30495 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE RTINO BUILDING-ELECTRICAL. - PERMITNO. 30495
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT'IDENTIFICATION
HUILgGADDRESS: � I � �� • �l'p ^� SANI'T'ARY NO. APPLICATION SUBMITTAL DATE
OWN NAME: /_ PHO fi: _•-2 COONFRAC C a `�q�
/VT (r7DY• N/C CONT ROI.#
ARCED'EC /LIN NEER i.jCNO:V ADDRESS. ❑
CONTACT: PHONE: BUILDING PERMIT INFO
G Yap 7ro 4 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
VVss++ ItIJC' ❑ A ❑ ❑
LICENSEDCONTRAC'I'OR'SIIECLARATION Q'ry. ELECTRIC PERMIT FEE
I hereby nation that 1 not licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
DMZ with Section 7000)of Division 3 of the Business and Professions Code, is RESIDENTIAL:
00 wr PERMIT ISSUANCE
n full for end effut [
�U6j Licens Li0.M ��V ❑SFDWL ' ❑PITCHINREMODEL
�7d-a Dme�Cnmmmr r APPLIANCES-RESIDENTIAL ❑gDDITION ❑PLUMBING RE-PIPE
Q ARCHITIiCT51l[CI. ON ❑MULTI.UNIT El STRUCTURAL
zp�4 in, a pts PANELS
I tmdersmnd m I h II be used us hlic records MODIFICATION
O z.-0 I]['TO POO AMT'S ❑INTERIOR El CHIMNEY RI3PAIR
I.�n Licensed Professi...I 201-1000AMPS - IMPROVEMENT
�Y•E' OWNER-lownpi fl DECLARATION
Contractor's
ON OVER 10MAMPS ❑RATH REMODEURHPAIR (]DEMOLITION
K Q I hereby a(firm that I nm uemp Tom the Comae,Co License Lew for the
3 L U following regrowan.(Section]I1DL5, 1.mill.
and 1ve.demob Code:Any city nr County SIGNS ELECTRICAL ❑OTHF,R p,nq�p
LL which requires u pmol re mwW[i,applicant
i t fors. demolish.r repair any.wment I�1(,��/ 17
Oqn that hor o,licensed personal
to theres the
..sior.rttfnr Cewch e mks Liclea signed mem SPECIAL CIRCUIT/MISE.
pppp L�}�
that he is llwnxaJ pumumnl In the pnrvisinnx of the Cnnlracmr's license Taw(Chepler9
^CO (commencing wish Senion]f100]of Divisi.n3of the Business and Professions Code)or TEMP.METER OR POLE INST COMMERCIAL:
dyx o a Ila,be is exempt therefrom:rod the basis Tia the alleged esvtptian.Any violmian of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES
❑TENANT ❑FOODSERVICE
Zy not more than five hundred dollars(8500). IMPROVEMENT
2p ❑Las owner of the properly,army employees with wages as lbcirsale mmpenswion, SWIMMING POOL HLGCfRIC
willdothework,and the stmc a is not intended or offered forsale(Sec.7044,Business ❑OTHER
' nod Profookas Code:The Contrualaea Lirense Low dues not apply t.an owner of OU'rLErs-SWITCfRS-PIXTURES
d' prrpeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ FE
sale.If.however.the building or improvement is sold within one yew of completion,the SQ.FT.FLOOR AREA $/SQ.IT.
awnerbuilder will have the hurden of proving that he did not build or improve for pur-
Pew w sole.).
[1 1,as owner of the property,am exclusively contracting with licensed contractors to T
mstmel the project(Sec.71004.Bicial,and Professions Cadc:)no Commcmrs SSR 1,i- - 91996�9(](VQ
cense Low does not applym as owner of property whreo
o builds or improves then.and QTV.. PLUMBING PERMIT FEF. SEP V7 k7U
ho cemmets far such projects with a contractor(%)licensed pursuant to the Contactors
Livi Law PERMI'TISSUANCE C•II i .:," V:6t ..,,I Bills)
Fjlam crop under Sec ,B&PCfclub warm
C(J�� ALTER-DRAIN&VENT-WAIERTA)
D VALUATION
ISIO
ORKER'S COMPENSATION DECIARA'I'[ON BACK PLOW PROTECT DEVICE
1 hereby afinn under Penalty of perjury one of the following welamtinw:
❑Ilmormidwilleamr,...Cenificnt of Conxnno xlf-insurt for Workers Camper- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSI'µUCI'ION
..tion,us provided fits by Section 3700 of the Lido,Code,for the perf.rmrmce of the
work for which this permit is issued FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M.(the Lost Col,f.nhe performance of the work for which this pe.iti,issued. GAS-EA.SYSTEM.I INC.4 OUTLETS
C.GROUP APN
Curfew:
Compensation Insurance carrier and Policy announce are:
Carrier. Polley No,: I OAS-EA.SVSTEMOVER4(EA)
CERTIFICA EXEMITION FROM WORKERS'
Tod /NSATION INSURANCE GREASPJINDUSTRL WASTE INTERCEPTOR
(This uc0o
corn
m Coup"
or
the pcmri,is for one hundred tl.11am($1110). flU1LUING DIVISION FP-ES
or less,) GREASE TRAP pl. :CK FEE
Ice ' That inthe iformunce.fthe w, r rich this to is owed,l shell SEWER-SANITARY-STORM EA.21X1 FT
not ecap, any persrni i ray manner so b r Lew h' uo the Wurkeri C.mpen- + ERG
O7. smion ws nfC " rat.Dat WATER HPATER WNENT/ELF.CI'R
7 O App'am G A FEE
F7 to N IC' APPLI l':If,after making this Certificate of Hsemption,you should WATER SYSTENVTRHATiNG
a ? subject WA
c Workers Compensation provisions of the Labra Code,you must SOILS Fir
[il •with comply with such provisions or this permin.all be deemed revoked. WATER SERVICE
Q o
az CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMH. SQ PATI
L)O I hereby affirm that there is a c.n.sauction lending agency for performance of Date cecip,a
f^ the work for which,his Swu,is issued(Sec.3007,Co,C.)
Ill.Q Lwho's Name
r LUlI Lenders Address TOTAL:
1 cenify that I have read this application and state undue above information is BUIL. E
h correct,l agreem I, ud,with all city and county mdiumov,and stem laws relating to QTY MECHANICAL PER MIT F
LJ z building consmaimarmd herds mehoriee representatives of this city,.emerupontbe SEISMIC FEE
n rol-mentiored popery lit,inspection pwpswes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against IERMIT ISSUANCE ELECT I
iabilitice.judgments.costs and expenses which may in anyway acerae against said City ALTER OR ADD TO MECH. -
incousequueeofthe granting ofthis permit. PLUMBI PEE'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. AIR HANDLING UNIT TO 10,q)11 CFM) MECHANICAL FIE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTI NTAX
Signmure.fppplicidlContmctor Date EXHAUST DOUG(W/DUC'ry HOUSING '1'IGATION FISH
MATERIALS DISCLOSURE.
Will thcapplicinsor furore buildin, ccupnot ear.or In de hamrdomsmlt,nalHEATING UNI'I'(TO 100,01X0 B Of
as defined by the Cupertino Man cr Code,Chapter 9.12,and the Health and Safety
Code,Section 25532m)? HEATING UNIT(OVER 100,(100 BTU)
El Yet No '
VENTILATION FAN(SINGLE RISID) PAID
Will the applicanoe
t nr future building cupam me equipment or devices which Dat Receipt N
••nor,fractions air coomminan1s e.,gpBned by the Bay Area Air Quality Management BOILER-COME OUT OR 100,000 BTU)
District? (��H/ '
E]Yes BOILPR-COMP(OVER 100,000 BTU)
I have owl boarders materials requirememts ander Chapter695o1'the Cali- AIR CONDITIONER SUA 1jATE
fomia Health&Safety Code,Sections SSB,25533 and 255th.1 undersmnd,hat if the NEW RESIDENTIAL MECH. SQ,Fr.
bud like,does wt cancnpy lacca terent that it is my m,To,,ibi lity to amity the occupant
of the requirements which must be met pow to issuance of o Certificate of Qcuponcy.
Own.....amh.omd.gemt Date TOTAL: ISSUED BY:
OFFICE