30423 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY /p� /(�
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 30423
k O T Z V
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL' 3
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
17WEI V i m s .LA Dd_. @ -ir5
OWNER'S NAME: HONE: CONTRACTOR'S NAME: LIC NO: BIC CO.TRj
CN 3 N❑ 27
1RCHITIiCf/E GINIiF.R: LIC NO: ADDRESS:
CD �
ACT: - PHONE: BUILDING PERMIT INFO
i�Q Ji n _ ` ❑ Consultant Fees Paid by Applicant(Initial) DG ELE PLUMB Ecx I
✓ 7 QY✓l b ❑
LICENSE.CO ACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE1 hereby uffimt thin 1 am licensed under pooisims.f chapter 9(c.mmencing OB DESCRIPTION
Osz with Sein full fore.ction 7000 of Division 3 of the Business and Professions Code,andm licensees
X W- ) y PERMIT ISSUANCE RESIDENTIAL:
U
F s effect. 1
�ULicense Class Lica ❑SFDWL [I KITCHEN REMODEL
rF�W Dam Contractor APPLIANCES-RESIDENTIAL ADDITION .PLUMBING RE-PIPE
b,Dm ARCHITECTS DECLARATION PANELS [I MULTI-UNIT El STRUCTURAL
zb'2z l underswmdmy plats shall he ns eduspublicrecmds MODIFICATION
02— UP 10200 AMPS [I INTERIOR [I CHIMNEY REPAIR
�•� Licensed Nuesnional 201.1000AMPS IMPROVEMENT
5kd OWNER-BUILDS RDEthe Com oto OVER 10181 AMPS ❑BATH REMODEUREPAIR DEMOLITION
CG 1 bereM1y afilrm that Tom exempt from the Cnmraemr'a hlcense Lew for the
&C tL O following ream..(Section 7031.5,Business and Professions Cade:Any cityor county SIGNS ELECTRICAL. ❑OTHER
{1736.['_ which requires a permit to comnuct.Ohio,improve,demmiah,m repair any structure
�LLO prianua
oite issnce,Orsi regoimsthe applicom for sun
ch peniuo fileesigneJ nm
amenn SPECIAL CIRCUIT/MISC.
g�yy that he is licensed pursuant the p,,,Lsions of the Contractors License Law(Chapter 9
,61'300 (commencing with Smtion 7011111 of Division 3 of the Business arm Professions Code)or m TEMP.METER OR POLE INST. COMMERCIAL:that he isexempt therefrom and the basis for the Aleged exemption.Any vitiation of ❑NEW BLDG/ADDITION ❑DEMOLITION
yx Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES
V.7—m ❑TENANT [I FOOD SERVICP.
n more than hundred propodollucy, SIX.. IMPROVEMENT
^ZQ ❑Lasowner k,tind pe it... r isnotm madoiNwagesastheir ale compensation, SWIMMING POOL ELECTRIC
will dothework,andthehe Contractors
notemended or.awdofon axlepplyt an owner
❑OTHER
ul and Professions Cale:The Coaractoes License law Jas not apply to an owner of OUTLETS-SWITCHES_pl%TURF_5
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements o2 not imetdW or offered for NEW RESIDEN'HAL ELECTR SQ IrT.
sale.If,however,the building or improvement is told within ane yinit'complction.the SQ.PT.POOR AREA ,EISQ.PT.
owner-builder will have the burden of proving that he did not build or improve for pur-
fsale.).
Mer of the property,am exclusively contracting with licensed conwcton to
ttxtrun the project(Sec.7044,Business umd Professions Code:)The Contracmrs Li-
c ul.aw does not apply no an..On of property who tumba orimproves thereon,and QTY. PLUMBING PERMIT FEE
who commas for such projects with o contruemr(v)licensed pursuant o the Companies
License law. PERMITI UANCI?
❑ ImneamnptunderSa. ,B&PCforthisrcainn
ALTER-DRAIN&VENT-WATER(EA)
Date VALUATION
www //I����g
WORKER'S COMPENSATION DECLARATION BACK PO P 1E DEVICE /'1 �1 tt 11
l hereby affirm under Penalty of perjury ane of the following declarations 1 (/L 59
❑I have and will maintain aCenludic of Consent scli-insme for Worker's Compen- DRAINS-TC R' ,A ,COND. STORIES TYPE CONSTRUCTION
onion,us provided fur by Senior 3700 of the Labor Code,fm the performance of the
work for which this permt is issued. FIXTURES-P B T
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700.1'the taborCode,f.r the penfammnc.af the work forwhich this permit is issued: GAS-EA.SYSTE - NC.` HITS (ICC.GROUP APN
My Worker's Compensation Insurance carricrand Policy numherarc: GAS-EA.SYSTEM-OVER IPA
Catimm. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRHASIUINDUSTRL WASTE INTERCEPTOR
(TTlssoddonneed nmtbacom..cus! fthepermit is BU11.1 O VISION POPS
or less.) GREASETRAP PLANCHCCKFEE i
I cmify that in the performance of the work for which this permit is issued,l shall SEWER-SANITARY-$'TORM F.A.21x11'0
not employ any person in any..ad,w m m hecnom subject to the Workers Compen- ENERGY FEE 11 U
Z cation Lows.(Celifomiu.Dam WATERHEATERW/VENTBiL.ECTR
Applicant GRADINGFEE
rpt NOTICETOAPPI.ICANT:lr..0enm0kin this Cenifca¢nf Exema should
rN. g pan yrs ou must WATER SYSTChf/TRGTING SOILS FEE
a became
(ni comply
o the Workers Compensation provisions of the labor Code,y
Da mhwith y with such pnrvisinnsnnhia permit shell he deeineJ«vnked, WATER SERVICE
Q
� Z CUC'UONLENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Pr. PAID
(.)W. 0 Iherehy affirm Matat them them isemnstpcninn lending agency for the performance of [Lin � Receipts
H the work for which this permit is issued(Sea 3097,Co,C.) -
Q Lenders Name TOTAL:
{U Lendees Address TOTAL: if
y, 1 certify that I have mail this application and state that the above information is BUILDING IT 1 r
pJ correct.l agree to comply with all city and county ordinances and sate laws relaningro QTY. MECHANICAL PERMIT FEE
UZ building coms0ucti.n.andbemhyaahodaetepmarandiveso!this citypemeruponthe SEISMIC FEE
above-mentioned property for inspection purposes. PCNMIT'ISSUANCII
(We)agree to save,indemnify and keep hmmless the City of Caperton against ELECTRIC LIC
in
ncoisequnce of thestarind of this Permit.
may in any way ncenmugninn said Clny ALTER OR AILD TO MECH.
consequence of the starting of thin permit. PLUMBING +E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO UL00I CFM) I,
SOURCE REGULATIONS. MECHANICAL FEB
AIR HANDLING UNIT(OVER Io.om CFM) CONSTRUCTIONTAX
Signamre.f ApplicannCnn «
tracr Dine EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will(lie applicant or future building occupant seine or handle haptdous material HEATING UNIT(TO 100.001(1 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(0)7 HEATING UNIT(OVER]WAS BTU)
❑Yes 0N VIiNOLATION FAN(SINGLE RESIDE PAID
Dam Recciptp
Will the applicomorfurs a building asoby the nt case Bay
Air Quciff ality
Mangwhich BOILER-COMP(3HPOR 100.000BTU)
omit hazardous Dir contaminants as defined by the Buy Arca Air Quality Munvgmnrnt TOTAL: 3
Dismct? BOILER-COMP(OVER IOQ W0 BTU)
❑Yes No
I have read the hvardma materials requirements under Chaper 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,M533 and 25531.1 understood that if the NEW RESIDENTIAL MECH. SQ.Fn
Wilding does notcunemly have.tenant lhmn is my responaihility modify me occupant
of the requirements which must he,net prior to issuance of o Cenificate.f Occupancy.
Owners authorized agent Date T ISSUED BY:
ST
OFFICE