30609 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY•OF CUPERTINO BUILDING ELECTRICAL PERMIT NO.
BUILDING DIVISION - APPLICATION/PRMIT E . PI•11nIBING-MF.CIIANICAL. 30609,
IIUII.I)INGPROJECTIDEMrIFICAI'IDN - ".
BUILIIINGADDRESS. „ _ ,t SANITARY NO.' APPLICATION SUBMITTAL DATE
a
OWN 9N ko A_Q —4 orw gam^y)- / LIC NO:ra� SIC CONTROL
ITEC
�A I'/'. NI?II '.. nn I.ICNG ADDRESS: - ( - ❑+
CONTACT: - 9PHONE r - BUILDING PIiRMIT INFO -
V�Of ❑ Consultant Fees Paid by Applicant(Initial)''- BLDG ' IiLRp '. -PLUMB MECH
❑ ❑ ❑
LICENSEDCONTRACTORS DECLARATION, - QTY. ELECTRIC PERMIT FEE -
O C y 1 herchy affirm thni I.m hcem,ed nnea pn+,5,iuns of chapter q(commencing . :, JOB'DESCRIPTION
{y wish Satinn]gXl)of Uivisian3ofthe Business anA Professions Code,anJm licenm is RESIDENTIAL:
F 00 foil(ase and eBcet y PERMIT ISSUANCE
Wl- Lice
i - 'CISFDWI, ❑KITCHENREMODEL
-
A V U Larose Class -Lie.M' -
FF.. W Dam Contract" ._.APPLIANCES-I2ESIDENTIAI. ❑ADDITION '• ❑PLUMBING BE PIPE
IN„ rajr ARCHITECTS DECLARATION PANELS
❑MUISbUNIT ❑STRUCTURAL
Z
(Don
z 1 understood my plans shall be used as public records MODIFICATION
OZ'y UPT0200AME '
C S'^'- - El INTERIOR [ICHIMNEY REPAIR
F+� ; Licensed Profceslon.l -- "' 201-UgX)AMPS '� - 'IMPROVEMENT
OWNER-BUILDER
ippi55,�C Ofr
W Q I h fl that I am exempt fromDECLARATION C ememo License Ir for the OVER 1000AMBS - [I BATH Ri{MvO/l_E�-1,RqEPUR-
0 DEMOLITION
6V follow gso (Section n]0315Rusine,,mal PoTfics,dom.
C.J
A Y ty a mntY SIGNS I'LECTRICAL ❑OTHER
i++W Why which tramax,a perhouto.cisminael,' hea' pooe,dertodsh.or repairy.t uuie
t•+y� pram its Loo q ' 0 applicant frtmch pennn Glen,+gned statement SPECIAL CIRCUIT/MISC. .
Ply that he is licensed pursaat to me provisions mfthe Contmam's License Lw(Chapmr9 -
�oo (a+mmeacingwith Section 7000)ofUookn3oftheBusinessand Pmfes9onsCodc)dr TEMP.METER ORPOLE INST. COMMERCIAL:-
the he is exempt therefrom and the basis for the alleged exemption.Any violation of - ❑NEW BLDOADDIT10N ❑DEMOLITION ^
aXl IIy
Section 70315 bynny applicant for. .it suhjmto the applicant to.civil penalty of POWER DEVICES
Fp,ZCt more then Eve hundred dollars S500L' ❑TENANT ❑FOODSERVICE
2arv.G ❑ Las owne,ofine property,inty employees with wage:us their...lecrmpenveien. _ SWIMMING PODI,ELECTRIC. IMPROV17MENT t ,
W so do the wrrk,and encomome is not intended or offered rorsale(Sec.70,14,Business OTHER
6 3 m and Pmfessiro,Code:The Conwcusei License Law docs nut apply"m not mwndmf OUTLETS-SWITCHES-FIXTURILS
property who builds or imposes theremn,and who d«s such work himself rnhrough=
his own employees,provided that such improvements arenot intended or offered for NEW RESIDENTIAL ELECT - SQ FT
sale.If,however Ne building or improvement is sold within one year ofeompleiinnj the SQ.Fr.FLOOR AREA $/SQ.IT. r
comer-builder will have the burden of proving that he did not build or improve for put-
pp D
sssc of sale.).
'J [] 1,as owner of the,property,an exclusively co oveting with licensed emanate a to TOTAL:
construct the project(Ser.70,W.Business and l'rnfession.c Core.,'Ihe Contramurs Li- a. A
verve Use doex not apply to an owner o'property who hadds on improves thereon,and QTY. PLUMBING PF,RMIT FEE I,pf= '11r ����
who contracts for such project,witM1a Inn tors)IicenseA rsainmme Coinracmis car ..,pua
License Law. - u PEItMI f ISSIfANCE.
❑'lam m IunderS<e. ,B&PCfor I +.
son
ALTER-DRAIN&VENT-WATER IRA) - - TION
1111 OF i
own D r '
WORKCR 'F:NSA II DN Oft] AItAT10N RACK FLOW PROTECT DEVICE
I heathyall a rle rally fperj ty ft f llr i g 1 laat n
•QlM1nve nnJwillmammnaCenific ofC n:tot scf so f Wk Cmpen- DRAINS-FLOON.RODR AREA,COND. STORIES TYPECONSTRULTION
im on,as free d for by genion 3II 1 of the Labor Csxle for the performance of the
• work far whiclmhis permit,,ismcA, FIX'T'URES-PERTRAP x '
71 1 have and will maintain Worker's Compensation Insurance.as required Is Sectinn -
f 37M ofthe L.MrQdgforthe perfotmmceafrhe work far which thi,permit is ixsued. GAS-E.A.SYSTEM-1 INE 4 OUTLETS g OCOGROUP APN
_ My Wnrkee,Compensation I...more carrierml Policy numberarc:' _
sex Carrier: Policy Na: ' GAS-M.SYSTHM-GVHR 4(EA) ...
CERI'IFICATEOPIiXF.MFfION FROM WORKERS' GREASIVINDUSTREWASTE INTERCHPIDR
COMPENSATION INSURANCE -
,(This section need ant be completed ifthe permit is future hmWrcd dollers(SHIT)
BUILDING DIVISION FEES
less)' GRHASE TRAP I•IANCHECK FEE.
lartfy that to meperfomtmiceofthcwark lorwhche,ipe tt'si,stivid, ohoul - -
templymyperson in any manner sat as to became subcnt theta k 'Com _ SEWER-SANITARY-STORM EA.2W FT. -
z n L f C 1 1' roto m Da ) an ENERGY DEE
tio
- WA'TEk HEATER WNEN'I'/ELECTR t
z'� Applicant GRADING FEE
NOTICE TO APPLICANT.If.after making this Cenifcaa of Exemption,you.should WATER SYSTEM/TREATING
a , become subject to the Worker's Compensation previsions of the Lothar Code,you must SOUS Flil?
Lkl tti forthwith comply sent;xuchprnvisiomor this permitshall bedeemed revoked. WATEiR SERVICE
wQ „
7z CONSTRUCTION LENDINCAGENCY NEW RESIDENTIALPLMR. SQ.FI'. - " PAID '
I hereby affirm that iso issued
tending agency fnnhc Performance of :'Date Receipt
. � � the work for which this permit is ixsu<d(Sec.7(191,Civ.CJ
p U Lenders Name 'TOTAL:
{SI Leader's Address - A
0. 1 certify Nat 1 have mad n+i.application end sate that the about in(armeinn is BUILDING FEE
y mrrem.I ugrce io comply win all city ant county oNimnccs and nate laws relining to Qry, MECHANICAL PERMIT I°EE
building nnxtrncdon.ard Hereby tathmiu 1Tm,usndvc,uf this citym+enerapon the S171SM IC FE P, 4•
abtwe-mentioned property for inspection porpoises. '^ -
(We)agrcemnavq indemnify and kttp harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC IEE s
iabilirio,,judgmcnts,costs and cxpcnscs which may,in any w.ynccnie alnumn,aid City ACfCR OR ADD TO MECH,
is crosequcnce of the granting of this fiennir: PLUMBING FEE lea
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITUO 10,000 CFM) '
SOURCE REGULATIONS. +� MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 Clow
CONS TRUCI'[ON'LAX s
Siliumme of ApplicanVCtmraenn Dae EXHAUSTHOOD(WIDUCY) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE -
Willtcit,lcnntar fetum hudding uu,,to momnr handle hazurdeu,matori.l HEATING UNIT TO IMAX)BTU)
as defined by the Cupenlm Municipal Code,Chapter 9.12,and the Health and Safety'
Code,Section 25532(a):' - HEATING UNI I'(OVER 100,000 BTU) -
❑Y ❑No VENTILATION FAN(SINGLE RESID) PAID •, .
Dam R ipt p
W II the applicant infaarc building ache B use a Air
r deuce:which
�emit Inaccuracieszv contaminants as defined by the Ray ArcaA Quality Management BOILER-COMP,(JHP ON IOH.q)H RTU) - -
TOTAL:
Dindct - r- BOILf:R-COMP(OVER 100,00)BTU)
❑Yes []Nn. - .
AIR CONDITIONER
(have Saferad hode,Sstmts iods 25505,25533 add
tualr 6.95mf the Cali- ISSUANCIi DATE
famia Health&Safety Code,Sections 25505,25533 and 25531 I to nemmd rose Both e NEW RFSIDEiNTIAL MECH. SQ.FT.
builAing Aiwx not atmunly hover;mn:nl,rhmhi,my respnn,ihilhymnmily rhe nceupum - -
' of the raluircmena which mustbeton prionnis,uance nl'a Certificum ofOreupuncy. •
Ownt,'m aahorimd agcm Dam TOTAL: .ISSUED BY:
OFFICE*'-