30927 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 0
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIFICATION
927
BUILDING ADDRESS: SANITARY NO. APPPLICATION SUBMI'FI'ALDAI
OZOS NAME: ��L 7 PRUNE: CONTRACTOR'S NAME: LIC NO:
�/I LA_/��M-.� z DO Z N/C CONTROL.
RCHITECENNGINEER: LIC NO: ADDRESS: ❑
CON'TAC'P PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG E E PLUMB MECH
❑ fR ❑ ❑
LICENSED CONTRACTOR under P DECLARATION QTY ELECTRIC PERMIT F'
1hereby 0)ofDma Iamr«e Bi underproveinn.ora,Coder9(«mmensei JOB DESCRIPTION
Oa7, wnh Section ,ampd'Diviaon3 none Bmxincss and Pmrns.inna Gde,and my Eerttxa is RESIDENTIAL
��O PERMIT ISSUANCP,
F in full fine unA ed test.
eut License Class Lica ❑SFDWL [I KITCHEN REMODEL
W
APPLIANCES-RESIDENTIAL
yGDam Contractor ❑ADDITION [I PLUMBING RE-PIPE
1„Dy ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O y? 1 understand my plana shall he used as public records
OZ-0 I UPTO 200AMPS MODIFICATION
1-,'�'.,.F,W licensed Pndeseinnal ❑INTERIOR 11 CHIMNEY REPAIR
201-1(XX)AMPS IMPROVEMENT
OWNER-GUILDER DECLARA'1lON
6' 6 1 hereby affirm that I am exempt from the Contractors License Law for the OVER I001AMP5 El BATH REMODEUREPAIR 0 DEMOLITION
X 3 a U following reason(Senion 703 S.Business and Profession.Cside:Any city or county SIGNS ELECTRICAL ❑OTHER
W LL< which rtyuires a pen,dl m ennmmn,al¢r.impro c,demolish,or repair any swaure
F'LLOJ prior to itsissuance.also requires the applicant for such pertniuo file a signed stammem SPECIAL CIRCUIT/M ISC.
04 Ihat he is licensW p...semno the prnviaions of me Commcmrs License Law(Chapter 9
�a0 (commencing with Section 7(1 e(Division 3o the Business and Professions Crde)or THIsM METER OR POLIS INST. COMMERCIAL
t1 o CC that he in exempt therefrom and the nasi,lin the ailegcd exetnjtruam Any vi station of ❑DEMOLITION
N Senion]0315 M1 ❑NEW BLDG/ADDITION
yany.pplt«mforapermitambjeastheap,llwnFt.acivii,nall,nf POWER DEVICES
ne Nan five hundred dollars($5(10). ❑TENANT ❑FOODSERVICE
SQp [ sowner of the propcny.or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
F rill dome work.wd meswnure is notimm�ded oroffcmd fur sale(Sec.7D44,Rosiness ❑OTHER
W m and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
6'; property who build,nr improve,thereon,and who does such work himself or through
his own employees,provided that.inch improvements am not intended or offered for NEW RESIDENTIAI,IELIEcrR SQ FT.
sale.If,haweveq the buildinger improvement issold withinore yemcdeempletion,the VSQ,FT.FLOOR AREA $/SQ.ET.
ser builder will have me burden of proving chat he did not build or improve for pur-
pose of sale.. �y
of the propmy,,B exclusivelynd contracting with licensed contractors L. N� !J
swat the project(Sas 91)14,Business and Professions Coded The Cunwnors Li- W
Ists
nee Law dues not apply man owner of property who huilJs nrimproves memm,and Q7-Y. PLUMBING PERMIT FEE
whoominnea for,mh projects with aeonuarmr(s)licensed......mm me Cnomrmr's /� A 00
License Law. PERM19'ISSUANCE FI 7
❑ 1 m anpl and Sca. .H&P C for is reason H!v/
Ac. GRAIN&VENT-WATER(FAG f
Ab
wncr Date U/- VALUATION
WORKER'S COMPENSATION DECLARATION
I hcmb sffimt under Penal, f BACK FLOW PROTECT.DEVICE NU
y yo perjury one of the following declarations:
❑I have and xilM1uaimaina CenifcmenfCnncemmsdLinsurefor Worker's Cnmpen- DRAINS-FLOOR.ROOF,AREA,COND.
sution,av provided for by Section 3700,40a,Labor Code Enthe pcdormmrcc of'the SI ORIF$ 'I'VPE CONSTRUCTIOP
work for whichmis permit is issued. I FIXTURES-PER TRAP
❑ I have and will maintain Worker's Compensation Insurance,as required by Sttamas
37M of the lsbur Code,for me performance of the work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
M Workeea Com tion insurance carrier and Policy OCC.GROUP
My pens. ynumnerare: APN
Cartier: Policy FROM
I GAS-EA.SYSTEM-OVER J(EA)
CERTIFICATE 017 SAFIO EXEMPTION WORKERS'
COMPENSATION INSURANCE 1 GREASPIINDUSTRL WASTE INTERCEPTOR
(Thi.section nceJ sol he eetnplvmJ ilthe pemtic is fnr one hundred dollvrs 15100) BUILDING DIVISION FEES
,it less) I GREASETRAP
PLANCHECK FEE
Loy any lnainme Ect-fixonany
ece rof the Becomeork far subject
this i1ba,WisissuCampe-hidl SEWER-SANITARY-STORM EA.200IT.
oat employ any person in any manner an m to become subject m dee workers'Camper- ENERGY FEE
Z Applicant
of California.Dae
0 WATER HEATER W/VENT/ELECI'R
Z Q NOTICE GRADING FEE
y NOTICETOAPPLICANT.rs Comtanking chisviki vial of Luther for yoniiam,r WAFTER SYSTEMn BEATING
a L�
become subjuv to the Workers lau Compensation prnviaions vial Luber Cade,you Inu.vl SOILS FEF
r� Ibrthwitn comply wiN such pmvi.ions onhls Lid! permit shell M:Jec'mcd revoked. SOILS
4
7 z CONSTRUCTION LENDING AGENCY NEW RFSIOENTIAL PLMH. SQ.FT. PAID
(.J P Ihix,by which for
lhead mem iso ed(Sem.3097.. gency for pcAonnanee of Dae R«iptM
C) F the work fin which this permit is isaacJ(sec.3097.Co,Civ.C.)
Lender's Nonce
O LJ Lender's Address. 'I'UTAL:
Fy I ccnify that 1 have read this application and state that the above information is IUtAI. BUILDING FEE
V) correct.I agree to comply with all city and county ordinances and state laws relaing to QTY. MECHANICAL PERMIT
U s� building construction.and hereby aumurir,repmsemmtives ofmis city to enterupnnme FEE SEISMIC FEE
above-mentioned property for inspection purpn.es. PERMIT ISSUANCE
(we)agree m save,indemnify and keep harmless the City of Cupcnino against ELECTRIC EEE
Iiabilicies,judgntems,ensts and expenses which may in anyway accrue against said City ALTER OR ADD TO MECH.
in mxqucnce of the gmming of This print,, PLUMBING IIiP.
APPLICANT UNI�L'RSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00(1
SOt CUL TI MECHANICAL FEE
��I,'/'/Y AIR HANDLING UNIT(OVER IO,Op CFM) CONSTRUCTION
Signa ur 0ApphcanVConmator / Dam (EXHAUST HOLD(W/DUC)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FETE
Wall'he aPPficanr or future building lmvpimsmm or handle hazallo-on.ccriul HEATING UNIT G 0 t lg NX)BTU) r
av defmaJ by the Cuprnino Municipal Cale,Chapter,9.12,and the fic.1m and Safety
Code.Salina 25532(0)1 HEATING UNIT(OVER 100,000 BTU)
❑Yes
VENTILATION FAN(SINGLE RESID) PAID
Will,he applicant or furore building occupant use equipment or devices which Dam Receipt p
cmitha>adnus it contaminant.as defined by the Bay Amo Air Qudil}Managemrnl BOILER-COMP OHP OR 100,000 BTU)
DistricC '1'UTAI:
F1 Y., BOILICR-COMP(OVER 100,0001311)
I have read the havardous materials requirements under Chapter 6,95 of the Cali. AIR CONDITIONER
fomia Health&Safety Code,Swings 25505.25533 and 8534.I undershoot that if the ISSUANCE DATE
buildingdoes Nerenly have a tenant,that i,ismy responsibilitym tify mrinem'n, NEW RESIDENTIAL MECH, SQ.IT.
ixd tt� the mel rinr to issuanceofgriir,)e of vPAY yi/
Ow IhortmA agent (_,{J Z'Dae -f/ 'PDLAL ISSUED BY:
OFFICE