30367 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..ELECTRICAL. PERMITNO. 30367
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROTECT IDENTIFICATION
BUILDINADDRECSS: SANITARY NO. APPLICATION SUBMITTAL DA'IT
kill el J Sot IM A S �-[�-�{QI
OWNER'S NAM PHONE: CONTRACTOR'S NAMR LIC NO:
.NIC CONTROL As
•sRCHII ECUENGINHHR: LIC No ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG P MB M 1
LICENSEDCONi'RACTOlt:S DECLARATION QTY ELECTRIC PERMIT IfiF,
1 hereby afar mat I am licensed under provisions of chapter 9 nammeaais JOB DESCRIPTION
0�Z with Section 7"ofOivisionJ of the Business end ProfessinnsCWe,enJm licenseia
ENDO ) y PERMI'I'ISSUANCF.. I RESIDENTIAL,
W.. in fall(arse rad effect.
�Ut License Class Lic.p ot ❑SFDWL ❑KITCHEN REMODEL
�Q,WM Date Criminal APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
E.pm ARCU11'ECTS DECLARATION ❑MIJI.TLUNIT El STRUCTURAL
ZOnz I understand my plans shall he used As public records PANELS
OZ�-• UPT0200AMPS � MODIFICATION
C C1 INTERIOR ❑CHIMNF,Y REPAIR
F�.F.W Licensed Professional 2ULI(XM)AMPS
d OWNER-BUILDER DECLARATION IMPROVEMENT
Q I hereby in.that 1 lith exempt formula Commerce's License Law for the OVER Hxu AMPS ❑BATH REMODELTEPAIR Q DEMOLITION
d U following rens....(Section]OJ I.S.Business raid Professions CnJe:Any city oe enemy ❑OTHRR
which requires a permit rt con.amct,alter,Annalist,demolish,or repair any a"clurv' SIGNS HLECTRICAI.
-
pnumI""'uance,also.spimsducifilicamlivsuchpermiuoIII,nsignedsummers SPECIAL CIRCUIT/MLSC,
£ } that he is licensed pursuant it)the provisions ofthe Comramtrs License Law(Chapter 9
Ydd1 �� (commencing with Section 7")of Division J ofthe Business and Professions Code)or TEMP.MLTIik OR POLE osS .. COMMERCIAL•
6 d e C that he is cumpr dromfimm and tM halls(or the alleged exemption Any violation of NP BLDG/ADDITION E)DEMOLITION
-•,y Section]BJI,S by any applicant for a pemdr subjects the Applicants to a civil penalty of POWER DEVICES
nm morclhnn Ova huvdad dnlWra($Slip, NT
❑FOODSERVICE
.0 O I]I,as owner ofthe prop (it my emplal with wages as their.still,rontpenallnn, SWIMMINGPOOLELEC'1'RIC 1 ROVEMENT
5A will do the work.and Ne structure is not intended or offered Raised(Sec.]04A Businesx ❑OTHER
W and Professions Code:The Contractors License law does nm apply to an owner a penI:S-SWITCHES-FIXTURES
property who builds or improves thereon,and whir does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL EL ECTR SQ FT.
sale.If,hawevao the building or improvement is sold wlthintae year ofcnmpletion,rhe SQ.Fr.FLOOR REA $/SQ.FT.
owner-builder will have the harden ofproving that he did not build or improve for par- '
pose of sale).
1,as owner of the property,ors exclusively contesting with licensed common.In L:
calumet the project(Sec.]0W,Business and Profession Code,TTe Contacrors Li-
seLaw does not apply toonowner of pmpery who builds or improves thereon,and QTY. PLUMBING PERMIT FEE;
whocommels for such projects with a cormetoe(s)Ilcensedpursuannotha Contractor's SSP 1 1000
License Law. PERM]'1'1 St1 C. SEP 996
❑I am exempt under Sec. ,R k P C for this reason
.Owner Dem ALTER- &V WATER(EA) - -
WORKER'S COMPENSATION DECLARATION " VALUATION
I herebyfirm under h f BACK[ W PR EVIC Q ^�
v Cera yo ofCananeoftlf-insmfor dedacCe Cu:
❑ Ihuve andwill for
neCerifcme of the EAhla Code.for
WnrkerxCamfum DRAINS-P-OX,RO ,AEA.COND.
anon,as provided roe by Section 3]W of the tabor CnJe,for the performance of the 5'TOk tS TYI'li Cl)NS'TkDG11DN
work for which this Permit is issued FIXTURES-PER TR C
I] I have and will maintain Workers Compensation Insurance,as required by Section
J]W of
to lA vie t performance of Nc wok for whit t ' FA.SYSTEM.I INC. LEES (KC.GROUP APN
My Workers C4 a Amm�cc eamier and Pall
Crrriee PolicyN� u a .-EA.SYSTEMAVI?R4(EA) � \
TIFIC COMPENSATION
INN FROM RKEk5 GREASWINDUSTRL WAS IT INTERCEPTOR
COMcona 'f10N INSURANCE RUIL I 'G ) 1510N Fines
(This section nerd not be completed if the permit is Talions hundred dollars($Ifxp GREASETRAP '
or less) PLANCHF.CK FEF O �O
certify that in the performance ofthe work or whichthis permit is issued,)shall SEWER-SANITARY-STORM EA.200 FT.
nor employ any person in any t aaner a as m become abject to the Wnrkere'C..mpcn- ENERGY FRE `
OZ senor Laws of Californin.,Date WATER HEATER W/VENT/ELECTR
77 Applicant - GRADING FEE
Imo- fo NOTICE TO APPLICANT.If,doer making this Cedificate of Exemption,you should' WATER SYSTEM/1'kEATING
a ? become suM1jen m the Workers Compcnsetion provisions of the LaMar Csde,you mu.a SOILS ETF
w ioMwith comply with such provisions or this Cc mit shall be deemed mvnked. WATER SERVICE
Q
UZ CONSTRUCTION LENDINGACENDY NEW ItIiSIDENTIALPLMB SQ.FII PAID
V p walk
rwhichum that is.amxmerin.lending agency for the performance of _ Dare Receipt is
� u tha work lar which this permit is issued(Sec.J(19],Civ.CJ
O Lender's Name TOTAL:
{ULl Lenders Address 'TOTAL:
0. o 1 certify that I have road this application dad state that the also information is BUILDING FF.
to correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT
U '4 building ennamdion,and herthy.ahnrinuclescnunives oRhiscity In enter upon the SEISMIC FEE
above-meminneJ pnrperty for inspecrinn purposes. PERMIT ISSUANCE
(We)agree a save,indenmify and keep handles, pe
the City of Cunino against ELECTRIC F.
Imbilities,judgr eais,costsrooloa enws which mdy in any way accmc against said City ALTER OR ADDTOMECL -
neomeque eufthegantingafthiapmmiL PLUMBING ER
APPLIC .TUN DERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Io,000 CFM)
SO' sREGULATIONR MECHANIC LFEE `
AIR HANDLING UNITT(OVER O,000CFM) CONSTRUCTIONIA
Signa of Applicant Conmcor Date EXHAUST HOOD(W/DUCD HOUSING MITIGATION 3E
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future huiliing accupurtamrc or handle hunadous martial HEATING UNIT(To 100,000 BTU)
lis defined by he Criterion Municipal Code,Chapter 9.12,and the Health and Surety
Code,Scott..n 25532m)? 'HEATING UNIT(OVER 100.000 BTI])
71 Yes No PAID
VF,NI'ILA'I'ION PAN(SINGLE RESID) Dote Re<cipt
Will the applicant or future building occupant use equipment or devices which
emit tonsi s air commitment,ax defined by he Hay Area Air Quality Manegement BOILER-COMP(SHP OR IOO,IXIO RTU)
District?
Dyes �No BOIL17R-COMP(EVER 100,0(x)BTU)
I have read the havudaus mammals AIR CONDITIONER ISSUANCE,DATE
requimmean under Chemie understand
of me Coli
fomia Healthn Safety Code.Sections boar 25505,is533 myand25534.Io unify
the
Natifthe NEW RESIDENTIAL MIiCH, SQ.FT.
building don not currently have t tenet p Nat o is ua responsibility tote o fy Ne occupant
of the requirements which must he mer poor m issuance of a Certificate of occupancy.
Owner lir autharued agent Date TOTAL:
Issuun BY:
OFFICE Ar