30975 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' BUILDING-ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 30975 O 97
BUILDING PROJECT'IDENTIFICATION 9J 1
BUILDINGADDRESS: SANITARY, APPLICATION SUHMDTALDATE
f 36 s. 2 1�
ONAME PHONE: CONTRACTORS NAME: LIC NO:
N Is/� 1,J G N/C CONTROL4
RCHIIH7UIHGINEER: LIC NO: 'ADDD iSSD ❑ `Ltp
CONTACT, PHONE: t BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT/ PLU�M/B/ Mum
LICENSED CONTRACT'OR'S DECLARATION Q'{•Y ELECTRIC PERMIT FEE
1 hereby affimt that I am licensed under provision of Chapter 9(commencing JOB DESCRIPTION
Cla'Z with Section 7001 Division 3o fine Businessmd Profession Cole.and my license is
C�O PERMIT ISSunNCP. FDWL C KITCHEN REMODEL
F in fullforceand efl'ed.
a UO License Class LiaN APPLIANCES-RESIDENTIAL / ❑ADDITION ❑PLUMBING RF.-PIPE
to Dae Co.,,,
FNpy ARCHU ECf'SDECLARA ION 14 - PANELS - ,� ❑MULTI-UNIT El STRUCTURAL
Z O 5 Z 1 understand my tans shall h used as Public records MODIFICATION
OZ1ZQ UP TO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
I•N.,~W Licensed Professional 201- 000AMPS IMPROVEMENT
ay'W ...II OWNER-HUILDIiR DECLARATION
i y��6 1 hereby alfrm that on exempt from Wu ContramOVER IWO AMPS ar's License Law for the C BATH REMODEL/BEP�IR p DEMOLITION
�(O L V following reason.(Section 7031.5,Business and Profession Code:Any city or county SIGNS ELECTRICAL. C OTHER
W 3 W F' which requires a permit m conarmi,apes improve,demolish,m repair any anucutre '
F'�O pri�rmits issuance,also rcyuire""a
the upplleenlforsuchpeminofleaxigncdswtement IPECIALCIRCUITIMISC,ZAJ I�
P QM thatheen,iti with
punmtn mthepmvisi,i v the❑Bionnors l.icense,ann,Capter9 -sgp`'�S_. �
OO (connnemcl.gwlth Sesxiooqui "n'Uiviai aI�[a aeyadeaenad Pii.Anynvi Cnde)or TISMP.MBTIiR OR POLE IN. []NEW,
!J �/
S 6 C that he is exempt therefrom and the basil foIt"all ed exemption.Any violation of {
x.n� CNEWiH�.St(IA�DITION CCDIiM L17'ION
W^fn Sectinn]OJLS by any apPlicnnt fora pcnnit subjects the upplicannn ectal.pcnahy.f POWER DEVICES ❑TENANT , LV�Cg�f1C195HRVICE
EZY ammoe thou five hundred dollars($500), IMPROVEMENT ttgU
Chas Owner ofthe progat or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
GEGC will do the work,and thestrucwre is not intended oroffeded forsule(See,70a4,Business POTHER
4x1 $ and Professions Gavle:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES'.
a'3 progeny who builds or impnwes thereon,and who does such work himself or through
ow
ho n mmployces,Provided that such impmvemmrts ore amt Intended or offered for NEW RESIDENTIAL ELECIR SQ FL
sale,If,however.the building or improvement is sold within one yemofromplelion,the .FLOOR AREA &SQ.IT.
owner-builder will have the burden of proving that he did not build or improve for par-
pose of snit.),
C I,as owner of the property,am exclusively contracting with licensed contmchma to as�
cons.aat the project(Sco.7044,Business and Professions C.dtJ The Common's Li-
cense Law does nor apply toannwner of property who builds or improvesthereon,and Q7-y, PLUMBING PERMIT I'EG ["� �Za'I TFlL%TG'_i
who contracts for such projects with acomracrogs)licensed pursuant m the Contractors V
Licence law' PERM IT ISSUANCE
❑I am exempt under Sec. ,H&P C for this reason
ALTER-DRAIN&VENT_WATER(EA)
Owner � D.Ic VALUATION
111
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
n r 1 hereby affirm under Penalty of perjury one of the following declarations:
�C Ihave and will mainWinaCenificam nl'Consentmsdl'instrc for Warkce,Compea- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
sari..,as provided for by Section 3700 of the Labor Gds,dome performance of the
work Por which this permit is macd. FIXTURES-PER TRAP
❑1 have and will maintain Workers Comprroution Imumnce,ac required by Section
3706 ofthe Labor Code,for the performance.fthe work for which this Permit is issued GAS-EA.SYSTEM-1 INC.4 OUT1-HTS OCC.GROUP APN
My Worker's Curnametion lasnrume carrier and Policy number arc:
Cameo Policy N., GAS-BA.SYSTEMOVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE.INTERCEPTOR
(ThistwOon need not becompleted ifthepcmut is foronehundred Jollaa(SI0to HUILDINGD ISION FL?P.S
nr lcsxJ GREASE TRAP PLANCHECK FEE ! '�
Loy any Person
in the any
of the work for which this the W shall - SEWER-SANITARY-STORM EA.200 Ff.
not employ any person in any manner so m to become subject m the Workeri Comport. ENERGY FEE 04, 1&0
Z oulan Lucas of Cul i hinia.Date
tz WATER HP.A'1'BR WNENTIIeLECTR
z Applicant GRADING FEE
a-a ti
NOTICE cona,TO APPhhe W k If,after making this Cedium of the
Exemption,you should WATER SYS'IEM/1'NEATING
a7 hearme subject m the Workers Compensation provlsloal of the Libor Code,you rant SOILS FHB
Lit
forthwith comply with such provisions or permit shut.be Jecmed revoked. Wp'ILR SERVICE -
Q
CONSTRUCTION dam Bitiom LENDING AGENCY NEW NESIDIiNTIALPLMI{. gQ,pp, PAID
L)Q Thereby affirm that Nerc issued Sce.30 len Jing agency fonhe perfonnance of Da¢ R e
� C✓ the work I'nr which This permit Ix issued IScc.304],Civ.C.)
Q V Lenders Name 'FAL::
Lenders Address TOTAL:
1 certify dist 1 have read this appacution and state that the above information is BUILDING FEE )�sectse
Ln correct.l agree to comply with all city and county ordinances and slam laws relating to QTY. MECHANICAL PERMIT 17EE
G71building ecomed!a asm forinspection Inrawes. mtiv.e oFlhia cirymanmr upon the SP.ISMIC FBE
eMwe-mee)agrepI. . forinspectionkeep es. PERMITISSUANCH
(We)agree m save,indemnify and keep harmless the City of CuPeninn against EEL�=RICEE
linhlllrimwhichnmy many wayuccme madmtsnid City ALTERORADDTOMECIL PHI? �APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,Oflf1 CFM) AI.FEE
SOURCE.RE ILATION'S. AIR ItANDLING UNIT(OVHN 10,000 CPM) TION AX
Signemre ofApplicanVConuadorDate EXHAUST HOLD(W/DUCT) ITIGATION
HAZARDOUS MATERIALS DISCLOSURE. - r
Will theapplicam or future building ntculmrtm.rtOrb-I-haxurd.11 n1 dal HEATING UNIT(TO I00,000 BTU)
as defined the Cupeninn Municipal Gale.Chapter 9J 2,and the 1leahh and Safety
Cala,Section 25532(x)'7 HEATING UNIT OVER IW.O'gI BTU)
❑Yca MNo VEN'JILATLON FAN SINGLE RE,SID) PAID
am Rcceip p
aaadme air contaminants
hoifined by thea Bay
Air
Macagameni BOILER-COMP011POR 100,000 BTU)
.mit harnNous air conwminams us defined by the Bay Area Air Quality Menugement TOTAL:
Din ct?
CVes NO BOILER-COMP(OVER l00,0f10 BTU)
1 have and to hamdous materials re AIR CONDITIONER ISSUANCE DATE
quircmems under Chapter fi.95.f the Cali-
' forint Health&Safdy Gale,Sections 255(15,25533 and 25534.1 andermund that if the NEW RESIDENTIAL.MECI I. SQ.PI'.
building does na curready hese a mrmnL that it n my responsibilityb notify dw occupant
of the becianat which must he met prior m issuance of a C,oricate of Greatim cy.
Owner or mahmued agent - Date TOTAL: ISSUED BY:
OFFICE