30204 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO, 30204
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BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. J
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
Isis Sr SMOL a - S�9rn UJL ll0 -
OWNER'SNAME `"'"• PHONE: CONTRACTDR'S NAME: LIC N(D
E2& 41
(`.�Il.,�,•�,, l ZS WC CONTROL#
ARCHITECT/ENGINEER: - LIC NO: ADDRESS: II''11 nn J J , l7Hr V"`"u'W (/1 024 ❑
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VszSa U�.Vas O�Th
CONTACM. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) pl.p➢ ELECT PLUMB MECH
L,ICCENNSSEEDD CONTRIA`CTTOORS DECLARATIONQ y ELECTRIC PERMIT FEE )jV ❑ ❑
1 hereby affirm that I.licensed underro
pvisions of Chapter 9(commencing JOB DESCRIPTION
a'z with Sedinn](NNp of UivisinnJofthc Buxiness and Pddessien(dX .v Ctulq anJm license is
�O Y P1BiMn'ISSunNCB RESIDENTIAL
W� in full force and eR
OF Late Class 5 Lica I Q S ❑$FOWL KITCHEN HIiMODEI.
z Dnte Commnnr AI'PLIANCF_S—RESIDF1gT1AL
F ❑ADDITION ❑PhUMBING RE-PIPE
F- ANCHITE.CTS DECLAH
s Farms PANELS - ❑MULTI-UNIT ❑STRUCTURAL
zOn7U Iundeclared myplans shallbeused aspuMlcrecnNv MODIFICATION •
Ozyfy—....m UP10200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
1.4p-W] 2U1-LINO AMPS IMPROVEMENT
Licensed Professional
pgA,..) OWNER-BUILDER DECLARATION
"+0 W I hereby affirm that 1 amempt from the Contmctnr'S'License Law for the OVER 1000AMPS 0 RATH REMODEDREPAIR 0 DEMOLITION
� ex
W 3,U a1mvengrenson.(Senion 7031.5,Business and Profession,Code:Any city or county SIGNS ELECTRICAL ❑OTHER
,F` which requires a permit m connme,nlmq improve,demolish,m repair any structure
1�0 priorm its issuance,alsolequirea me applicant forsuch Permit is) asignedstmcment SPECIAL CIRCUIT/MISC.
y thin he's firs, edpursuanl to the powwonsofthe Cmmnal.in License Law(chapter 9
p0 (commencing with Section 70m)ofDivision 3 oddic Businessand Pmfcss'ons Counter TEMP.METER OR POLE INST. OMM R .IA
than he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLaGIADDITION 0 DEMOLITION
4X1 w Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
n more than five hundred dollum($500). OTENANT - CFOOD SERVICE
I' 6 1.as owner of the norm IMPROVEMENT
G ❑ property, my with r sale
0,14,Business
SWIMMING POOL ELECT
coal dothework,and me he Contractors
intendedo Lawddforsale(See.oan Business ❑OTHER
a3 andProfessionswho builds Cod e:Theoves Chemo Licene Lawd«snmapply slfowner of OUILEI'S—SWITCHES—t1 URLS —
pmpeny who oges,or improves thereon,and who ansa such work himself or orthroughour
solI'll own.cvc,,me provided that such Improvements are not intended or offered fur NEW RESIDENTIAL ELECT SQ[T,
ownse. f,uilder all have he bur en of proving
is at he did not b year or improve
the SQ.IT.FLOOR AREA 'S/SQ.FT.
owner-builder will have the M1UNen of proving When he did not buil)or improve for par-
,ase of
❑ 1,as owner of the pmpeny,at.looelsine slvely mofessi ns with t T e Cmatrdoors u, TAI•:
.wet the project(Sec.7(H4,Business and Professions but ds or i The Contractor and
Q JUL
Genu Lew Jtws not apply men owner o(pmpety who builds or improves thereon,and TY. PLUMBING PERM FF.E J/ (I^�
who contracts for such projects with a commands)licensed pursuant m the Contmcmr's / a7y
Llcensc Law. I'lilt MIT ISSUANCE G��p
O l am exempt under Sec. ,B&PCfmthi.vre...o Ut. `VrG ,
ALTTR—DRAIN&VENT—WATER( )
Owner Dme VALUAttON
WORKER'S COMPENSATION DECLARATION BACK FLOW
s
PROTECT.DEVICE
Iherehyufirtn ry
O Unveiled will manuina
Cetificateofconsenrmseif-iosumforWorker's Compem DRAINS—FLOOR,ROOF AREA,COND. STORIES TYPE CONSTRUCTION
ut!on.M provided for by Section 3710 of the Labor Code,hostile performance d the -
work for which this permit is issued. FIXTURES—PER TRAP
1 hme mW will maintain Workers Compensation Insurance,as required by Section r
3]00ofr�m,LubryorpCurde,fnnhe performance ofnhe work for which
rthis
ppermitis mud. GAS-EA.SYSTEM-I INC.4 OUTLET'S OCCGROUP APN
MY Wo.]YBI'g-21P1t'�1 e
Policy No.Y� �O\10001 GAS Carrier: -
CERTIFICATEOFEXEMPTIONFBOM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
This It..need non becompleted ifine permit is formal handled dollars($U0) RUILDIT DIV NFEES
or Iro.) GREASETRAP
I'LANCHECK FEE
Loy any mat in the any
,as t work for whhjcct In The Workers'
C..,eLicl SEWER—SANITARY—STORM EA,200 FT.
of employ any person in any mannenn as m become subject m the Workcri Compen- ENERGY F t r
Z anter,Laca of California.Dane
O Applicant NATER HF.A'IER WNENT/ELECTR GRADING FEE
NOTICE TO APPLICANT:If,after making this Cerliricate of Exemption,you should
become subject to the Worker's Compensation provisions of the].shot Code,you must WATER SYSTEM/1'REA'1'INC SOILS FL'
forthwith comply woo such Provisions or this permit shall he deemed revoked. WATER SERVICE
r7O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.EL PAID
afirm that there is o construction lending open,for me perl'ormanceol' Dme Recciptp
F the work for which this permit is issued(Sec.3097,Civ,C.)
I hereby f
Q lenders Name TOTAL:
W Lender's Address TOTAL:
Ly 1 coni fy that 1 have read ads applie,don and emte that the above Ia lbrmammm is RUILD1 FEI
Ii!) comet.l agree in comply with all city and county oninances and state laws mating to QTY. MECHANICAL PERMIT FEE
U z building coo.amnion,and hereby mthame tepreamedises of this tiny to enerupmnthe SEISMIC E
above-mentioned plotted,for impectitn purposes. - PERMIT ISSUANCE
(We)agree to sive,'indemnify mW keep hunnlcvs the City of Cupertino against P.LEETRIC
liabilities,judgments.costs and expenses which may in any way accrue against said City ACT ER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING HI
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIH HANDLING UNIT(TO 10.0(10 CI'M)
SOURCE REG/µ�NA�TIONS.� 1 MECHANIC LFEE
(Illi -A ill AIR HANDLING UNIT LOVER III,WtI CFM) CONSTRCC'IONTAX
Signamreof Appliiccard/Oonnttracttlmnrnn+---"`xxx Dole t1 a EXHAUST HOLD(WIDUC) HOUSING ITIGATION FEE
HA9ARDOUS MATERIALS DISCLOSURE
Will the applicant or more buildingoecu,ant some nr hurdle haaamommatenid HEATING UNIT(TO 1110,000 BTU)'
as defend by the Copcninn Municipal Code.Chapter 9.12,and me Health and Safety .
Coda,gains.25532(.)] HEATING UNIT(OVER 100.000 BTU)
'O Yes X. VENTILATION FAN(SINGLE RESIDI PAID
WiE Int. hema or f n...building occupant use Dam
pp go pan equipment Quality
BOILER—COMP 3HP OR 100,000 BTU
emit hazardous air contaminants as Defined by the Bay Area Air Quality Management ( )
Diariet0 Yes �n WBOILER—COMP(OVER 100,0RTU) T A
I have read the harardous mamrials requirements miler Che AIR CONDITIONER ISSUANCE DATE
q makerm5of at if
Toledo Health&Safety Cade,Seniors I la 25531 and 25534.1 understand that if Ne NEW RESIDENTIAL MECH. SQ.FI'.
builAing da re nOn oath Cly nave anen.nt.thmit is my res of a Crlity to notify Js tx:cupant -
onnrregnirenmennaw n �tt11^an be n,iaaaanee nfacetife�.Tre/ora a
E Titi. /1 II fatly '
Owner or aumotzed agent I Date TOTAL: ISSUED BY: -
OFFICE