30597 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. O 1/
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT HIRM'IFICA'1'ION
BUIl.D1ONG AllDRE55: /✓/1��� �� �� /I ��� / ���D� SANITARY NO. APPLICATION SUBMITTAL DATI
&cj
OWNER'S NAME: 04j, PHONE: CON CTOR' NA . � �i�^ LIC NO: 4
S;,t NIC CONTROLS
ARCHITECT/ENGINEER: LIC NOi ADDRES(DIDS /N ,S ❑
CONTACr: PHONE: lriJ l/J BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) Dc ELECF PLUMB MECH
❑ ❑ ❑
LICENSED affirm
CONTRACTORS ions of DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby arm Ihm I am licensed underrde,provisChapter 9 mm
nmencin8 JOB DESCRIPTION
D00 with Section]00f1)of Divi' 3ofnc�Business and l'rbfes ions Cafe,anJm licenso is
°mo �1 3 PERMIT ISSUANCE RESIDENTIAL:
infull censcaeond e(1� it C1Ot�� ❑SFDWL ❑KITCHEN REMODEL.
�V�j Dvoc Class Contractor
T APPLIANCES—RESIDENTIAL
W Dam Contractor ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
I unm
JcrsnJ my plans shall waited u rtPANELS ed public coNs MODIFICATION
OZ—O UPTO 2W AMT'S ❑INTERIOR ❑CHIMNEY REPAIR
F anI"N Licensed Professional 201-10(IOAMPS - 'IMPROVEMENT
�4 ZI OWNIiR-R1111.IlER DECLARATION OVER IOW AMPS [:1BATH REMODEUREPAIR [IDEMOLITION
1 hereby df rm that 1 am exempt from the Canso a License Law for the
a V following mason,(Section 703 L5.Bmincn it Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
lsl O F' which requires.permit to caribou,ohm.improve,demolish,or repair any avucmrc
prior to its Issuance.also rcgnires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant o the provisions of the Contractors License Law(Chapter 9
�f�p0 (commencing with Section 7f100).f Divisinn3af the Business end Frofenions Caie).r TEMPMETERORPOLEINST. COMMERCIAL
0. that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of []NEW BLDG/ADDITION ❑DEMOLITION
$ Section]031.5 by any applicant for a Fenno subjects the applicator o a civil naltyof POWER D17VIC17S
sn ❑TENANT FOOD SERVICE
Z M not mare than five hundred dollars y employees
OLaw owner
,rooddmpery.rn myctimelodmuwages mtheir wle compensation SWIMMING POOL ELECTRIC IMPROVEMENT
� will do Ne work,and the swnurc is not intended rindlcred for are(Sea]DW.Rosiness ❑OTHEN
HE and Professions Code:Thu Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
.. propvey who builds or improves thereon,and who does such work himself or through
Ill.own cmPlnyeex,provided that such improvements vat an intended or abroad for NEW RESIDENTIAL ELECFR SQ FT,
sale,IL however,the building or improvement is sold within one year of completion,ihe SQ.IT.FLOOR AREA $/SQ.FT.
owner-huilder will have the burden of proving that he did not build(it improve for pit-
Pas of sale.).
❑ 1,as owner of the property.am exclusively contracting with licensed contractors to
conslace,the project(Sec.7044,Business and Professions CcdcJ The Contractors Li F�
cense Law does not apply to un owner of property who builds or improves Ncrcon,and QTY. PLUMBING PERMIT Fri
who contracts for such projects with a contortionist licensed pursuant o Ne Contractor's
License law. PERMIT ISSUANCE
❑lam exempt under Sec. ,B&P C for this reason J9
Owner - DamALTER—DRAIN&VCM—WATER(EA) .w VgLU x`TIUN
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
I heocbyaffirm under penalty of perjury meofine following declarations `/ ' •"`
I]I have and will maintain a Certificate of Consenuneelf-in.sure far Workers Crimper. DRAINS—FLOOR,ROOF,AREA,GOND.
sation,us provided for by Stains 3700 of the Labor Code,for the wiformarce of the STURIES TYPE CONSTRUCTION
work for which this permit is issued. Fl%TURES—PER TRAP
❑ I have and will maintain Workers Cooperman Insurance,as required by Section
37W ofthe Labor Cale.for the performance of Ne work for which this permit is issued GAS—VA.SYSTEM-1 INC.4 OUT 1.1-75 OCC.GROUP APN
My Workers Compensation Insurance'carrier and Policy number are: -
Carrier: Policy N..:- GAS—EA.SYSTEM-OVER 4(EA)
CHRURCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
(This station need not be completed if Ne permit is for one hundred dollars(8100) - BULLRING IIIVISION PP.BS
or less.) GREASETRAP PLANCHECKFEE
I cectif min Ne perfur mote -the boo m which this Permit is issued.l shall
natcmploy pxo nary m- a usm o -so bcuolhe Workers Ciupen- SEWI?R—SANITARY—STORM EA.2fg1 FT.
�y ENERGY PEE
Z sation Laws Ch f' i>♦Dam WATER HEATER W/VEMI'/ELECTR GRADING HE
H NOTICyyarlTL CA ,alta w emficate o or should WAI'HR SYSTEM/TREATING
a ^ became subject to the Worker's Compensation provisions ofthe Labor Cede,you must SOILS FEE
was G forthwith comply with such pmvisions or this permit duall be deemed revoked. WAI'IiR SERVICh
a O
oz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
U O 1 herbyrfiloon.don themiso conuboction lendingagency for the performance of Date Re ei to
LTs I—t the work for which this permit is issued Ser.3097,Cil.C.)
Q U Lenders Name TOTAL:
Leaders Address TOTAL:
I rectify that 1 have read this applimtiim and stoat that the.hove infaomatimn is BUILDING MT
VI correct.I agree to comply with all city and county ordiimnce.s and store laws relating to QTY. MECHANICAL PERMIT FP17
C.) bnildinY ronsvuninn,and hereby amhorizc repreuntetivea of Nis city memo upon the SHISMICFE:
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to cave,indemnify uad keep harmless the City of CLpectino against ELECTRIC iE
liahilitics,judgmems,con"end expenses which may in an waynccmeagaim.st said City ALTER OR AIID'I O MECFI.
incrosc f the granting",'this peau PLUMBING It
APPI AM' )ERSTANDS WITH ALI,NON-POINT AIR HANDLING UNIT(TO 14000 CFM) MECHANICAL FE
SOUR 'UI .TI '
AIR HANDLING UNIT(OVER Ig000 CFM) CONSTRUCTION A%
of AppmvnV na Dvte EXHAUST HOOD DYMUCI')
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITI ATION FEE
Will Neapplicantor future ImIdingracupam store.,handle haranfous mumrial HEATING UNIT('to 100010 BTU)
as defined by the Cori Municipal Cade,Chapter 9.12,and Ne Health and Safety
C le,Section 25532(x)] HEM ING UNIT(OVER 100,000 BTU)
❑Yes FlNo
VF.M'l1ATION FAN(SINGLE RESID) PAID
Will the applicant or fmwu hullJln6 occupant use a uip uncia or devices which [)are R Feim k
emir huwrdous air comm it ent,as defined by the Bay Area Air Quality Management BOILER—COMP(3HP OR 100,000 BTU)
TAL:
District? BOILER—COMP(OVER 100,000 BTU)
❑Yes ON.
1 have mod the hazaddau materials reuirearri under Chapter 6.95 of the Cali- AIR CONDO IONER
9 ISSUANCE DATE
famia Heath&Safety Coda,e a terra SSaS,JSSJJ end 255N.1 to norsund that if the NEW RESIDE,YHAh MECH. SQ,FT.
of tNngdoesnatcmrenth have am nam.tat it ismy ctresPnnsibilitymnmify Nepancy. t
of the ryviremenn which must be nhet prinrmis tome (if it Cenllicum of Occupnnay. -
Cistern,authorised nor, Date 'TOTAL: ISSUED BY:
OFFICE