00050032 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECYRICA]. PE )
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJECT IDENT'IF'ICATION
HUILDINGADDRCSS: SANITARY NO. APPLICATION SUBMITTAL DATE
56FeliRZ 'qd,
OWN17RIS NAME: = PHONE: CONTRACTOR$NAME: LIC NU:
vog a a-3� I n�G N/C CON ROLx
��:HE PECTEN INFF,R: LIC NO: AI]JAWy SI: O V1C 1 ❑
CON'I'ACC'I': PHONE: IY Ir✓` BUILDING PERMIT INFO
-��� ❑ Consultant Fees Paid by Applicant(Initial) BL❑UC ELECT' PLUMB MF,CH
i
LICENSED CONTRACTTORS DECLARATION QTY. ELECTRIC PERMIT FEF.
1 hereby afern that 1 am licensed Haden provision.,of chapter v(arrodwo mg JOB DESCRIPTION
MQZ with Sectio 70X0)of Division 3 ofthe Business and Professions Code.and/m�y license is I p13HMIT ISSUANCE RF_SIDENTIAL:
YW_ in full fmro mal elTec �L.,:��Lfl ❑SFDWL ❑KITCHEN REMODEL.
"U Llccnse Class O Lic.M
NGi Uvrt16e> Cmoracmr <Im5 -o APPLIANCES-RESIDENTIAL. ❑AUDITION El PLUMBING RF.PIPE
ARCHITECTS DECLARATION ❑MULTI.UNIT ❑STRUCTURAL
Z O.z 1 understand my plans shall be used as public records PANELS MODIFICATION
OZNO UPTO200AMPS C3 INTERIOR [I CHIMNEY RU?PAIR
F�FW Licensed Profcsdounl 201-10XOAMPS IMPROVEMENT C]SWIMMING FOOLS
yds" OWNER-BUILDBR DECLARATION OVI?R Paul ❑BATA REMODP.IIREPAIR C1 DEMOLITION
a fyal a I hereby affirm mat I atm excmpl Bent the L'mnraemr's License Law for the
i O ,U Iollowin (Station]0315,Business and pool'csslans Code An t t ❑OI'I{I?R
%3 F g mown.form iony ci y m mon y SIGNS ELL'C'I'RICAL —
_uQywhich y - pa ao cnn%tmct,ober. p , I:h pa Y t tore
that
11: q 'm ppl 'ntl l Permit fl g J.t t Hent SPECIAL CIRCUIT/MISC.
W.T that helicensedp n thep of the Contractor's L La ICI p¢r9
z�a0 (commencing with Secton 7")ofDvson 3 mf the Busness and Professi .Cade)or TE NR METER OR PULE INST.- �COMMERCIAIe
m-00
a a e z that he is exempt memrrom and me naris for the allege)exemption.Any violation of C:1 NEW BLDG/ADDITION ❑DEMOLITION
Iki'�m
Section?031.5 by any applicant(or a permit subjeats the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
..,noes.than Br hundred dollars(5500).= IMPROVEMENT QI]Lasowner.fthe properi,or myemployces with wagc,as thek,cilecompensation. SWIMMING POOL ELECfItIC ❑OTHER
r- will Jo the work,and the nructum is not intended or offered for sale(See.]BW.Business
i 3 m and Professions Code:The Contractors License law does not apply to an owner of OVI'LITS-SWITCHES-FIXTURES
pmpeny who builds to improves themoa,and who J«s such work himself or through
his two employees,provided that such improveomnts arc not Intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.IL however,evThe building or improvement is sold within one year ofcomplelum.the SV In'.FLOOR AREA 5/sQ.FF.
c,hm1der will have the hurdun of proving that he did not build or Improve for pur-
x"oI Wad. 'FO'1'AL
❑ 1.m owner mf Ise property,an,asalunivdy eommcting with harmed mmmctors m
construct the project(Sea.WOL Business and Pndessions Code:)The Contractor's U.
Law does not apply in an owner of popery whir builds or improves dm
proveeon.and QT V. PLUMBING FERMI'P FEE
comic
se ho commeu for such premeds with a rmuscon(s)licensed pursuant to the Com oson s
License law. PERMIT ISSUANCE
C]I um exempt under Sec. .H&P C for this reason
:FER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dae
Wrm OR KERS COMPENSAI[ON DECLARATION BAG'F1EOWPROTECT.DEVICE DOV/T)
1 hereby athunder penalty of perjury one of the following declarations: p —
Ihnvivalwillmaintain aCertificateofConsent a,self-insure for Worker's Compcn- 1 DRAIN FLOOR,ROOF.ARE ,CON STORIES TYPE CONSTRUCTION
tion,as provided for by Section 3710 of the Labor Cod,for the performance of,he
whichlhis permit is is sued FIXTURES ER TRAP
[tI hove and wat maintain Worker's Compensation Insurance,o required by Section
9700 ml the Labor Coca,for the perfnrmwtmoLhe work for wblehthis permit is is'sead GAS-EA.SVS 'M-I INCA( 'I'LL?'I'S OCC.GROUT' AI'N
My WurkarX , pent yty/- r and Policy numbs(
m L �K_3�)37Je7. GAS-HA.SYSTB. VF: (EA)
Cartier: �r/ ///kfaeJ/IS ePaliay Nu.:1(
CERTIFICATE OF FNEMP11ON FROM WORKERSGRE ASM- NDUSTRI. STE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed if the pcnni,is fur one hundmldollars(Stan) GREASETRAP
or less.) PLANCHIiCK FEE
IcMify thin in the per(ormanee of the work for which this Perot is issued.(shall SEWER-S TARY-STORM .200 IT.
not employ any pawn in any manner so as to become subject to the Workeri Camper- ENERGY FEE
Z suti,,n laws of Califnmia.Dare WAT17Rf TATER wNENT/F:hECDt GRADING FEE
Z Applicant
N(YI'ICE TO APPLICANT If,after making this Certifier¢of Exemption,you should WAT SYSTEM/TREATING
I•' ; becomuo m
e subject the Worker's Compensation provisions of the Iatx,r Cade,you mow SOILS FEC
lorthwith comply with such provisions or this permit shall be deemed revoked. WER SIiRVICE
"lliqQ
Z) Z CUNSTRUC'I'ION hIiNUINC ACIiNCY NIiW RESIDEN'IIAh PLMH. SQ(1'. PAID
UO l hereby uthnn that themisa construction lending agency l'orthe performance of Dine .ReeaiplX
P: ILe work for which This pamnit is ismed(See,a1Y)],l'iv.C.)
0 Um
Idse's Name Ttil'AL:
WLenders Address 'TOTAE.
Q. I eenify that 1 have read this application and start that the above infnrowhun is BUILDING FEE
FN erect.l agree mcomply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
Q building construction.and hereby authorirc representatives ofthis city to enter upon the SEISMIC ECF.
aMrvementioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep humorless rhe City of Cupertino against ELECTRIC PEE.
liabilities.judgments,costs and expenses which may in any way acerae against said City ALTER OR ADD TO SUCH.
PLUMBING PEC
in m cof the granting of thisWIL
APPLICANTICANTUNDERSTANDS AND
WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB,lXO CPM) MECHANICAL FIF:
SOURCE RE IILATB S.
Q AIR HANDLING UNIT(OVER BI,O(O CFM) CONS'I'RUC'FIONTAX
Signora Ap iFat/Cmumalor Due dxi IAUS'r HOOD(W/DUCT) HOUSING MI'I'IGATION FEE
AZARDOUS MAI PR1ALS DISCLOSURE
\ Will theappl:am or future build'mgoccodintsmrc or handle hanalloos mmentil HEAPING UNI'I'(TO 11X),000 B'1'U)
a,)alined by the Capsmnn Municipal Code.Chapter 912.and the Hamm and Safety
Code,Seat io 1255320)? �, HEATING UNIT(OVER Ian.anP H'FU)
1A
p Ye. t.n/ PAID
VEM1TIL\TION PAN(SINGLF:RElID) Dole RcttiplX
Will the applicant or future holding receptor use equipment or devices which BOILER-COMP OHP OR IOIhanO BTU)
ami,harmdous air contaminants as defined by the Ray Area Air Quality Manxgemem TMA
District? / BOILER-COMP(OVER 100,000 BTU)
❑Yes n
I have mol the navmdous materialsmlolrcntam,soder Chapter 6,95 of the CalAIR CONDITIONERl. ISSUANCE DATE.
fomiu Health&Safety Coda Sections 25515,25533 and 25514.1 understood that if the NI?W RESIDENTIAL MECH. SQ.t1'. a e2
huildinp0741,
Jocsn ncurrem huvemm�un6 tI it is myregmrsibiliy to notify the oesvpunt
of(hue of cntsw' test ba stet ri sn,tnm"Inclnl�
Owner or vuthori J ¢nt Dote IOIAL: ISSUIiD HY:
OFFICE �(� � Ck V