30969 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. A
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL JlO I6 9
BUILDING PROJECT IDESrIFIC'AT'1alN
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL.DATE
Do o 630 tlliis� �Zq 'Z-, It'
OWNfR'S NAME: PHONE: CONTRA�R:S NAME �yC p:
T S Z NIC CON NOLp
CIIII"Cf/ENGINEER:
AD
LIC O: D9:: O ❑
G-
NTACT. PHONE: BUILDING PERMIT INFO
��5 ,/� /� ���—/�/ys ❑ Consultant Fees Paid by Applicant(Initial) G ELECTPLUMB MIiCI
�V
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm Nat 1 am licensed under provision or chapter 9(commencing JOB DESCRIPTION
O=Z with Section70Dnaf Diveion3 ofthe BusincssvnJ Professions Cale.and rayliccuse is RESIDENTIAL:
WOO PERMIT ISSUANCE
Fly_ nfull force an�+y do 3�'i3 ❑SFDWI. [I KITCHEN RfiMODEI.
CUF- Liccna Clas Lic.p
IZ U APPLIANCES-RESIDENTIAL [1 ADDITION [J PLUMBING RE PIPE
y G V.1 Doe Cnnlmcert
RCI("It 'I'S I 'CLARATION ❑MUCI'I-UNIT ❑STRUCI'UItAI.
�` PANELS
ZOy- 'tstapd l�' used puMierecods MODIFICATION
OZ-+ C UP TO 200 AMPS A El INTERIOR ❑CHIMNEY REPAIR
F 1f-W Lw,, Pral......1 201-1000AMPS IMPROVEMENT
C 6 1 hereby affirm Nat 1 am cmlmp GmmLN ConualO
Mai LicenseLaw fur the OVER 1000 AMPS ❑BATH REMODEL(REPAIR [I DEMOLITION
EoudX 3 LL U following tenon,(Section 7031.5.Business and Professions CWe:Any city M County SIGNS ELECTRICAL OTHER
ya which requires a permit to consuuct,alter,improve,demolish,or repair any ehucmre
I"�OJ prior to its issuance,also requires the applicant for such Permit em
o file a signed shipment SPECIAL CIRCUI
f;!(y that he is licensed pursuant the provisions or the Contractor's License Law(Chapter 9
win (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.METER( OL (NST. COMMERCIAL
mC that he is exempt therefrom and the basis for the alleged exemption.Any vlolntion Of ,W BLDG/ADDITION D DEMOLITION
iC m N Section 7031.5 by any applicant fir.parotin mbicme ma.,Iwma m u dvll penalty of POWER DEVICES " ANT [:J FOOD SERVICELL^yy nal nunu than five hundred Jnllun Win)), IMPROVEMENT
6 D Las owncrofnhc pmpedY•or my employees with wages as theirmlecantpenoemn. SWIMMING POOL ELI;(Ttic
will dothewmk.and NewownecOnim
nandedmivarcilmowle(Sec7Ff4.Business Cl OTHER
3 1.2 and Professions Code:TComms License Law docs not apply to an owner of TLETS-SWITCHES-FIXTURES
pmpeny who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such impmvenlems are not intended at offered for NEW RESIDENTIAL ELECTR SQ FT.
ole.IL however,the building ur impmvemem is old wiffimme yemcif,ma,lefan.me SV 17.FLOOR AREA 5/SUIT,
wncOmilder will have Ne burden of proving that he did not build or improve for per-
pncoTealeJ. t! e1W
0 h as owner of the progeny,am exclusively contracting with licensed comr ,mars to T
instruct the project(Sec.7,CL Rosiness and Professions Code.)He Comraaor's LI-
cense Law does at ap,1,to an Owner ofpmpcnY who mlds Or improves Nerum.and QTY. ING PERMIT FEE FEB 21 RECD
who umlmar,mr such projects with a mnunmlar(s)licensed paromo,,the Cnnenemr's
License law. I PERMIT IS; NCF
u ❑I tan exempt under Sec. .B&1'C for this reason 'I . . .-.. ,at
Owntt I Date ALTER-1 ER(CA) , y VALUATION
WORKER'S COMPENSATION DECLARATION BACK ROW PRO .VICE I A t
I hereby afro under pen rhy Of perjury one of the following chastener..nx: ZJ 1
I I have and will maintain a Carotene of Cunsenuo self imum for Workers Cumpetr DRAINS-FLUOR.ROO .A � ,COND. STORIES TYPE CONSTRUCTION
tion,as provided for by Section 3701 of the Labor Code,for Ne performance or the
4work for which this permit is issued. FU(TLRES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section -
37B0ufnhcLabor Code.for Ne performance of the work for which this permit is Issued. GAS G.SYSTEM IINC n OUTLETS OCC GROUP MIN
My Wor is Cnmpe Inwruna carrier and Policy
� PnIIcY Nno �0 �� CAS-f?A.$YSTFM-OVER 4TA)
rsr CERTIFICA vOPEMP(ION PROM WORKERS' GRI:ASFANI)USTRLWASTE1M'ERCEFfOR
COMPIiNSAI'ION INSURANCE BUIL] D SIGN PENS
17bis section need not be completed ifthc permit is for one hundred dollars($100) ORGSE TRAP
or less) PLANCIIECK Fp "`�IJA
gra
I cerify that in the performaerc of the work for which this permit is sound,Ishall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any ananycr s is� lemae subject.,he Wmkeri Cm,Rm- ENERGY HE
Z amiun laweof Car ' D i5d9; WATER fIGT/
Tlilt WNENELEC R
Z APRlicam xr✓]/ GRADING
0 NOTICE TO APPLICANT:IL after making 'enificate of Exemption,you should WATER SYSTEMITREATING
(~ become subjelt m the Worker's CourNes, prov
7 isions of the Labor Code,you must SOILS PEE
fnnhwinh comply with such provisions or this permit shop be deemed revoked. WATER SERVICE
� Z CONSTRUCTION LENDING AGENCY NEW RPSIDEN'1'I AL PLMH. SQ,19'. PAID Date Receiptp
U O l hereby affirm that there is a construction lending agency for the performance of
P
the work for which his Remain is issued(Sea 3197.Civ.C.)
U Landers Name TOTAL:
1<dee,Address
W I ecnify that I have read Nis application vnJ sate Nauhe above inbmmation is [HOUSING
LDING Frf: e Z�
fA correct.Eugene,mcomply with all city vol county Odlnanees anal state lows minting m QTY, MECHANICAL PERMIT FEE
U Z building construction.and hereby authorize representatives Of this city to caner noun the MIC FEEa Cal
abuse-mentioned propery for inxpection purposes. PERMIT ISSUANCE
(We)agree to save,Indemnify and keep harmless Ne City of Cupenim,ugidnat CTRIC PEfi 1
iahiliar,mJgmems,cossandexpemes whichnne,many way ucemeagainst sail City qT OR ADDTO MECH.
PLUMBING Pfili
in ognNT NDEgrunting SThis Remail.
APPLICANT UNDERSTANDS ANTI WILL COMPLY WITH ALL NON-POINT RIR HANDLING UNIT(TO IO.UOfI CPM)
SOIL '.ATIONS. HANICAI,I :E
S/j AIR HANDLING UNII'(OVER I0.000CFM) STRUCI'10 TAX
Sigwtmc of ApPicam(Contmamr Dam EXHAUST HOOD(WMUCq MITI ATION FEE
HAZARDOUS MATE—RIALS DISCLOSURE
Will theapplicant or future buildingmaupeat stamorhandlehazamous material HEATING ohirr(To IOO.gp BTU)
as defined by the Cupenloo Municipal Code.Chapter 9.12,and the Health and Safety
Code,Sciatic.25532(a)1 HEATING UNIT(OVER 100.000 BTU)
D Yes KI No VENTILATION CAN(SINGLE RESID) PAID
Will the o Beano or mine huildin,occu t use e I m devices which Doe ttiptx
pP 6 pan qumnacn
iii hazardous air room ares u.0 Acf incA by Nc PnY Arm Air VntllilY Munugmncm BOILER-COME'(3HP OR I00,0W BTU) (ll'AI,:
sbiel'7 BOILL'R-COMP(OVER 0(.(NNIBTU)
D Yes )[flea
I hute readthe harandar.mmedds ocu under Chapter 6.95 of the Coli- AIR CONDITIONER ISSUANCE DATE
quirt
lbuildin
mia Health&Safcry Code,Sections 25505.25533 and 25531.1 unJentuM Nm if the NEW RP_SIDENTIAL MECH. SQ.Ff.
not currently have v tevnt that it is my respomibility to notify the occupantt uwhich mu nnnissuanm ofa Cerykgvmn ancy.ncrorauth...ad agent G Date Tt ISSUEDBY:_
OFFICE