30732 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 30732 O 17
3 Z
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 3
BUILDING PROJECT IDENTIFICA'OON
BUILDINGADDRESS: 59 MAMCC- CJ -Lq, j SANITARY NO. APPLICATION SUBMITTAL DA]'1!
e o g qL >~ � o C r* kj0 y) LLAr 1
OWNER'S NAME: PHONFi NTRAC'IT)R'SNAMB: LIC NO.
01J D11 � i Llas LL-C. J e c NIC CONTROL#
\RCHITECT/ NGINEER: CNO: (jC�,3G 096 ADDRESS: ❑
-W F td telZ(011 OAUVIxgur A•. lt"0
MACE: n q PHONE: CA 9n� BUILDING PERMIT INFO
❑ Consultant Fares,Paid by Applicant(Initial) BrLLEXI ELLEECT P1 UU-MBB� MECH
�Rl L f(kl L\Q Ll' Ltd
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby offom that I am licensed under previsions M Chapter 9(commencing JOB DESCRIPTION
�QOwith Section]gNl)of Division 3oflhe Bnainese tad 11 feWons Cade,andoly license in ( PERMIT ISSUANCE
LiRFSI DENT I A L:
ELL_. full forcer eflttt ❑SFDWL [-1KITCHENREMODEL.
aF.UU Lcense Out: Lice
NGContractor
APPLIANCES ❑ADDITION ❑PLUMBING REPIPE
SUatc ARCHITES DECLA ATIHW1 ❑MULTI-UNIT ❑STRUCFURAL
FOy PANELS
Z O,t2 Z^ I undeo nnJ my glints shell be used as public rcermt MODIFICATION
OZ-O UI'T02W AMPS [I INTERIOR ❑CHIMNEY REPAIR
LL Licensed Pmfewional 201d0013AMPS IMPROVEMENT
0OWNER-BUILDER DECLARATION OVER l000AMPS ❑BATH REMODEI/RF.PAIR C3 DEMOLITION
CC f��a 1 hiller,uffrm thin I nm exempt from the Commeo is License Law for the
LV following rcusnn.(Section 7031.5.Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
I+T 3 LL l- which requires a permit to concoct,alter,improve.demolish,or repair any structure
oo
`LLOQ pdarm its >,arng,ld-acquiree thcapplicam forsuch pensum fileu.mgnedsuuawn SPECIAL CIRCUITMIISC.
that he is licensed pucmanttothe provisions oftheContractor'sLicenxWwlChapit,
al C) (.ommemcimg with Senion7IN )of Dlvision3nfthe Businessaod Pmfessions Cbde)or TF,MP.METER OR POLE INS L L
a a oy IMT he is exempt therefrom and the basis for the allege)exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
X m_LL Section]031.5 by any applicant for a perrou suhjcaapp
s de lieam m a civil penalty of POWER DEVICES
W m ,more than ars
hfive hundreddoll ($5g). ❑TENANT ❑FOODSERVICE
F Y - IMPROVEMENT
56 1,us owner of the property.or my smsployces with wages as their sole compensation. SWIMMING POOL ELECT RIC
�F.O will de wnd thoro
the ork.acsuvaure is not imendedffered far sale(Sec.]Teta,Business ❑OTHER
u�j m and Professions Code:The Contractor's Limns Law does nm ripply to an owner of 1 LETS-SWITCHES-FIXTURES
a 3 progeny who builds or improves thereon,and who does such work himself or through
his own employees,provided thin such improvements an,not intended or offered for NEWR 'DENTIAL ELEC R SQ FT.
soleIf.however,the building or improvement is sold within one yea ofcempletion.the SQ.IT.FLOOR AREA $/SQ.PT.
ner.bu lder will have the burden of putting that he did not build or improve fo par. IZ) D2 T IkAs11
grist,of sale.). X I
i] I,as owner of the property,am exclusively Contracting with licensed contractors to TOTAL: COMA ACTOR YiJCLsI SUP.k
instruct the project(See.70,4.Business and Professions Col The Contractors Li. Y
cenx w
Law does not apply to an oner of progeny who builds or improves theme..and QTY. UMB G PER FEE l( Map.
who contracts for such prejeca with a cumracums)licensed pursuant to the ConOactora
License Low. I P17RM1 UANC
I am exempt under Sec. ,B&PCft,hisixasw
ALTER-DRAT VEM'- TER IEA) VALUATION
Own Dme tut
WORKER'S COMPENSATION DECLARATION BACKFLOWPROTF. )EVICE (O
too
Owner I herchy i llinn under penalty of perjury rime of rex following amlarationa
]I have and will maintain aCciificatc of Commmself-insure for Worker's Compem DRAINS-FLUOR,ROOF AR COND. STORIES TYPE CONS]RUCTION
do¢as provided for by Section 37M of the LaMn Code,for the performonce so the '1
wolg for whichthis permit is issued FIXTURES-P�RTRAP t4/A
�I hma and will muimaln Wnrkcr's Compsmahnn Insummce.as rexpired by Section .Y•
3700 ofthe Luba Code.for the performance of the work for which this permit is issued. GAS-EA.SYVIM-I INC.4 DO LETS OCC.GROUP AI'N
My Walker'SCompenxIinn Insurancecomerand Policy p ,1
Comer:�-sa'BK_T.a '�.wfl� Policy No.: L�IN3�ipT GAS-EA.S' I:R 4(EA) N/X
CERTIFICSFEOFEXEMPTION FROM WORKERS' GRIiASFIINDUSTRh ENCL+I'TOR
COMPENSATION INSURANCE liU .DING DIV ION FEES
CThixsection need net becompincJ ifthe Permit is for one hundred dollars(SI00) GREASETRA
or le".) PLANCHECK FEE W/JjjjW,. 11
Icerify that in the perfonnanccot he work for which this Permit is issued.[shall 1 SEWF. SA -S'r0R A, FP. �a
ratemploynn"U'ro to any mnnncrur os toharnnl subject unhe Wnrkers'Cnmpcn- 1 IiNERGY FE
z satiety Laws of California.Date WATER HEA ' W LECfR
Z Applicant GRADING
ti N NOTICE TO APPLICANT:If,after making this Cenilicau of Exemption.you should WATER SYSTE ATI
F ; bcmme subject to the W..keds Compensation loo kions of the Luhor Colt,,you mint SOILS FEB
fnnhwith comply withsuch provisions or this Permit shall be deemed revoked. 1 WATER SERVICE
0
az CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. AID Uau Receiptp
U O I hereby affirm thw Iherc is a con.aruaiou lending agency fur the Pcr unower of
f-'Ll. the work for which this Permit is issued(Sec.3097.Co,C.)
Lenders Name TOTAL:
U Lenders Address TOTAL:
1 cr,m,that 1 have read this application and state Ihar the above information is BUILDING
Vat correct.1 agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U z, building co®vuction.and hembyauthodzc represenutivesofthis citytoenterupon the SEISMIC Ful L
shute-mcmioned progeny for inspection papoxs. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of C.Pcnino aguinm ELECTRIC EEE
An
habilaia,juJgmuns,one unJ expenses which may in any way ucerueagainnt said City ALTER OR ADD TO MECH.
in ,sequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IB,N)i CFM) CONSTRUCTIONTAX
Signature of ApplicanJConuactor Dau EXHAUST HOOD(WIDUCI') HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant more or handle hazardous material HEATING UNIT(TO]W.00)BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,cod the Health and Safety
Cede,Section 25532ND --// HEATING UNIT(OVER Fill."BTU)
❑Yes L]YNo VENTILATION FAN(SINGLE RES]U) PAID
Will thea applicant or future huildin t use e I nr devices which Uau Receipt e
pp gLtiti�mym'storedbityl.
Area
n BOILER-COMPUHP OR I00,WU BTU)
1 hazWoun air cnnuminanu a Jbyay Area Air Quality Management TOTAL:
m41'r // BOILER-COMP(OVER 100,000 BTU)
❑Yes W<a
1 have read the hmadous outnts under Chapter 6.95 of the Cali AIR CONDITIONER I, NCE DATE
hsmia Health&Safety Code,Serino, ad 25534.1 understand the if the NEW RESIDENTIAL MECH. SQ.IT.
building dress not currently have aenaspnnsibilitym otify theacupumnI aCenific:c of,cc Pancy.
Owner or authorized
plot O¢ TOTAL ISSUED BY:
OFFICE