30481 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY /p� 1
CITY OF CUPERTINO BUILDING•ELECTRICAL. PERMITNO. 30481 O T H 1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILIIINGADDREMS: SANITARY NO. APPLICATION SUBMITTAL DATE
ioglo do I L_�_ as
OWNERS NAME VU
e PHONE: CONTNACTOR'SNAME: LIC NO:
11�154
NIC C�ONIIROOLLp
�ARCHITECTINGINEER: LIC NO -�J DURESS: ElV y 1
APgMx;� v txcrroS 457#8
CONTACT: ^ PHONE: BUILDING PERMIT INFO
/ISG ' �Tll tl f C '_/ �--1 r-/ E:, Consultant Fees Paid by Applicant(Initial) n1 DG EL PLUMB MECH
LICENSED CONTRACTORS DECLARATION(O J.C/ QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�Z with Section 70101sT Division 3 of the Business and Profasimis Code,whdmy license is 1a'1_ RESIDENTIAL:
00in full force and effect. +e P13NMIT ISSUANCE —7
P.e.UZ U License Cess Lie.p `� ❑SFDWL C1 KITCHEN REMODEL
N6� to Consrasm APPLIANCES—REMID IAL DEEON ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATI( y PANELS OLTI-UNIT ❑STRUCTURAL
1 understood my plans shall he used as public records MODIFICATION
Z 4 UP'10300 AMPS p EI INTERIOR ❑CHLMNEY REPAIR
N�W Licensed Professional 201-1000AMPS IMPROVEMENT
rs�kd ,',,42I OWNER-BUILDERDECLARATION
ON
K�Q I hereby affirm that 1 am exempt fromm thee Conwctaes License Law for the OVER IOdp AMPS 11 BATH REMODEVREPAIR [I DEMOLITION
aG U following reason.(Section 7031.5,Bmincss end Prnfcsxions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
.k.0o rwhich requires a pernot to comucL tralter,Improve,demolish,or repair any structurean _
E' I prior to its issuance,also requires the applicant for such Permit o rile a signed statement
SPECIALCIRC IMIS
that he is licensed pursuant to the provisions of she Commences License Law(Chapter 9
W 00 (commencing wont g<ctimn lll00)of Divinion3nf the Business and Pmfcmimm Cale)nr TEMP.METER OR L COMMERCIAL:
6 c c that he is exempt therefrmn and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION Cl DEMOLITION
yx 44 Section 7031.5 by any applicant for.perm,[subjuesducopplicannn u civil penuhyolPOWER DEVICES
LL7^ver TyYAN'1'� FOOD SERVICE
_
not more than five hundrcJ dollars(5510). P I V ENT .
ZC ❑Lo the wousa nd propeny, remyemployces wi[hwageaasshei(Sele mm,Buss ass SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended proffered tarsale(Sea 7044,Business []OTHER
and Professions Cade:The Controcmr's License Ince Jars not apply to an owner of OUTLETS—SWITCHES—FIXTURES Olga
a' r propeny who builds or improves thereon,and who docs such work himself or through
his own employees,provided that each improvements are not intended at offered fur NEW RESIDENTIAL.ELECfR SQ FT.
sale.If,however,the building car tmpravement is told withirimeyesrofcompletioo,the �� — lF rSQ.FT. REA LSQ.FT.
cr-builder will have me burden of proving that he did not build or improve for per. VssU�ri♦`N�� (�I�,yaNa�
posotfade.). T {."(/ iK
❑ 1,as owner of[he property,any exclusively contracting with licensed uta manta m
mnamact the project(See.7044,Business and Professions Code,The Conmacmr'a-
came, L Q
ceLaw does nut apply to an owner of propertyTry, PLUMBING PERMIT FEE
y who builds or improves flu eon,and
who contracts for well projects with a comrumr(s)licensed p oxy anuo the Commandoes
Liceme Ince. PERMIT ISSUANCE
❑ I am exempt today Sec. ,R&P C for this reason
Owner
N.TER—DRAIN&VENT—WATER(HA) VALUATION
Dam �p
WORKER'S COMPENSATION DECLARATION BACK ROW PROTECC DEVICE
I hereby affirm under penalty c f pe jury one of the following declarations: _
�❑ I have and will maintain aCertif ate ofCanunno self-insure for Wurkels Compen- DRAINS—FLOOR.ROOF,AREA,COND. STORIES 'TYPE CONSTRUCTION
sation,as provided for by Section 371X1 of the Labor Case,for the performance of the
work for which this permit is issued, FIXTURES—PER TRAP
❑1 have tad will maintain Workees Compensation ho mmce,as required by See ..
37M of the labor Code,for 0¢performance of the work for which this Permit is issued. GAS—EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Wurkees Compensation Insurance carrier and Policy number are:
/1 Carriol Policy No.: GAS—EA.SYSTEM-OVER 4(EA)
/ CERTIFICATE OF EXEMPTION FROM WORKERS' GREAS[/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE ❑ GOIVISION FEES
(This section ncedom be compkteJ ifthepe.it is for one hundred unlikely ply lop) GREASE TRAP
or lac) PLANCHEC 'EE
I cenifythad in the perfirnunce of[he work far which this permit in issued.I shall 51?W ER—SANI'TANY—STONM PA.200FT.
nod employ any perabn in any manner cos i s to beemo subject da the Workers'Compete ENCN n I'N
Z mtiun laws offyl[amiu. am v
z 0 Applicant 11for �re WATER HEATER W/VENT/ELECIR GRADIN FEE
h NOTICE.TOI ICANT.If,of making this Ceniricxde of Exemption.you should
abecume subject m the Worker's Cumpenvmion provision,of the Labor Code,you WATER SYSTEM/IREATING ound SOILS FEE
IkI forthwith comply with such provisions or this frocaush.11 he deemed revaked. WATER SERVICE
6 0
U 0 CONSTRUCTION
tumora leadinING AGENCY NEW RFSIDFMIAL PLMB. SQ.Pf. PAID Doe Rexei tN
61 O I hereby aliithi that Here is a ed Sce.0 0 lending agency fertile pedommnce of
L4 F the work(or which this ryrmit is issued(See.J09],Co.C.)
O U Lender's Name CS
TAL:
Lkl
Lender's Address TOT L:
Ty 1 certify that I have read this application and Bram that the above infortmetion is BUILDING FEE /
to context.l agree to comply with all tidy and county ordinances and state laws relaingm QTY. MECHANICAL PERMIT FEE 0
UZ building construction,and hereby authorize represenerives ofdhis tidy to enter uponthe SEISMIC FEE
abovomcntiored propeny for inspection purports. - PERMIT'ISSUANCE
(We)agree mems,indemnify and keep humbles,the City of C.Penlno against ELECTRIC PRE
liabilities,judgments,costs and expenses which may in any way accoreagainst said City ALTER OR ADD TO MECH. PLUMBING FEE
in cormequence,of the granting of this Permit.
APPL NT UNDERSTANTeg AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.1X10 CFM)
SOURC6 , GULATION - MECHANICAL ECF.
1 �-��A� AIR HANDLING UNIT(OVER 10,030 CFM) CONSTRUCTION TAX
aKl5 mututeo pplicen omr or W Dose EXHAUST HOOD(W/DULT)
HA US ATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building socupam stare or handle hazardous material HEATING ON['[ TO 100,000 BTU)
redefined by the Cullom,Municipal Code.Chapter 9.12,and the Ilahy and Stony
Code,Section 25532(a).' HEATING UNIT(OVER IdA0p)BTU)
❑Yes ❑Nm VENTILATION FAN(SINGLE RISID) PAID -
Date Receipt N
will applicant orfmtum building occupant use equipmentserdevices
ement 11011FR—COMP(31IPORI(Xl,(NX)BTU) '
�yndiso ict? us air ammminants us AcOncJ by the Iluy Arca Air Quality Management .TOTAL:
District? I3UILHR—COMP(OVER 100.000BTU)
L—..th.Hzad
❑Nn
mad the hazardous materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
&Snfety Cnle1understandthatiiia NEW RESIDENTIAL MECH. SQ.IT.ot cummly have a tenant.that it is my responsibility[o notify the occupantents which mus[be met prior to issuance of a Certificate of Occupancy..Hzed agent Date T ISSUED BY: C
OFFICE