ISMIC FEE
above-mentioned property for inspection Purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Calandra against ELECTRIC FEE
Iiabilithes,judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. a y,
• consequence of the granting of this permit. - PLUMBING FEE V
APPLICANT UNDERSTANDS AN WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 Ig000 CFM)
SOURCE REGULATIONS. MECHANICAL TEE
ag.f AIR HANDLING UNIT(OVER 10,000 CEM) CONSTRUCTION'1'A%
- ,U/![auto.. Appjiccitr Contmcmr Dole f/ EXHAUST HOOD(WIDUCU
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will meapploml or Estate,building a:cupatnsme,orbitale harsrdous material HEATING UNIT CFO 100,001 BTU)
to defined by the Cupertino Municipal Cale,Chapter 9.12,and the Healm and Safety
Code.Section 25532ho? HEATING UNIT(OVER 100,000 BTU)
El Yes ❑No
VENTILATION PAN(SINGLE RESID) PAID' '
Data Recei #
Will the applicantorfuture budding byoccupant useea Air Quofdevicewhich BOILER-COMP(3HP OR 100.(00 BTU
emit District?
hazardous air cnnmminants as JcfincJ by me Bay Area Air Quality Management ) TOTAL:
Dtsmct
Li Yes FIN. BOILER-COMP(OVER Ioff"BTU)
I have read the hazardous material,requirements War Clta tar 6.95 close Coli AIR CONDITIONER
4 P ISSUANCE DATE
fitmia Health&Safety Code.Sections,sch i,,IiSO,my and 25534.I understand that if the NEW RISSIDIiNT1AL MEG.((. SQ.FT.
ofthengdoesnotas whicyhust be
pmuto i,uace of a Can cae ofythelter, _
of the requirements which must be tan prior to nfu Cenilicate of p:cupancy.
Owner or aathori[c l agent Data TOTAL: ISSUED BY:
OFFICE