30878 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINQ APPLICATIO /YERMIT BUILDING-ELECTRICAL PERMITNO308787 Q%o,
BUILDING DIVISIONPLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - - r SANITARY NO. APPLICATION SUBMITTAL DATE
i ~ a �
OWNER'S NAME: 1 P ONF:: CONTRACTORS NAME: LIC NO:
P `n O 04 (j rI . N/C CONTROL#
CHIT T/ENGINEER: LIC NO: ADDRESS: '
CONTACT: PHONE. BUILDING PERMIT INFO
G 1'sG 0� e
n .:. aSa - iaS�G .
❑ Consultant Fees Paid 6y Applicant(Initial) BLDG ELECT PLUMI_ MECH
1. LICENSED CO CTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licenced under provisions of Chapter 9 mommcnaing JOB DESCRIPTION
�Ou 00 with Section 71000)of Division 3 of the Busine,stand Pormewlore Code,and my license is RESIDENTIAL
F Or in full force and effect' PERMIT ISSUANCE -
lUUo
LiterseCless ' _ Lie _❑SPDWL CHEN REMODEL
APPLIANCES-RESID17NTIAL
NZadate Conuacurz ❑ADDITION D LUMBINGRE-PIPE
ARCHITECTS DECLARATION DMULTI-UNIT ❑STRUCTURAL
Z O n Z I understand my plans shall be used as public records PANELS ..
-
0z UP 70200 AMPS MODIFICATION
F4F-'tbbi/, Professional _ ❑INTERIOR DCHIMNEYREPAIR
OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT
W Q 1 hereby affirm that I am exempt form the Contractor License Law for the OVER IOW AMPS D BATH REMODEUREPAIR D DEMOLITION
at1 P following reason.(Section 7031,5,Biomass d P f Col Any,dta county SIGNS ELECTRICAL D OTHER
which requires permit tconstract,afted'improve,demolish, P Y structure _
y
prior tot,berance,al,em4nind,do applicantfor lull permsno File aligned statement SPECIAL CIRCUIT/MISC.
p.
[Iran he is licensed ptt the pr ten of the Contractors License Law(Chapter 9 -
�� (commencing withSection 7")ofDivision 3 ofthe Business andPref Code)or TEMP METERORPOLE INST. COMMERCIAL-
e's a that he v,eadoup,th ref oro and the basis far the alleged exempt a.Any viola[00 of
,,, Section]01LIb '¢ant for permit thea lieant to a civil It I POWER DEVICES [I NEW BLDG/ADDITION ❑DEMOLITION
y hundred
permi I Op pens yo OTENANT ❑FOOD SERVICE
„y t---,ban Eve hundred dollars(empl.
0
sd ❑Loowner k,the properly,or bemyet intended withwages
red for their(Ssole.compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
Fo
will dothewok,and Wasic Clanianot r,Lilemp offered o,apply.. a,easiness ❑OTHER
eo and Professions ills o The Cos there's License Law does no[apply s if rarer of OUTLETS-SWITCHES-FIXTURES
progeny who builds or improves therms,and who does such work himself or - _
his scan employees,provided that such improvement,arc not intended offcmd r offeretl for
NEW RESIDEM'IAL ELECTR S
sale.If,however no buildingor improveiriem is sold within one year of complebmime SQ.IT,FLOOR AREA $/SQ.FD.
�vvncr-buflder will have the burden of proving that he did me build or improve For par, _
pogo of sale.). P 41 -
( 11,as owner of the propel,am enclas vel,contracting with I tensed coronae,...m .r T
construct the project(Sec 9044,Business and Professions Coda)The Contractors Li- 4P#^
arm.Law d.not apply toan ownerof property who builds or improves[homes,and ryP#
QTY. PLUMBING PERMIT �.aw ^
who va dwct,ho,oeh projects with a contmcmr(a)licensed puns...,,the Comrstm's (�
License L . _ PERMIT ISSUANCE
❑Iame.mtptmall,Sce. BSePaforthisreason — /rYGh' L'
s r Date ALTER-DRAIN&VENT-WATER(EA) ' VAL 1:Rr
WORKER'S COMPE TION DECLARATION BACK FLOW PROTECT DEVICE ,II'O
I hereby affirm, penal[yn dory one of the fdmaingdecbua[ions: _
I headmal will maintain a Certificate of Ciammooci1fousure for Worker's Compel- DRAINS-FLOOR,ROOF,AREA,GOND, STORIES TYPE CONSTRUCTION
smion,as provided for by Section 3700 of the Labor Code,for the performance of the
' work for which this permit is issued, 0 FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 fine LuberCotte,for the pdrmonamce ofthe work for which this permit is issued, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.CROUP APN
My Workers Cma,momm Insurance carrier and Policy number are: ,
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIi/INDUSTRI.WASTE INTERCEPTOR
(This seamm i ceA norbe comploted if the permi[is formed hundred dollars($100) BUILDING DIVISION FESS
or lees.) GREASETRAP
t loenify India filo pdrfowence.the work foewlinh thispemti[is issued,Idoill PLANCHECK PEE
no[empiny any person in any manner loss m hoodlum..pied ro the Workers'Compen- SEWER-SANITARY-STORM EA.200 FT. ENERGY FEE
sroion Laws oC California.Date
`
Applicant - WATER HEATER WAENT/F,LECIR
PP GRADING FEE
h NOTICE TO APPLICANT:If,after making this Certificate of Exemption,yon should WATER S YSTEMITREATING
REai Delmore subject to the Workers Compensation provisions of the Labor Gide,yon mus[ SOILS HE
W tli,4.0 comply with such provisions or this wma,hali bo doomed revoked. WATER SERVICE '
A
5 z ' CONSTRUCTION LENDING AGENCY NEW RES IDEM'IAL PL MB. SQ PT. PAID
U Q l hereby affirm that there is a construction lending agency for the performance of - Date Receipt#
Me work for which this permit Is issued(Sec.3097,Civ.C.)
O U Lender's Name 'DOTAL:
Lenders Address TOTAL:
I certify that I have read this application and state that the above information is BUILDING FEE
h correct.l agree to comply withal)city and county ordinances and state laws mining to QTY, MECHANICALPERMPT FEE
U building eonswclinn,and hereby authorize representatives of this city menter upon the SEISMIC PEE
above-mentioned property for inspection purposes, PERMIT ISSUANCE
(We)agree to save,indemnify esti keep harmless the Chy of Cupertino against ELECTRIC PEE
Imbilites,judgmems,costs and expenses which may many any acerae against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQOf10 CFM)
SOURCEREGULATIO MECHANICAL FEE .'
7 AIR HANDLING UNIT(OVER 10,000 CFM)
. L CONSTRUCfIONTAXAME
gnature of ApplicanVCon"'mUatEXHAUST HOOD(W/DUCT) BOOM ,MITIGATIO
HAZARDOU ATERIALS DISCLOSURE '
Will the applicant or Poor i'ding occupant'mm or handle haairdous material HEATING UNIT(TO 100,000 BTU) _
as defined by Be Cupertino Municipal Code,Chapter 9,12,and the Health and Safety
' Code,Section 25532(.)? HEATING UNIT(OVER IW,WO BTU) -
❑Yes ElNo PAID
VENTILATION FAN(SINGLE RESID) Dote Receipt#
Will the applieant or future building occupant use equlpmetn or devices which
it hazardous air contaminants as defined by the Be,Arca Air Quality Management BOILER-COMP DHP OR 100,000 BTU)
setrin? TOTAL:
❑Yoe, - E:lNo BOILER COMP(OVER I00p00 BTU)
AIR CONDITIONER
I have read the h ode.S s tions 2 5 5,25533 an under 1 understand
rsta of the if the - ISSUANCE DATE
Cmmia HmIN&Safetyboa Cada,Sections 25505,it or, and 25534.I mderswnd[hat if the NEW RESIDENTIAL MECH. SQ.FT. '
building does no[is which bust a resent,Nato is my re ofa Certificate
mollify offy Ne carbonate
ancy.
of the requirements which must be mer prior,.issuance ofd Certif[eofOmnpancy.
use nu or ,anthonecougent Date TOTAL: ISSUED BY:
OFFICE
\ t
a� ��rA . � ash. . �;,. s� �$ • o� � z=� 3. : 3� .�s; , � �,
1111i2lill
-scan i
R:.:'�+.s 2r, 4 `�..t.t u - a - 't, Y.t - r r •r a z
A1' fere d(.,
b +. k If 3,4�� R6a�v '� l�:ey e
�. f . .
:----- -
n
h
f
.,,.:,.. L
. FF
I .
' -'-`- -
Q�1.�u',yyJ
t... .j-t..y - - - ---- - --- - - ---- - - - - - - -- - - -- - --- - - -- - --Ci--- -71 �lp'�GPAL-- - -
.
---------------
'Gotltf �ae�
�^ge'��,P qh
Y .
-
,
Ll
wo
rF
J
,
,
Over=-
fff
/O
a
r .
� .1NS �'ffCMN EPAfl r "NF �.
-, -, •i,. iii ii ;
aha+ 'f� s�rw -•�
��..Y�MRa,i.:4"�.fi.`�� �:^M.*���d�.�rY ��i'� �'�'�K�.i1PA`. '��`R �l�9�'�".3'..,= F_- '.v,'i.'• 'y Yk'tlo'2Ay
_ ...'._��� +:...x;.a •a.'a'3 �Lta-s .'T'.4`der'Sl"`�"v.'!tir•�eSM"a��7.`.^Q'fiF:;^�:.�r��+•,� ,: -��...» •4.e'+...:m