30038 APPLICANTTO FILL IN INFORMATION WITHIN BRED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEi RTINOBUILDING-ELECTRICAL. PERMIT NO. 30038
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDFNMFICATIf1N
BUILDING;DDRESg:�-Jt � /I /I.�- i r - ' SANITARY NO. APPLICATION SUBMITTAL DATE
:SNAMW: (J' Ct t ��J`1`0''YN-I{i - CONTRACTOR'S NAME: LIC NO: G�
W Cyq,,,� It—OA N/C CO�MTR\OL#
( � NCHITIECT/ENGINEEN: LIC NO: ADDRESS: ❑ O / ,
[�
t. 'ONTACT: ^� 'PHONE:' •BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) - BLDG EI M ME CH
LICENSEDCONTRACD)R'S DECLARATION QTY. ELECTRIC PERMIT FEE
I nereny mrirtn mal am Eamsed under proviniomn or chapter 9(emmnemrimg - . FT) JOR DISC PTION .'
DMZ with section 700inafDivision 3 ofthe Business and Professions Code,and tory license is - - RESIDENTIAL, '
�
O O in In l force and effect. - PERMIT ISSUANCE.
W F l -
_
GUV License Class 'Lic,# ❑SWI. ❑KITCHEN REMODEL
�<i Date Contactor APPLIANCHS'-'RESIDIENTIAL - []ADDITION ❑PLUMBING RE-PIPE
Z8Drs, ARCHHTCTS DECLARATIONPANELS - ❑MULTI-UNIT ❑STRUCTURAL
7a 'l undenJ my plane shall[caused as public records ' _ 'MODIFICATION
OZ- r 'uP'1'02W AMPS
prsm [I INTERIOR ❑CHIMNEY,REI'AIRI
F N.Ft�i
Licensed Yrofesainnal - - 201-10(g)AMPS. IMPROVEMENT
OWNER-BUILDER DConN OVER 1000AMPS '❑BATH REMODEUREPAIR ❑DEMOLITION
1 hereby affirm that 1 am exunpt from the the DECLARATION
License Law for the -
606U rnllowingreasmn.(Section 7031.5,Bmnfnessand Professions Cwle:Anycitymemarty SIGNS ELECTRICAL. LJ OTHER
3 y which requires u permit to construct,alter,improve,demolish,or repair any structure
poor d,its issuance,also technicstne applicant fpermit life a signed saaartent SPEC' IAL Cl RCU1T/M ISC.
that he I 11 Jp rs it thep ne oOf the C 't tor's_I n La (Chapter9 `
IICy�O (comment g th Seni ]1810) fO sio ass dPa[ na CaMpn THMR METHN OR POLL INET COMMERCIAL: ,
0. o: that he is exempt therefrom and the basis far the alleged cxentpuor,Any violation of ❑NIiW BLDG/ADDITION ❑DEMOLITION
%'..y Section 7031.5 by any applicant for a peroutuctne,la lher.,licuntwic civil penally of POWER DEVICHS _ AT r El FOOD SERVICE
til oat marc man five hundred dollars($500). MPROVENdwr F
(]E.,nwnerof the propcny,or my employ.,with wages ax their,mle annpenmtion, SWIMMING POOL ELECTRIC, DOTTER
W CG will Jo the work,and the structure is not intended or offered for rule Ser.7044,Business
and Professions Code:The Contractors License Taw does not apply m an owner of UTLETS-SWITCHES-FIXTURES �` •n
property who builds or improves thereon,and who does such work hi maelf or through'
his own employees,provided that such improvements arc;of intended or offered dirt NEW NESIDL'N'TIAL HLL'CEN SQ FI'. '
aide.If.bowev will
buildinguren of iment issoldhe ithinone yeorofcontpletion.the 5 00 . I;/SQ
pocr-builder coil l hove the harden nl pmvin6 that he did not M1uiId to'c:, Inr par- \1
se oia own. R
❑Las owner of the property,em exclusively comraning with licensed romacmrs m T 6l
aonshuet the project ISea.70,14 and fesnions Cole:)The Contactors LE- '
e rel.aw docv supply man aur ofprr cr whobuihl.,or improves means;nmol QTY. PLUMBING PERMIT FEE
who contacts 4t s ch projects it ocont r(s)liecnsed puMount m the Onatactor's
License Low OCT 14140
lam exemp iSec ,N PC Gn this ream PERMITISSUANCE
Owner - Date ALTER-GRAIN&VHW-WATER(EA) ION
WORKIER'COMPENSATIONI]IECIARA'nON BACK FLOW PROTF.CT.DEVICIE 2� O `O �—
I hereby affirmunder penalty ofperjury one of he following deeorutions,
have and will maintain a Cmifcae ofConaenuo o0f-bs re for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES - 'TYPE CONSTRUCTION
action,as provide]for by Section 37Mof the Labor Crsle,for 1M perfonnance of the ,
work Inr which this Permit is icto,d, - FIXTURES-PER TRAP -
❑1 have and will maintain Worker's Compensation Insurance,m requited by Section'
3700ofthe labor Code,for the peformunceofthe work forwhich this permit is issued. GAS-EA.SYSTEM.I INC.4 OITILE1'S OCC.GROUP APN
My Worker's Compensation lnsymnce carrier and Policy numhur are
Carrier. Policy No,:' I GAS-EA.SYS'fE,M-OVER 4(RA)
CERTIFICATE OF EXEMPTION FROM WORKERS' e
COMPRNSATION INSURANCE GRPASFIINDUSTRI.WASTE INTERCEPTOR
(This snninn nerd na M1r contpleled if the permit is loran<hundrcd Jullars($103) - BUILDING DIVISION FETES
or lens) GRIEASF.TRAP' PLANCHECK PEE" h
I certify thait in the perfnmmncenfine work for which thi,vornit is is..ed.[an,][ SEWER-SANITARY-STORM EA.200 IT.
not employ any'person in any manner so as In becoe subject to the WOrkcm Conapen- o ENERGY PIt' r.�
O ,'� WL
m'action Laws of Califomia,Date WATER HEATER WNENT/ELECTR
O Applicata _ GRADING Il'
NO LICQ TO'APPLICAN'1':If,attar snaking this CeniOene of Exampllnn,you should' WA'1'I'R SYS'TL'MfTNIEATING
a ;
become subject the Worker's Compensation provisions of the Labor Cole,you must _ SOILS I'EE '
Gkl ... formwith comply with such provisions or this permit shall be Jeered revoked.- WAmRSERVICE ,
7Z CONST is.acu Nindam lNGAGENCY NEW NFSIDEN'tIAL1'LMB.. SQ.1T. - PAID
V. k for which
chatthemisomn(Sea 30 leading agency for he performance ofr )a Receipt at
.. W.0 I'd work Name
U (11
oris permit is issued(Sec.3097,CIe CJ
0 U Lender's Name - TOTAL: -
LzndersAddoN, - TOTAL:
1 certify that I have read this application and stale that the above information is" BUILDIN gra
(ZI elmeua I agree to comply with all city and county ordinoners and state lnws'relion,to QTY. MECHANICAL PERMIT FEE
L.)Z building amiarachon,and hereby culhudm
zerepreumiveto
s idad,&,yenmruwmthe SIiISMIC •G'
above mentioned pmpeny for inspection pugasus. PERMIT ISSUANCE
(We).,,.,a sane,indemnify mrd kcrp harmless the Clty of Cupertino ugnimt ELECTRIC FIB
liabilitiesuence ofthe gmks and enpempemit.h may in any way umae against sail City �/"' ,
in consequcncc a(the grvming of mss permit. � LEN OR ADD TO MECH. PLUMBING FEE '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM)
rw
SOURCE REGULATIONS. MECHANICAL F li
l Calk
AIR HANDLING UNIT(OVER 10,"CPM) CONSTRUCTION TAX
- Signaare Of AppllcanUCont...am' Dole EXHAUST HOOD(W/OI1C'I)' HOUSING MITIGATIONEE
HAZARDOUS MATERIAIS DISCLOSURE
Will he applicant or future building occupant store or handle haumluus material HEATING UNIT TO 100,OW E'TO)
as deOncil by the Cupertino Municipal Coale,ChSpter 9.12,and the Health and Safety -
Code,Section 255320)7 HEATING UNIT(OVER IaQ(NN)BTU)
❑Ye-s C]NO VENTILATION FAN(SINGLE RfSID) PAID -'
' Date Ruceipt
Will the air annimorfucuml a building occupantuse
.Air uurdevice,which BOILER-COMP OHP OR 100,000 BTU) _
mit haxardoos air commninants m defined by the Bay Area Air Quality Marageniem - TOTAL:
isticrP • - PI '
[3 ye, []NoBOILER COMP(OVER 10(fxa)BTU) "
� '. .
I have read the hm.nrdoms materials or,mr6a tv under Chapter 6.95 th
95 ofe C.IE- AIN CONDITIONER ISSUANCE DATE
' mints Health is Safety Cale,Sections 255(15,25533 and 25534.1 undersand that it the NEW RESIDENTIAL ME CH. SQ,IT
building does not amorally have a tenant.Vat it is my mxponsibilay to notify me Occupant
Of the requirements which mum he am,pd.,In issuance of.Camfi.m of Occupancy,
Owner or outhurized agent - - Da¢ - - TOTAL: - ISSUED BY:
OFFICE