30152 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT.PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 30152
� 0 /]
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. J L
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
21 r7 3q T4SZ,2�G '1 9 9
OWNER'S NAME: PHONE: CONTRACTOR'S NAME,: LIC NO:
UO001E27 '7- V 1 MZr_ 3/o NNYC CONEROLN
RCHI'TECf/ENGIN[ER: LIC O: ADDRESS' IW
;Lq Ti�nl=a E k
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Q ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby)(Otto Thal l min licensed under pmvisions of Chapter 9(cnmmencin6 JOB DESCRIPTION
in QaZ ith Sarre=ite)of Uivisinn3of the Business and PmfessinnsCode,.ndm license is
Wr�O w y PERMIT ISSUANCE RESIDENTIAL:
U� full force and effect. /.)R'^2 /_/w ❑SMAT, ❑KITCHEN REMODEL
) License Class Lir.N Y R JJ Yl_1
W Dam vector ConAPPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
a' ARCHITECTS DECLARATION
FON PANELS ❑MULTI-UNIT- ❑STRUCTURAL
Z O�Z em
1 undand my plans shbe all used as public mw eoMODIFICATION
OZ O UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
❑ R Licensed Profession al 201-100CAMPS IMPROVEMENT
"'333 ^0.�' OWNER-BUILDER DECLARATION OVER IIHNIAMPS K,q�BATH REMOVE REPAI El DEMOLITION
p, I hereby affirm that 1 am exempt from the Contractor's License Law for the W
x 3 L U following reason.(Section 71171.5,Restricts and Professions Code:Any city or county SIGNS ELECTRICAL. C OTHER f�
auxuarnum
which requires v permit t°conswc6 alter,improve,demolish,or repair any swemm
r�O
Old he is licensed
also re qui res Novisiosof for Contrasuch rmiuoicense awJChaptr9 SPECIAL CIRCUIT/MISC.
,cot heencin with
pursaam 70th)provisions 3the)Basins nd Preelaw(,Coded 9
00 (e°mmencing with Seclinn]g107 ofOivisionJofthe Business and ProfessionsCode)orTEMP.METER OR POLE MSL COMMERCIAL:
that he is exempt therefrom wd the hasis for the alleged exemption.Any violation of NEW BLDG/ADDRION ❑DEMOLITION
iC 4,
1e1li°n1011,1 by any applicatn for a panni,subject,the applicant to a civil penally of POWER DEVICES ANT ❑FOOD SERVICE
not more than five hundred dollars($500). IMPROVEMENT
Qi] I,as owner of the property,or my employees with wages as their sole contpcasmion, SWIMMING POOL ELECTRIC
will Jo the work,and the swcame is not intended or offered for sale(Sec..W4,Business C OTHER
and Rofessions Code:The Convector's License law does not,apply m an owner of OUTLETS-SWITCHES-
FIXTURES
.. property who builds or improves themon,and who docs such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR - SQ ff.
sake.If,however,,be building or improvement is sold within one year ofecmpletion,the SQ FT FLOOR AREA ESQ.FT.
owner-builder will have the burden of proving that he did not build or impmve for put.
resc of aale.). 1'
Q [,as owner of the property,am exclusively convening with licensed contractors to TOTAL:
construct he project(Sec.71N4,Business and Professions Code:)The Co neaur's Li-
cense JUL
Law does not apply to an owner ofpmperty who builds or improves thereon,and QTY, PLUMBING PERMIT FEE k/(f ll t7 �90L�
who contracts for such projects with a conwemr(ad licensed pursuant to the Commit), 96
License Law. - PERMIT ISSUANCE I'�f Y (/f-
❑IamesemptunderSec. ,B&PCfertbareaon ('Vf"Cfl/Iryf)
ALTER-DRAINA,VENT=WATER MA) - VALUATION
Owner Dale // O G O o
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTEC[DEVICF. .-I`�fYy
1 hereby d[mai undo Penalty of perjury one of the following r Wo ker'i°m:
I.,.and will ]in bynetion ficido37M of the wd,toLabor
self-iCode sure for Workers Compen- DRAINS'-FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
smion,m provided for by Section 3]00 of the Lalmr Code,for the perfnrmnnce of the
work for which this permit is issued. FIXTURES-PER TRAP
C I have and will maintain Worker's Compensation Insurance,as required by Suction
37M of the labor Code,for the perfmwance of the work for which this pewit is issued, GAS-HA.SYSTEM-I INC.4 OUTLETS - IXC,GROUP APN
My Worker's Compensation Invariant,Cartier and Policy number art:
Carrier. Policy No.: GAS-FA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION ETES
Tlbissection need not he completed ifthe permit is for one hundred dollars ISIW) GREASETRAP
or less) PLANCHECK FE F"
Loy say,hmiuthe,.ria, orcin, of the kfmwhich this the ilisissued,Cmupshill SEWER-SANITARY-STORM EA.21X)FT.
notemployLoy any person in vnym a m cnnm ulyeeno,he Workers'Cnmpen- ENERGY FEE
Z cation laws '1� .D,�
zO Applicant i UJI�j_ �� — WATER HEATER WNENT/ELECfR GRADING FEE
fA NOTICE TO APPLICANT: ,a, making this Cenillrale of Exemption,you should WATER SYSTEMITRGTING
' I^ beryme subject,o the Worker. ompeasam.provisions of the labor Code,you most SOILS FEE
WQforthwith comply with such provision or this pewit shall be deemed revoked. , WATER SERVICE
. Z z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. [PAID
UO I hereby affirm that then is a corewc,ion lending agency forthe performance Of Gare eeeiptN
GL P 'the•mrk for which(his permit is issued(Sec.7(97,Civ.C.)
IF.1 lenders Name TOTAL:
Lenders Address TOTAL:
y1 certify that I have mad this application and state that the above infuwmion is LDING ` �
y .rest I11.comply with all city and mumyordln..cesandststelewerebdngto QTY, MECHANICAL PERMIT FEE
U z building convection,and harbyautbonne representatives ofthis city to enter upon the MIC A
above-mentioned property for hopeahm purposes.
(We)agree to save,indemnify and keep harmless the City of Captain.against PERMIT ISSUANCE CTRIC FEE
liabilities,judgments.costs and expenses which may in any way twerm against said City ALTER OR ADD TO MECH. MBING
inconsequence of the granting of this pewit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000C17M) MECHANIC FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRU IONTAX
Signatumaf ApplicanVConlrector Date EXHAUST HOOD(W/DUGD HOUSING ITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or building occupantsmreorhandle haze,dous..led.] HEATING UNIT(TO 100,000 BTU)
as defined by the C.Nnam Municipal Code,Ch ip e,9.12,and the Health and Safety
Code,Section 25532(a)'! HEATING UNI'P(OVER 100,000 BTU)
❑Yes `�j No VENTILATION PAN(SINGLE RESID) PAID
Date ccipt N
Will the applicant or centore building occupant
-
use equipment or devices which BOILER COMP(BHP OR 100,000 BTU)
Tit haaallous air cnnmminant,as defined byby theNe Buy AAir Quality Management TOTAL:
46asurid?
❑Yes No BOILER-COMP(OVER 100,0111)BTU)
I have read the haurdous Wondsrtuiremenis under Cha AIR CONDITIONER ISSUANCEDATE
q pier 6.95 of the Cali.
Health&Safety Code,Seen...25505,23533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not cumendy hvvca lenmt der it ism res 'bllity to notify the occupant -
uf the ),)menu wh' xl he ton prior m is a nifi 7 of Oc-upypc
Owner or authorffj agcn J Date TOTAL: ISSUED BY:
OFFICE