30492APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMB NG. MECHANICAL.
PERMIT NO.
30492
BUILDING PROJECT IDENOFICA'rION
BUILDDI(NGGADDRESS: -
SANITARY NO.
APPLICATION SUBMITTAL DATE:
Z, ..
OWNER'S NAME: r, PH
PA
CONTR CTOR'S NAME: LIC NO:
u, 04/ 'to
N/C
❑
y
QQ14TROL#
ARCHITECT'/ENGINlil1R: LIC NO:
ADDRESS:
15& E.s poral v qr 6Elle
CONTACT: PHONE:
BUILDING IS INFO
'
❑ Consultant Fees Paid by Applicant (Initial)
BLDOi ELECT PLUMB ME,CH
❑ ❑ ❑
LICIINSEOCI]NTRACFOR'SDECI.ARATION
1 hereby affimt that 1 am licensed under provisions of Chapter 9 (commencingI
with Section ]000) of Division 3 ofilm Business nod Professions Code, and my license is
> in full farce and office
License Class Lie g;z % S
1 Du¢ Conwcmr N
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
ElSFDWL ElKRCHEN REMODEL
(I ADDITION ❑PLUMBING RE -PIPE
❑MUI.TFUNIT El STRUCTURAL
MODIFICATION
0IN'rI1RIOR C1 CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODELIREPAIR ❑ DEMOLITION
❑ OT'H17R
PERMIT ISSUANCE
APPLIANCES -RESIDL'NHAL
i RcjwrDcrs ABAT
j d,,—Ad lo."Vens, ublic oras/.
I
PANES
UPIO100AMPS
.ice a to al _
4 DIfCLARATION
WNE - U rapt from
I 1 hereby affirm that 1 am exempt Imre the RATION 9 License Law for the
following rcsann. (Selling ]031 S, Business and Prolcsnionn Cale: Any city or county
which requires A permit to mrouma, cher, improve, dmmitsh, or repair any n,..am
201-1000AMPS
OVER IIXp AMPS
SIGNS ELECTRICAL
pnon. in i..... ..lsorequims thcupPlicam for such pcnnitos Men sigouLivamna,
that he is licensed pumuum to thepnwisionxofthe Contractors License Use (Chapter9
SPECIAL CIRCUIT/li
T17MR. METER OR POLE: INST.
CAMM R -IA . -
(commencing with Section ]000)of Division3 ofthe Business and Professions Code)m
that he a etemPt therefrom and the basis for the alleged exemption. Any violation of
Section'/031.5 by any applicant fora permit subjects the Applicant o A civil penalty of
rat marc than five hundred dollars ($5(10).
h as owner ofthe property, or my employees with wages as their sole compensation.
will do the work, and the swctum is not intended oroffered for sale (Sec. ]044, ]business
041iii BLDG/ADDITION ❑ DEMOLITION
� ANT ❑FOODSERVICE
IMPROVEMENT
OTHER
si
POWER DEVICES
- _
SWIMMING POOL ELIIC]'RIC
i and Professions Cade: The Contractor's License Law does not apply to an owner of
OUTLETS - SWITCHES '-FUCTURU
property who builds (ir improves thereon, and who does such work himself or through
its own employees, provided net such improvements am not emended or uttered for
NEW RESIDENTIAL E.LECPR SQ PT.
sale. If. however. the huiming.1 nalrovement o wild within oneycarofcoar inn, the
SQ. FT. FLOOR AREA
$/SQ, ET.
er-builder will have the burden of proving that he did not ur-
build or improve for p
paOfstle.). -
❑ Las ownerof the property, am exclusively contracting with licensed connAtors to
corown the project (Sec. ]fed, Business and Professions Code:) The Convactnr's Li-
,
TO'T'AL:
come Use does not apply to an owner of property who builds or impmves thereon, and
QTY. PLUMBI G ERM FEE
SFR
who mamas fur such police's I th n mmn¢lor(s) licensed pursuant ni the Getramors
Lieenre Law.
❑ I am exempt under Sec. , B & P C fonhis reason
y
rs`/ /9gf�
996
PERMIT ISSUANCE'
C:R ) As—
BACKFOW
f (
Owner Date
IdJ`^LUATIOIJ�`�
SnalMPENdury on DECLARATION
Wm under
Ihereby :
one of the following declarationsWorker's
PROVENT-
BACK FLOW I'NOTECI'. UEVI (--
DRAINS-FLOOR,ROOP,ARF:A,CO ff
will Iain a Cewlt cote ofjury
Cend3cute of[ticmuo soda, for the Worker'sce of the
t]Ihave prowled for
snook, as provided rnr by Section 3]W of Lha Labor Code, for the performance a1'the
STORIES
TYPE CONST RUCTION
FIXTURES - I'11R TRAP
work for which this permit is issued.
❑ I have andLa will maintain Worker's Compensationceothw Insurance, require) by Section
PWof the Luber Cale, for the performance of the work for which this permit is issued.
h
My Worke'Com Inx ut corticr and Policy nambgrpiVpq
GAS - SA.SYSTEM -I INC. 40UTLFTS
OCC. GROUP
AI'N
GAS-F.A. SYSTEM-OVfik4(EA) "
��/yb
Cartier. Policy ✓� fl
ER FI FROM WORKERS'
ONFRAN WORKF;RS'
COMPIiNSAT1ON INSURANCEGRRASFIINDUS'Bf.
OMPTIN ATION
(This section need not be counde ml if the permit is I'or one build red dollars ($I W)
or ]ess.)
I cenify Nat in the performance oDhA work for which this permit is issued,[,hall
nm empdoyany person in any Avian.... as In tommaewbjecrto the Workers Compen-
WASTE INTERCEPTOR
NG DIVISION
FEES
GRI3ASE TRA]'
PLANER K :11
SIiWER- SANITARY- SFORM Lett. 200 FT.
ENERGY ,
WATER HEATER WNIiNT/ELECTR
Appli Laws Af Calif nrniu. Dom
and
-
GRAD E
NOTICE
NOTICE. TO APPLICANT: If, after making this CertiOcme of Labor to d you should
become subject to the Worker'spmvisdons of the Bund Cade,you moa
Croons
WATER SYSTEMITREATING
SOILS
WATER SERVICE
pro A, this
forthwith comply with such provisions or this permit sholloddeemml revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that hem is a construati.n lendingagencyfanbepeil'ormanceof
NEW RESIDENTIAL PLMB, SQ. FI'.
PA
me Receipt#
the work for which this permit Is issued (See. 309), Civ. CJ
OTAL:
Lenders Name
Le Wer s Atlify
TOTAL:
t
1 cmify that I have real this application imJ smut that the shove infnnnmion is
'C
QTY. MECHANICAL PERMIT FEE
comn.l.greof comply wire all city and county ordinances and state laws mlmingto
building consaumi..,akd henebyamhodra rcpresentutiv.x.f this city to entarupot the
.
above-mcminned .,.pony for inspection purposes.
(We) agree mspve. indemnify end keep harmless the City ol'Cupertino against
PERMIT ISSUANCE
E
VTAX
liabilities.judgmems,co..asand expenseswbich may in any way Acme against said City
in e...quenceof g ling iI.
ALTERORAUDTOMECH.
ABL HANDLING UNIT(TO IQWO CI'M)
APPLICANT E TA' 'AN WI. C PLY ITH .L NON -POINT
SOUR L ONS
L FZ17
AIR HANDLING UNIT(OVER IQOW CEM)
ION TAX
941gratilit BTKISRIaliff, nus Date
AZAR S MATERIALS DISCLOSURE
EXHAUSTHOOD(W/DUCp
HOUSING MIT[GA'f10N F'E
HEATING UNIT (TO 100.00) BTU)
Will the applicant or future building seaopem store or handle hamNous material
as defined by the Cupertino Municipal Code, Chapter 9.12, And the Health and Safety
Code, Section 255320) l
HEATING UNIT (OVER I WAW HI ID
Fl Yes ❑Nn
Will the applicant or future building occupant use equipment or devices which
rmit hamedous air comn nomas its defined by the Buy Area Air Quality Management
PAID -
,Arekecet t #
VENTILATION PAN (SINGLE RESIfI)
BOILER -COMP (3HP OR 100,000 BTU)
❑Yes 0 N
BOILER- COMP (OVER I00i BTU)
AIRCOND11IONER
I have maddw haunJousmaterials nenthomeans under Chapter 6.95 of the Cud i-
P
Code, Sections 25505, is my and 25534th onersmnd that if the
fomes Health & Safe,,currently
hulloing Joex nm curtenoy have n moan', that it is my resrymsibiliry m notify the oempant
ISSUANCE DATE,
NEW RESIDENTIAL MIiCH. SQ. FT.
of the requi...N which all be met prior to issuance ora CCumfenm of Occupancy.
ISSUED BY:
Owner or authorized.gent Dale
TOTAL:
OFFICE