30838APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO IBUILDING- ELECTRICAL. PERMIT NO. 30838
•S O A � A
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MISCHANIC AI, Jd 1V( l8J
►-31
Ai
ARC ITECUENGINEER: LIC NO:
ADDRP' �
❑'
CONTACT: PHONE:
•
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO '
RLLDDGDG ELECT PLUMB STEEL
ACJ\ ❑ ❑ ❑
DO
W
aULF
H 7 m
Z O S/J4
02
LICE33EI CONfRACTOR'S DECLARATION
1 hereby affirm than 1 am licensed under provisions of Chapter 9 (commencing
whli Se,ser'7O0O)ot n3ofthullueivess anL ol'iall ns Coalca t lkensc is
in full force end effect R� i "-
ImenseC !/ Lic.M ` %
Carlos r
ARCHITECTS DECLARATION
I nnJemand my plans shall he used as public records
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL'
❑SPDWL ❑KITCHEN REMODEL.
❑ADDITION ❑ PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REM_ODIF.I/REPAIR DEMOLITION
❑OTHER �g�p
PIiRMn'ISSUANCE
APPLIANCP_9-11MIDENTIAL
PANELS
UPTO 2IN)AMPS
-- X
< s'�
0 Y
F U
W OI•'
Fypdono
{ }
P� 0�
6 y o rL
'a h
F-
Q. 3 =
Licensed Professional
OW I a. BUILDER DECLARATION
1 hereby affirm Nm I am exemq from he Contractor's License Law far the
fallowing reason. (Section 7031.5, Husiness and Prumasions Code: Any city or county
which requires a permit to commucl, idler, improve, demolish, or repair any structure-
as issuance, also reclaims The applicant forsuch permit to file a signedstam
teem
That he is licensed pursuant, the provisions oflhe Contractors License Law (Chapter 9
(commencing with Sectio 7")off)msion3oflhe Btaimessand Professions Cosi
that he is exempt Iherefram and The basic Traffic alleged exemption. Any violation of
Section 9031.5 by any applicant fora pemnteubjeete the appii... I to a civil penalty of
at more than five hundred dollars M0O)
❑ Las owner ofthe property, or my employees with wages as their sok compensation,
will do the work, and the structure is nm intended oroffered forsale(Sec. T}W, Business
vnd Professions Code: The Contractor's License Law does not apply to an owner of
Ptolemy who builds or improves Ihereen, :ted who does such work himself or Through
his own employees, provided that tech improvements no not intended or offered for
aide .If. however,int huildingor impruvemevt issold within oneycarofcompletion, the
owner -builder will have the burden of paving that he did not build or improve for put.
pose of Yale.).
1, a owner of the Sri. 70,1 am exclusively cmntrasOng with license] aatlrMlmrs to
onstruct the project (Sec, ]W4, Business and Professions CafeJ'1'he Contracmr'x LI-
nse law does not apply to an owner of Napery, who builds or improves theater, and
whoa mtmcts for such projccls with a conttactons) licensed pursuant o the Contractors
License Law.
1 am exempt under Sec. , P & P C for this reason
201.1(100 AMPS
OVER IM) AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC. xnr
TEMP. ME717R OR POLE INST.
COMMERCIAL:
❑ NEW BI.DG/ADDITION ❑ DEMOLITION -
El TENANT 0 F60 SERVICE
IMPROVEMENT
❑OTHER
At 13
MOWER DEVICES
SWIMMING POOL IlLEC1'RIC
UTLUS-SWITCHES-PIXTURF.SP
N13W RESIDENT IAL ELECT SQ FOE '
• AIRFIg7 Aral
V /� U.S. R[(!
CITY Ur UUPEH i INU
,
ESQ. IT.
'
.
-
QTY. PLUMBINGPERMIT FEE
PERMIT ISSUANCE.
ALTER -DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
Owner Date
VALUATION
•
O,Z
Z 2
tti fn
abecmne,abject
W
a. a
V Q
W (~
Q U
yI
y
WORKER'S COMPENSATION DECLARATION
I Iherebyaffirm under penally ofperjury one of the following declarations:
❑ I have and will maintain a Certificate ofCnnxm to self -insure for Worker's Camper-
son, its provided for by Section 3900 of the Labor Code, far the performance of the
VqOR for which This Pamir is issued.
ave and will maintain Worker's Compensation Insurance, as required by Section T)fWim to grCale' fur Ne pomme v er aadP I yfm whichwhich thl
MyWim mtlmnce and l•olicy nt'
Certlur. •e Polley Nn.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(phis radon need not be completed if the permit is for one hundred dollars (51 OO)
or less)
I certify [balm the performance of the work for which Nis Farrah is issued, LshalI
not employ any person in say manner en as m became subjeeu. The Workms'Cmmpem
salion Laws of California. Data
Applicant
DRAINS- MOOR, ROOF, AREA, COND,
STORIES
OCC. GROUP
TYPE CONS'fRUC71ON
APN
- ,
FIXTURES- PER I RAP
GAS - EA.SYSTIiM.I INC. JOUTLETS
GAS- EA. SYSTEM OVER 4 MA)
GREASFIINDUSTRL WAS III INTERCEPTOR
BUILDING DIVISION FEES
GREASE. TRAP
PLANCHECK FEE
SI?W13R-SANITARY-STORM ?A. 2O0 Pf.'
-
,ENERGY FEE
WATER HEATER W/VENT/ELI3CIR
GRADING FEE
NOTICE TO APPLICANT If, after making This Certificate of Exemption, you should
m the Workers Compensation provisions of the 1.nbnr Code, you mea
Tomhwith comply with such Doctorons or this penial shall be dcemcd revoked.
CONSTRUCTION LENDING
eading NCY
I hereby affirm that there isacd(See. NO,Cis. agency Taube pertonnaare of
the work for which this Permit is issue) (See. JO9], Civ. CJ
Lender's Name
WNLRSYSTEM/TREATING
SOILS FEE
WATER SERVICE
PAID
Dere R eiplM
NEW RESIDENTIAL PLMB. SQ. 17.
'T'O'TAL:
'
Lender's Address
- TUTAL:
BUILDING FE. ^�
ccaify That 1 have and Nis application and store Nat the moan information is
contact. l agree to comply with all city and county ordinances and state laws relating,
building construction, and herebyauthorize representatives of Nis city menter upon the
above-mentioned pmpcny, for inspection purposes,
(We) agree m save, indemnify and keep harmless the City of Cupmino again.d
liabilities, judgment, costs and expenses which may in any way accrue against said City
I. esm facace of Ne gaming of Nis term t
APPen arrLICAN'ER57AND AND ILL DMPLY k5'CfH ALL NON -POINT
QNSi
-VAIR
QTY MECHANICAL PERMIT FEE
SEISMIC FEE
I'I?RMIT ISSUANCE
ELECT RIC FEE
ALTER OR ADD TO MECH.
PLUMPING FF.P.
IT
AIR HANDLING UNIT (TO 10,(00 CFM)
MECHANICALPLUMBING
FEE
HANDLING UNIT I O,(OO CFM)
CONSTRUCTION T,
Sig tura ofApplicant/Con r to
Will Neappli m future building occupeal store or handle hazy ?to
H OUS MATERIALS DISCLOSURE
as defined by the Ca no Mrmailan Code, Chirpier 9. 12, and the Health and Safety
Code, Saininn 25532 I'!
El Yet No
use equipmentordevices which
Will Ne applommuicant rfuture building by
'mil hamnlous air cmtmnimms as JeOneJ by the Be Fes Arca Air Quullry Managetncm
Q Yes ❑No
I have read No hamrdous.,ad.), tment.sunder Chatter 6.95 of the Cali-
m, a
famia Health & Safety Ode, Sections 25505. isay and 25534, 1 understand Nat, thehau
to tate unity the oeaO,
often# dom am tern which havelia met 6 for o is ua reef a Certificate
of Ne reyuimmenrs which marl M run prior to issuance of u Certificate of Occupancy.
EXHAUST Hi(W/DUC,
HOUSING MITIGATIONFEE
'10 HEATINGUNIT('I'O 100,0011 RTU)Sir
HEATING UNIT (OVER I W,000 RTU)
PAID
Date Receipt#
VENTILATION FAN (SINGLE RISID)
BOILER- COMP(3HP OR IW,OIO BTU)
TOTALDistrict?
BOILER -COMP (OVER 1FILM) BTU)
AIR CONDITIONER
ISSUANCE D�TF,
— —//'l/
NEW RESIDENTIAL. MUCH. SQ, IT.
Ai