30961 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL , PERMIT NO. y
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 30961
BUILDING PROJECT IDRNTIPICATION
BUILDING ADDRESS: - SANITARYNO. APPLICATION SUBMITTAL DATE
ldiOe 14
OWNER'S NAME: HONE: CON CfDR'S NAME: LI
e �� CNO:O D N/C CONTROLM.,
ARCHITECTAfNGINEER: LIC NO: ADDRESS: ❑
S3 1141 Loy
Z S
CONTACT: PHONE: BUILDING PERMIT INFO
' a. ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH 4-4
VY 1 ❑ ❑ Cl ❑
LICENSED COT R'STHCLARKUON
hereby provisions p L QTY ELECTRIC PERMIT FF.E
1 ion 7 )of the I nm licensed ed under t'Chapter 9 my license
JOB DESCRIPTION
�Cio with Section 71p0)ofDivision Sof Ne Busineasand Professions Calc,and my license is RESIDENTIAL:
00 in fulifoac and cff PERMIT ISSUANCE
�,C. �' ❑SFDWL ❑KITCHEN REMODEL
VV License Cl Lias APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING REPIPE
��+GL Dam Comrocm
ZO�to AR HITECTS DECL RATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z 1 understand my plans shall be usedns public recmda MOD ATION
UP*r0200AMPS
O ZFp�Cm - ❑INTERIOR IMNEY REPAIR
�yG.4 Licensed Professimnul 201dg10AMN - IMPROVEMENT
3`
OWNER-BUILDERDECLARATIONCLARATION OVER["AMPS DEATH REMODEDREPAIR DEMOLITION
a
yy 6 1 hereby affirm that 1 a.5 exempt from the Contractors License Ad,s Lew for Ne
pe36V whichingmaura archon 7031.5,onsm r,alter,
Professions Castle:Any city Summery SIGNS ELECTRICAL ❑OTHER
ttvvll 4. which requirex n permit re consumer,applicant
improve,such
demolish,fie a sig vry swcwm
���� thior t he its ficrmncqalso requires fire
so far Contrarmei LiceseLow(Crned mmant SPECIALCIRCUIT/MISS.
IN that he is licensed pursuant to of Division I the CBusiderani Proeiuw(ChupmrY
OC (atmmencing with Seclum 7gp)of Division3of the Business and Professions Codepn TEMP.METER OR .INST. COMMERCIAL:
1.2 C that he is exempt forefront and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITIO
ISLL• Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVIC
^.� ❑TENANT ❑FOODS ICE
p.,
not more than five hundred dollars(SSIK)' IMPROVEMENT
�Q 0Lo the
wnerofthe pro peuctremyemntendewlNwagn os isle(See.
cmmpensiness SWIMMIN LCLECfRIC'
O will dmhewmk,ands: he Convector's
int ended draws doe not apply 7044.Business ❑OTHER
W and Profession Code:The Cos there's License Law saes not apply m on owner of OUTI 'S-SWI'TCHFS-FIXTURES
a' r properly who builds or improves thereon,and who does such work deed or ar through
la
his own employees,the provide)that such ensis
soldimprovements are not intended or offered for RESIDENTIAL F.LF.CI'R SQ IT.
sale.ILhower will have
the burden mvementixolddidcmneyearofcampletiaathe SQ.rOF
E@ _^^ 9SQ.FT '
w croth..)r will have the burden of proving that he did mol buil]arimprave torpor-
Put
ur par- 1U4L.IV•post a osis.).❑ has owneroftheProperly,am exclusivelycomredingwird licenedcmm�etrs to TOTAL:
emswcnheproject Sac.IIU4,BusinessandProfessionsCocle:)TheContracom I..- r REGI
cense Law docs not apply m an owner of property who builds or improves thereon,and QTY. PLUMBING PER FEE
who conuacte forsuch projects with v corms'or(a)licensed pursuant to the Conwclor's
License Law. PERMIT ISSUANCE
I amexamplunder Sec. ,B&PC forthisreason.
ALTER-IJRAM&VENT-WATE VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following Jeclarmons: 3 D Q
❑Ihave and will meimuino Certificme of Cmnsenuosel Ginwrcfor Workers Cooper- DRAINS-FhOOR.ROOF.AR D. TORIES TYPE CONSTRUCTION
moon,as Provided for by Section 37W of the Labor Code,for the perforn.na of the
work for which this permit is issued. FIXTURES-PER'TRAP
Is,5z-
0 1 have and will maintain Worker's Compensation Insurance,as required by Section
37Mofthe[.shot Code,for the perforrance of the work forwhich this permit is issusi GAS+G.SYSTEM.]INC.4 OUTLETS OCC.GROUP
Worker's Compensation Insurance carrier and Policy number am:
artier. Policy No.: GAS-EA.SYSTEM-OVER 4(FA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRLWASTE R R
BUILDING DIVISION FEES
phis senior neediol he completed if the permit is form.hundred dollars f$1001. GREASETRAP
or leas) PLANCHECK FEE
lanrfon
ify Nal in Ne penanceof Ne work mr whichlhis permit is issued lshall SEWER-SANITA -STOR ,A.20(1
not employ any person in any rmnners uml me' j to Ne Worker Camper- ENERGY HE
Ap......Laws ofC bFvvtAl�ate w_' _ WATER HEAT W/VENT/ELECTR GRADING FEE
NOTICE TO AP I ANT.IL after making this Certificate of Exemption,ptmn-y.0 should WATER STEM/TREATING
abecome subject to the Worker's Compensation provisions of the Labor CMe,you must SOILS FEE
IiI fmMwilh eimply with such provNians or mix permit shell be clamed revoked W .R SERVICE.
A
O CONSTRUCTION LENDING AGENCY F.W RESIDENTIAL PLMB. SQ.IT. PAID D Receipt p
1 hereby acorn that there is a conswction lending agencyW. for the performance of
0 Pthe work far which this permit is issued(Sec.3097.Civ.C.)
Lender's Name TOTAL:
WLender's Address TOTAL:
I certify that I have.read Ibis applicadon it stem Ont Ne ubswe Infemetimn is BUILDING FEE
correct l agree to comply with all city and county ordinances and state laws reining to QTY. MECHANICAL PERMIT FEE 77
V z building construction,and hereby aumm mdrepresentatives of this city to enter upon the SEISMIC WE
abovcmendaaed properly for inspection putlwses. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupenino against ELECTRIC FEE
Iiahilides,jidgments,emm.aid expamcs whichmay inuny way ocerueagaitelond City AI,TFRORADDTOMMIL
in conuquence of Ne granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AR HANDLING UNIT GO 10,000 CFMI
SOURCE REG TIONS, - MECHANICAL FEE
AIR HANDLING UNIT(OVERM."CFM) - CONSTRUCHONTAX
nmurc of ApplicanVCuntmcmr Date EXHAUST HOOD IW/DUCT) HOUSING MITIGATION FEE
HAZARDO MATE RIALS DISCLOSURE
Will the upplicum or Powrt building ottvpam store ahandle harardmus material HEATING UNIT(TO Ifq,gA1 BTU)
os defined by the Cupenino Municipal Code,ChoMer 212•and the Health and Safety -
Conde,Sarinn25532(0)? HEATING UNIT(OVER IOO,gpB )
❑Yes ❑No PAID
VENTILATION PAN(SING ESLD) Date Receipts
Will the applicant or future building by the Bl use eyvi it Qu or devices which
mil havudaus yr comeminmts no,Oefinedb the Ba Atm Air Quality Management BOILER-COMP(JHN IW,gq BTU)
Y Y Y g TOTAL:
District? BOILER-COMP ER 100,000 BTU) ,
❑Yes ON.
1 have read the hi andi mencrials nips iremems under Chapter 6.95 mf the Cali- AIR CONDIT NER ISS ANCE DATE
family Health&Safety Cole,Sections 25505,25533 and 25534.1 understand Nat if Ne NEW R DENUAL MECH. SQ.FT.
Iwllding ui no mrcnlly haV[altn t ur'11lamylcxponslhllltym notify the IXNpanl
of Eich must be or to issuance of a CeniOcam of Qcupancy.
G i
Owner nr eu@arms egcm � � Dae TOTAL: ISSUED BY:
OFFICE