30637 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF OUPERTINO ' - BUILDING-ELECTRICAh I'ERMI'I NO,
BUILDING DIVISION APPLICATION/PERMIT' 'PLUMBIN'G-MECHANICAL 3O6 7
8UHMING PROJECT IDRNI'IkICATION
UILDING ADDRESS: ,/ SANITARY NO. APPLICATION SUBMITTAL DATE
F /oi90 STD.dyD�{c� DSP, /,ry�A/y� t 6LA
SHOE/'-�/L'TPHONE.' DNt..r✓�GI�/ /✓O I.ICNO: .
��r�!v�� SIC CONTROL#
\'RCHITECUENGINEER: LIC NO: eDRESS: �- ..❑, - -
CONTACT: PHONE:- - BUILDING PERMITINFO
_ , -it. ❑-Consultant Fees Paid by Applicant(Initial) BLDG• ELECT - Is UMI) I
LICENSI7D CON'I'RAC'LOIt;S DECLARATION 'QTY ELECTRIC PERMIT FEE Ltd/'
1 hereby aff mal I am licensed under 1...smom of chapter 9(commencing JOB DESCRIPTION '
{0aZ with Section ID0mol'Divmon 3oOhe Busi emmid Prn@ssions Cole,and my license is RESIDENTIAL
F O in full force unit effect. - PERMIT ISSUANCE.
wwr ❑SFDWL'S CHI?N RIIMODF.I.
Q V U License Class _ itis.p APPLIANCES-RESIDENTIAL. 6'_ ❑ADDITION PLHMR ING RE-PIPE
tFZ{�y Dme Contractor
to GOH ARCI{I'TIiCT'S DIiC1.ANA'I'ION PANELS (.• 'chnil.T'I-UNIT El s Ulm URAI.
Z O 'I understand my plans shall be used as Public records MODIFICATION "
UPTO200AMPS .E]INTERTOR ❑CHIMNEY REPAIR
F4t Licensed Pmfemi...I - - - NILI(g0 AMPS IMPROVEMENT
I
s OWNER-BUILDER DECLARATION OVER 1000AMPS - ❑BATH REMODEUREPAIR 0DEMOLITION
GL C � rv"Dhetcby nfllrin that I nm exempt from the Contractor's Llccuse Law for the,
)d36U follo g (S i ]0315 ❑ dP f v.Ede A Yday rc ..ly SIGNS ELECTRICAL ❑0'1'1{IiR
4477�qwhich requires a permit t t,alter,improve.demolish,or repany structure
� 'pnnn I t y tit ppl' tf 1 pe n fl g cite temm�t SPECIALCIRCUIT/MISC > ^'
} that he is licensed pursumua the p..vismavofth Cmilrommit's License La (Clarpler9
as0 (commencing with Section 7") fD"_' r3 Of the B dProfessions Core)or TEMP METEROR POIEINST COMMERCIAL' .
a n Nm h is exempt thuef nand the basis I m,.dllsged exempt r t Any violation trades of NEW BLDG/ADDITION ❑DI?Ivl ION
x 'Section 7031.5 by any applicant for v permit subjects the applicant m a civil Penalty of POWER DCVIGE$ '
W•�y \` ENApT ❑FOOD SERVICE '
F„>} nounnre lM1mt five M1unJreJ dollars($500). - �- \ �ROvIin't v
Sa ❑"Laaowna ofN unfired rnuny500). ccs wWt wagesm their sole compensation, SWIMMING POOLELHCfRIC
qE,O will do the work,and thesracture is not intended oroffcred for safe(Sec.]M4,Business ER"..
W•" and Promssin a,Gxle:jThe Cumracmr's Licence Law docs ant.apply td an owner,, OUTLETS-SWITCHES-FIXTURES
�"�' pmpeny who builds or improves thereon,and who does such wink himself tar through
his own employees,pmvided that such impmvemenw am not intended or offered for NEW RESIDENTIAL ELECfR SQ Flt '
late,If,however me buildingorimprovemcnl is scld within oneyestrofecooptction.the SQ.Ff.FLOOR AREA., S/SQ.PI.,• .
'owner huilder will have the b.mVd of prow ng Nat he did I build or improve for put /
❑ e
as w of propene mat am exclus v ly t tiny with licensed Con ractins to, A
consumer the pmjmt(See.7044.Business and Prp&afons Code:)The Contractors Li-
censeLaw does not apply to on owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE ,r -
who conldr s for such pmjecis with a mmtnictoKs)licensed pursuant the Contractors
License Law. - PIiRMIT ISSUANCE �t 1 1996
'❑ Imnnxmnplunder Sue, ,B&PC for thi ornoun - - .. r -
'ALTER-DRAIN&VENT-WATER(EA) I+t„ )V,TION
owner Dole
WORKERS COMIENSAI ION DECLARATION s BACK FLOWPROTECI DEVICE'have
by R Ce ificampe Consent
on a fm f 11 gd Ictal - _ ` STORIES
TI
�� Iha a anJwiefomaintain ann lane U tatCmde, ureln Workerce 01 the
DRAINS FLOOR,ROOF AREA,COND. � STORIES TYPE CONSTRUCTION
worm,sa hich this
for ni Section 39IX1 of.IM1e Labor Code,far the performance of the -- ”
work have
Nis maintain
issued. FIXTURES-PER TRAP (�
I have and will ode,for
Worker's Ca ce of the w Insurance,h respired by Section
3]1X1 of the Lobar Coale,fnr the perfnrmvnm of the work for which this permit is issued. GAS-EA.SYS'TEM-I INCA DUTLIi'LS � OCC GROUT' APN
My Workph�syyM6nha�rtrane easier and Policy�� G4-9G GAS-EA.SYSTIiM-OVF.k4(EA) ,
Carries �(_[,ZL(.r Policy Nn.: ,
CHBTIFICAI'E OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GREASUOYDUSTRLWASTE INTERCEPTOR
'I. ' (Thissectinnnwlnnt bamnnpletel it ffin,nnil is Ennneh.nd (SI
,WdnlMmt10) BUILDING DIVISION PERS
orlexx.) - GREASE,'TRAP - PLANCHRCK FEE '
Icertify Nalinthe perfomlmce of IM1e work forwhich this permitis issued,l shall ,SEWER-SANITARY-STORM FA.200 FT.
r mitrunloyxny Person in any manncrsnus m heconue,amr t tolhc Worker'Contpen- ENERGY FBI?
it
Z smion Laws of California.DateWATER PLATER WNENT'ELECTR
s, _z 2 Applicant .r - GRADING FEE
(y .N., NOTICE 10 APPLICANT':If,after making this Certificate of Exemption,you should WA'T'ERSYSTEMn BEATING
' become subject to the Workers Compensation provisions of the Labor Cade,you must _ SOILS'FEE
forthwith comply with such provisions or this pemut that l he deemed revoked. WATER SERVICE -
yO
r7z CONSTRUCTION LENDING AGENCY - NEW RF_SIDENTIALPLMB. SQ Er. PAID e{ N .
.,U O ,( ihcrchy affirm re issed(Sc i 1.Civ.xgmmytrn the perfarmnnm of _ e
Lc work for which this Permits Issued(Sec.J09].Civ.CJ
1'T•' F" Lender's Nnme TOTAL:
O U. Lende's Address •.r� - Y A: - .
y : 1 cenifY mat i have re d Nis apPliconion and eta thin the tali ve info matin is BUILD E ,�
rn correct asrce m comply with all city and ddumy ordinance.and state laws relating to QTY. MECHANICAL PERMI'P FEE
SEISMIC FEE
U z builJin nswctinn.-and herebyxuthorimrerepresentatives of this cid to entcru slits _
p P
aMry itioreJ pro 'r mrinsl<mmnputposcs.
PERMIT ISSUANCE ELE RIC FP.
( .7 agree save,mdemnily vnJ keep harmless the City of Cupertino vguinst .. ELECTRIC
s, dgm ts,costs and expenses which they in any way vecme against mid City ALTER OR ADD TO MUCH: -
in consc fthegradngnfmixpermit. - - - PLUMBING EE
AFELL u NDERSTANDS AND,WILL COMPLY'WITH ALLY NON-POINT. ' AIR HANDLING UNIT(1011L000 CPM)
SOURC t 'l ATIONS. MECIIAN 'ALLIES
y.' AIR HANDLING UNIT(OVER 10,000CFM) s CONST CTION TAX
igmwre of p an✓Comracmr s. Dam HXHAUS'F HOOD(W/DUCT) 1` HOUSI '1'IGATION hEF,
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicxnt or future buildingocto,cnl store or handle hazardnustruunial I]HATING UNI'1'('TO 1 '"p,I3TU),
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Cole,Section 25532(x)^., , I'. HEATINOUNIT(OVER 100,000BT1J)
❑Yes ONO , VENTILATION FAN(SINGLE RFSID). s PAID
Dam Receipt x
Wi115he xpplicam or furans handing oecupunt me equipment m devir's which BOILER-COMP(3HP OR I00.00D BTU)
emit haaandoos air co6mminams as definel by the Buy Area Air Quality Management '. t TOTAL
District?❑Yes L]No
BOILER-COMP(OVER 100,11X1 BT'U) t
I have read lheharardoun minerals requirements under Chapter 6,95 ofthe Cali- AIR CONDITIONER ISSUANCE DATE,
form.Health&Safety Cal,Sections 25505,255. it 2553,UI understand that if the NI3W RESIDENTIACMECH. SQ.Irl'. '
building does net curnmety have a lemon,that it is my tesIonsibility to iii eacustat
tithe requirconents which randh •t pris it to issuancefaCenf ate fOccupmmy,
�
Own mmithumurd age tDate 'TOTAL: - ISSUED BY; -
OFFICE P'.