30489 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO _ - BUILDING-ELECTRICAL_ PERMITNO. 0
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIIANICAL .
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUHMITTAI.DATE
201o8lto CtA-1 it GT
OWNER',& oy _ PHONE: logo nriUSNAME; _LIC Nom_ f NIC CO�RO/Lt-Is
�AR ITE IFNGI F CLIC NO, RF.SS; a L;G; / ❑ V _ '
CONTACT, PHONE: �j BUILDING PERMIT INFO
Pr_ 005me VK-99P90
Consultant Fees Paid by Applicant(Initial) NI rytiC� P UM MECH
vvr r LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that i am licensed under provixionx of chapter 9(commencing JOB DESCRIPTION
"Z with Section]000)of Division3of,he Business.ad Professions Code,and mylicense is PERMIT ISSUANCE RESIDENTIAL,
�ly m full c CI.and effect. ❑ V WL TCHEN REMODEL
UU License Close Lic.p APPLIANCES-RESIDENTIAL ITION LUMBING RE-PIPE.
GDam Commcmr .
Z ARCHITECTS DECLARATION PANELS MULTI-UNIT STRUCTURAL
1 understand my plans shall be used as public records MODIFICATION
Z820UP TO 20B AMPS ❑INTERIOR R❑CHIMNEY REPAIR
r,41pp"IY Licensed Profession.] 201.10100AMPS - PROVEMENT � �-
g W 5' OWNER-BUILDER DECLARATION - OVER 1000 MPS REMODEUREPAIR ❑DEMOLITION
C eYt]Q I hereby affirm that I an exempt from Ne Contractors License Law for the
Li�5�6U following reasun.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECBICAL OTHER
sec 4r,F' SEP 5
which roquirex a permit to cumtnmt,edict,improve,demolish,or repair any swdure ,
priono its issuance.dsnregalreathe...he..,for such pennomfileusignW statement SPECIAL CIRCUIDMISC.
;!I that he is licensedpursuant to the provisionsofthe Contractor's Liceme Law(Chapter9
x02 (commcncingwithSection?Ot10)ctDivision3oftheBusiness endFrnfessionsCale)m TEMP.METER OR POLE INST. U
COMMERCIAL:
vsar s•t.IJrf,J
that he is evemp,therefrom and the basis for Ne alleged rxemplion.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
_ Section 703 IS by any applicant for v permit subjects the applicant o a civil penalty of POWER DEVICES
of mom,
five hundred dollars($50T. []TENANT ❑FOODSERVICE
> IMPROVEMENT '
6 ❑I,Its owner of the pmpeny,or my employees with wages as their sole compensation, SWIM M ING POOL ELECTRIC
0 will do the work,and theswcture is not imencieduroffered for sale(Sec.704d,Business ❑OTHER
t�i1 and Professions Code:The Convacmea License Law does tat apply to i m owner of OUTLETS-SWITCHES-Fl%TURFS
propeny who builds or improves therm,and who does such work himself or through
his own employees,provided that such improvement am not intended or offered for NEW RESIDENTIAL ELECTR SQ FL
sale.If,however,thebuildingm improvement is sold wiainoneyearafemopletinn.the SQ.FT.FLOOR "'Q$7$Q.FT.
owner-builder will have the burden of proving that he did not build or improve for par.
pose of tile.). Lot
❑1,ea owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Buaims.c and Professions Code:)The Contractor's Li-
cense Low does not apply to an ow rer of pTt)pcny who builds or iniprovei thereon,and qrY. PLUMBING PERMIT FEE
who convects for such projects with a commons)licensed pursuant to the Contractor'a
License Low. PERMIT ISSUANCE
❑1 am exempt under Sec. ,B A,P C far this reason
ALTER-DRAIN&VENT-WATER(PA)
Owner VALUATION
Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �
I hereby ethic,under,penalty of perjury one of the following drelar : V�r'.7a,ions
❑Ihaveandwill n,RimnineCenificam of Consenno ml4insom fm Workers Compcn- DRAINS-FLOOR,ROOF,AREA,COND. STORIES a TYPE CONSTRUCTION
cation,ox provided for by Section 3]00 of the Labor Cale.for rhe perfomence of the
weak far which this venni,is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3]0(0of the Labor Code,for the performance of the work for which Nis permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Workers Cons ensmion Insurance carrier and Policy number are: -
Cartier. Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - GREASHANDUSTRL WASTE INTERCEPTOR B DI ISION FEES
(This seelmnneed nm be completed ifthe permit is fnronehundred dollars(MM) GREASETRAP
ca-less) PLANCHEC FE
I certify that in the performance ofine work forwhich this Permit is issued,l shall SEWER-SANITARY-STORM EA,.201)Ff.
not employ any pension in any rr y uyyepo the t1'itns Compen- ENERGY Fli
C Z cation laws of C.11f its��s f_7� / WATER HEATER WNENTIELEC II -
rZ O Appr.am �- �— GRA EE
n NOTICE TO APP mu ' tela of Exe tion,you should WATER SYSTENUTREATING SOIL E
become subject to me Worker's Cam .anion provisions Nor Case,you must
foMwith munply with such pmvisumsor this permit shall be domed invoked. WAIERSERVICE
Uz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL TIME. SQ.ITT. - PAID ate Receipt.
L)Q Ihereby ichaffirm his
the there iso issued
lending agency for the performance nl'
(L(✓ the work for which this Pcrmi,is issue)(Sec.3097,Civ.CJ
lenders Name TOTAL:
U Lender's Address - T
W I certify ma,l have mad this application and sums that above information in BUILDIN FEE
W mormt.l agree to cmnply with.11 city and county ordlnmtcesandmme btwsrelaung it, QTY. MECHANICAL PERMIT FEE
above-mentioned property for inspection purposes.
V building construction,and hereby authorize representatives ofthis city to enteropnn the SEISMIC I .E
gr
(We)aee m save,metrically,and keep hamdess ar City of CulminaPERMIT ISSUANCE against ELECTRIC
liabilities.judgments,coats and expenses which may in any way seems,against said City -ALTER OR ADD q'O SUCH,
in consequence of the grunting of this Permit, PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANLCALFER
SOURCE REGULATIONS. -
AIRHANDLINGUNIT(OVER 10.01)CFM) CONSTRUCTIONTAX
Signature of ApplicanUConttucmr Dice EXHAUST HOOD(W/DUCO HOUSING MITIGATION
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building cem,mtstmo nrhebdle hazardous•material HEATING UNIT OD 100.(M10 BTU)
as defined by the Cuprrinn Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt.
Will the applicant or future huilding occupant use equipment or devices which -
emit hazardous air contaminants as defined by the Boy Area Air Quality Management BOILER-COMP(3HPOR IW,(XIU BTU) TOTAL:
District? BOILER-COMP(OVER 100,001)BTU)
E3 yes ❑Na
I hove road the hmardou materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DAT
fomia Heald A,Safety Code,Sections 75505,25533 and 25534.1 understand that lithe NEW RESIDENTIAL MECH. SQ.PT.
building does tat currently have t Record.that it is my mr onsibility to notify the occupant
of the requirements which must be met prior o issuaree of a Certificate of Occupancy. '
Owner or authorized agent Dam f ♦ ISSUED BY:
OFFICE