30850 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 3 0 8 5 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL JK �][J
BUILDING PROJECP IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'1'I
1 U 1 iIA N — Cil G1qT7II.10 , CA '2—..4—Cr7
OWNER'S NAME: I'110N1i: CONTRACTOR'S NAME' LIC NO:
I YJ 1S 3-z - NIC CONTROL.
CHITECTA INFER: - LIC o ADDRESS% ❑
C_ 2_61_31_l_3
CONTACT: PHONE: BUILDING PERMIT INFO
01br4El Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMBS MECH
L�lr\
sit
_7/�—
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
I herchy of irm mat 1 am licensed node,pm.iaom of chapter 9(emmneneins JOB DESCRIPTION
QRZhSmith.Tl00)of Division 3of1he Busincesand lhoGal
ficed ns e.and my license is
�00 fnf PERMIT ISSUANCE ❑SPU pp
p� rWpKITCHEN REMODEL
full force and effect
QUV License Class Lie.« APPLIANCES-RESIDENTIAL ❑ADDITI LJ PLUMBING RE-PIPE
NN
F�a Date _ Contractor
ARCHITECTS DECLARATION ULTI STRUCTURAL
-
PANELS
TION
Z O y Z 1 understand my plans shall be used az public remarks MMIC REPAIR O Z 0 UP TO 21X1 AMPS -MR PR
, MNFiY REPAIR
F4LW Licensed Professional - 211LI(MIB AMPS IM , V13.MF.NT
OWNER-BUILDER DECLARATION I'r/
C I hereby aft n that I am exempt form the Conaucmis License Law In,the OVER 11XNIAMI'S ❑ 10DEI/RE�AIRr�/13EMOLITION
x6060 following reason.(Section 7031.5.Business and Pmfessinhx Cale:Any city ormum, SIGNS ELECTRICAL ❑OTHER V
1+1'3 W y which empire,a permit m consumer,eche,improve,demolish,or repair any structure
FLLO I prior to its issuance,also"rams the applicant for such penniuo file a signed statement SPEC1ALCIRCULDMISC.
>. that he is licensed pursuant to the provisions of the Contractor's Licame Law(Chapter9
y20 (commencing with Section]gN)of Division afore Business and Pmfcssinns Code)or TEMP.MITER OR P(st
" NST. COMMERCIAL:
0.q e C that he is exempt ihertrhm and me basis for the alleged smoulder,Any violation- I NEW BI.DG/ADDI]'ION Cl DEMOLITION
W y Scn...a7031.5 by any applicant for a permit subjects theapplicant to a civil penalty of POWER DE ICES
y of moa mon five hundred dollars fS500t F'PROVEMENT ❑FOOD SERVICE,
0 Las owner ofthe prepenR or my employees with wages as their sale compensation, SWIMMING POOLE
f F.O will M the work,and the structure,is not intended oruffceed for sale(Sec.704,L Rusin
❑OTHER
L 3 and Professions Code:The Commcmis Limes,law does not apply m an owner of LETS-SWITCHF FTXTURIS
pot who builds or Improves thema,.hd who does such work himself or through
his awn employ.,provided mat such improvements art not intended or offered for NEW RESIDENTIAL ELL SQ ET.
sale.If,however,the building or arprovemem n sold within one year of compI I th SQ.IT.FLOOR AREA LSG.FT
owner-builder will have me burden of proving Nm he did not buildor in rpur- L �a�X
of sale.). W
❑I,m owner of he Delaary,am esdmivcl,con with licensed a,a w
comwct Nc pmjcct(ticc.]MJ,Business tensions CodcU Thc acmrs Li
more law ores nm apply¢r ane r pmperty who builds hr' vcs Nercon,and QTY. PLUMBING PERMIT ,
who contracts for such p .wnh a contractors)hm2eoumto the Contmcto 1
License Law. ` PERMIT ISSUANCE
❑ lame under Sec. .N&PC for this reasonALTER-DRAIN&VENT-WATER IEA) VALUATION
ter
KE CO PENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one ofthe following declarations: J v
I have and will maintain a Certificate ofCommhno self-.sure for Worker's Compcn. DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPECONSTRIICTION
anti kf as which
this
for by Section 1]00 of the LaMa Cale,for Nc pcdnrmantt of Ne
work for which this permit is issued, FIXTURES-PER TRAP
❑1 have and will ode,fon Wo PerfoIch'srmance
Compensation work
for nce.which
h his Pmaludend by Section
My oINe Lahr,timmumnhepounce sheen tedwork fnu wberms is permit is issued. GAS-EA.SYSTEM-I INC.i OUTLETS OCC.GROUP APN
Ca Works',Compensation Insumnec carrierani Policy numberore:
GooierPolicy No.: GAS-FA,SYSTEMB
OVER i A)
CERI'II'ICATIi OP EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE GRTASOINDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION h1sGS
(This section need not he completed if the permit is throne hundred dollars(SIM)
GREAs
or less) Ii TRAP PLANCHECK PER Q
I ccnifythm in the performance of the work for which his permit is issued,Ishalf SEWER-S NITARY-:S RM EA.20012
not employ any Person in any oftener so us to become subject to the Workers Camper- ENERGY FI?E �«
ZZ safe.Laws hf C.Iikml Date ATER HEATER W ENT/ELEM to
2 Applicant GRADING IEE
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should W TER SYSTEM(REATLNG SOILS FEL,
become subject to the Worker's Compensation provisions of the Inbar Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
5z CtthemwUCTIONLENDINCAGENCY NEW RESIDENTIALPLMH. SQ.FT. PAID Dae Receipt«
L)0 Ihemby affirm that ise<onsnfhtma
ion lending agency for the pernce of
e-t the work for which this Perot is issued(Sm.3097,Civ.CJ
0 F' Lender's Name TOTAL:
4ULender's Address L"
y 1 cenily In.I I have read this applicwion and omit that the above information Is BUILDING FEE «^
h
correct.l agree to comply withal)city and county ordinances and sort au QTY. MECHANICAL PERMIT FEE
building madomlior,and hereby authorimmine,emaives ntymen on the SEISMIC PEE
abovementioncJ propcny Nr inspection purposes PERMIT ISSUANCE
(We)agree m save,indemnify and m lcos N of Cupenino against1q7 ELECTRIC FEE
limilipts,judgmems,mon index Swhlchmuyi way.acerumgainsl said City TER DRADD TU ME CIL
inconsequence oftlace Nis permit PLUMBING FE;TAX r—
APPhICANT UNI' ANDS AN I,COM ITH AL1.NON-POINT PIR HANDLING UNIT(TO 1401X1 CFM)
SOURCE RFC', ❑ONS. MECHANICAL
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION
pplir nr u Dore EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
IAZARDOUS MATERIALS DISCLOSURE
Will the applmortorfuture building vesipant amte or handle hazardous material DEAL NO UNiI'(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Heath and Safny
Code,Section 25532(.)? MEATI NO UNIT(OVER 100,000 BTU)
❑Yes ❑No VF. FAN(SINGLE RPSID) PAID
Dae Receipt«
Will he applivem or future building hocaWm use equipmvhich
it hazardous air cmmormarc s as defined by he Bay A u Quid tnagemeni HOILC:R-COMEpHP OR 100.1100 RTU) TOT 15 7, J
,9°ct!❑Yes [D No BOILER-COME(OVER 100,001)BTU) l
I have read the hauNn .rials re mens under Chapter 6.95 of the Coli AIR CONDITIONER ISSUANCE DATE
6omia health&SafetySections' 5,2551].nJ 255341 undersand that if the NEW RESIDENTIAL MECH. SQ.IT.
buddingdoesnote niy have tthau yrcspimsihll'aymnaify the«cupam epi/
o ilmicaui his whir t t cue oftCcnificam of G,m n O./
Zr��_
orized agent Ute ISSUED BY:
OFFICE