30182 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING.ELECTRICAL PERMIT NO. 30182
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUD DING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NU. APPLICATION SUBMITTAL DATE
I' OWNER'S NAME:• PHONE: C NTRACfOR'S NAME: ,LIC No Q -d_•ted NIC CONTROL#
ARC CTIE INEER: LIC NO: ADDRESS: ❑
<< r.
CONTACT: PHONE: i BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ByLQG_ ELPLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE r—r�I(_- C1 El
1 hereby affirm thin 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�0Z with Section 7000)of Division 3 of the Business and Professions Code.and my license is 00 PERMIT ISSUANCE RESIDENTIAL
In full force and ffc}}t.
UZ V License Class�c6 1—IJ Co N 3 '#A !-_/ r O SHDWI. ❑KITCHPLUMBING
REMODEL,
E
�6L Date Comretor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
fF..., ARCHITECTS DECLARATION PANELS ❑MULTI-UNI'T OSTRUCURAL
z O t2Z 1 understand.,,]..a shall he used as public records MODIFICATION
OZ—a UPT0200AMPS - ❑INTERIOR ❑CHIMNEY REPAIR
F,wtn1 Licensed Professional 201-1000AMPS IMPROVEMENT
-•j OWNER-BUILDIBE DECLARATION OVER Has)y a I hereby affirm that 1 am exempt and the Contractors License Law I'or the El RF.MODEVRF.PAIR ❑D OLITION
x 3 d U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. - O OTHER
❑1 LL, which requires u Fermin m construct,stir,improve,demolish,or repair any structure t
11darto its issuance,also requires Ute applicant for such permit to file a signed statement SPECIAL CIRCULDMISC.
that he is licensed........the pr osinons of the Commences License Lao,(Chapter 9
�C) (commencing with Section 7")of Division Sof Ne Bmineasind Professions Crib)., TEMP.MET ER OR POLE INST. COMMERCIAL
d ry,oy that he is exempt therefrom and the haris for the alleged exemption.Any violation of ❑NEW BLDG/AUDITION O DF,MOLff10N
IitC1 {,• Inchon 70JLmi
S by tiny applicant far u pert subjectsm the applicant a civil penalty of POWER DEVICES
j not more than rive hundred dollars 3500). ❑TENANT ❑FOOD SERVICE
Q01,ra owner of the property,or my employees with wages as their sole compensation. SWIMM LNG POOL ELECTR IC IMPROVEMENT
_ will do the work,and the seuaure is not intended or offered for aide(Sex.]014,Business OOTHER
and Professions Code:The Co areftses License Law does not apply to a,owner M OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through —— _q
his own employees,provided that such improvements are not intended or offered far NEW RESIDENTIAL ELECT SQ IT.
sale.If,however,the building or improvement is sold within one yearof completion,the SQ.FT.FLOOR AREA $/SQ.FT.
mwncr-builder will have the burden of proving that he did not huild or improve for put. '
,an of salo). -�
El 1,asowner ofct property,am exclusively contracting Cob,)ThdCcontractorsno 'I'OTAI #
mnswa m<pmjeet(Sec.]034,I{usines.and Pmfessinm Cale:)The Comrecmes Li-
censelawdoesnotappiytoanownerofpaiwhobuildsorimprovesthercon.and QTY, PLUMBING PERMIT F JUC 01.
who contrazm for such projects with a conttactorts)Residual Forward to the Comrectnes
License I e.. PERMIT ISSUANCE 1911"
m
O I am exnpt under Sec. ,B&PC for this reason es / ti
ALTIBE-DRAIN&VENT-WATER(EA) VI VALUATION
Owner Dam Q 2.111111 '_
WORKER'S CDMof peep,
BACK FLOW PROTECT.DEVICE. —Il o
1 hereby affirm under Certify of perjury ane of the insure following d ander')ora,
❑,have andpro will for
maintain 37su ofCe Labor soL.fortfor Worker's Camper- DRAINS-FL(X)R,ROOP,AREA,CONp. STORIES T PE CONSTRUCTION
soden,as provided for mi Section 3700 of the Labor CNe,far the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will main min Worker's niece ofthe w rk bruec,h required by Section
3]IH)ofthe Labor CttJc,for pednrnnmcc of the work far which this pewit is)count, GAS-I!A.SYSTEM-I INC..OUTLEfS ❑CCG 1' APN
My Worker's Compensation Insurance carrier and Policy mother um:
Carrier: Policy No.: GAS-HA.SYSTEM-OVER 4 IEA) '
CERTIFICATE OF I XIEvEs'IGN FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTR,WASI'I:INTERCEPTOR
(This section need not be completed ifthe permit is formic hundred datan(SIW) I DING (VISION j.FS
or lead.) GRF.ASETRAP PLANCHE fillwnrl
m Ioyary permit us by
cal'the work forwhich this per dtlsiss'Cns,en- SEWp12-SANITARY-SIURM HA.2W FT.
nm employ tiny perm in any manner w a m he me subyy'em m the Worker)Cumpen- ENERC F
zsation[awsof .' Date ��"3A 4 h
O Applicant x o�* "AWN,
WATER IWA'ILR WNENT/ELECTR GR GME
NOTICE TO APPLICANT:If,after making this Certificate Exemption,you should WATER SYS'IEM/BEATING
a [^ become subject m the Worker's Compensation provisions of the Labor Code,you must 5ItFE
Ibl G forthwith comply with such provisions(it his permit shall be Jmmed revoked. - WATER SERVICE _
s
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ,PU PAID
l hereby hick thi thattheni isactm(Sect30G.Cis for perfowance of Uam Receipt#
� (~ the work for which this permit is issued(Sec.3W],Civ.Cd
O V bender's Name TOTAL:
f<ntlees Address TOTAL:
1� a 1 Certify that 1 have read this application and state that the above infowation is BUILDING FEE
Z) correct,l agree no comply withal]city and county ordinances and state laws re,ntingto QTY. MECHANICAL PERMIT 'FEE
U 4 building consumed n.and hereby m.Iloi,raitrewitiawrisol th is city to enter mptmthm SEISMIC FEE
above-mmmmred Fame.y for historian purposes. '
(We)ugrcchtsave,indemnify and keep harmless the Cityof Capertime.,aural PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way amre against said City ALTER OR ADD TO MECH.
in comaequerce mf the gr oming of this permit. PLUMBING IEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO ROIN)CFM)
SOURCE REGULATIONS. MECHANICAL FEE
�a•T/N J AIR HANDLING UNIT(OVER 10.010 CFM) CONSTRUCTION'IAX
�uromf pleanl/Cortredor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fume building occupant store or handle haasrdous material HEATING UNIT LTO I W."BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety
Calc,Section 25532(.)? HEATING UNIT(OVER I00,111K)BTU)
❑Yes Fl No PAID" VENf[],At'ION FAN(SINGLE R ESID) part Receipt#
Will the applicant or future End Ed ing occupant use equipment or devices whioh BOILER-COMP(3FIP OR I(III,IXW BTU)
cov
is,coil hardous uir contaminants as defined by the Bay Area Air Quality Management - TOTAL:
Distinct?
❑Yes ON. BOILER-COMP(OVER 100,00)BTU)
I have read the haoWous minerals requirements under Chapter 6.95 of me Cali. AIR CONDITIONER
9 p ISSUANCE DATE
fomia Heath&Safety Code,have
inns 25505.25533 and 25534.I understand that it the NEW RESIDENTIAL MECH. SQ.PT.
of berg doe not t"'lucurrench have h e et p thin o is ua ce ofa Carifim notify the occupant
of the nquircmenm which mus be met priormissuhnce nf.Certifcum of Occupancy.
Owner or sustained agent Date TOTAL: ISSUED BY:
OFFICE
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NOTE �Fp4:s xFeaO a m ,W iM T POSTS n
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