30645 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I - BUILDING-ELECTRICAL PERMITNO. ,S 0 ^ s�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J! f6n 5
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATE
ec o 236 C e �t r 1 ►�o Ca:
OWNER'SNAME: 1 .PHONE: CONTRACTOR'S NAME: LIC NO:
,F60 1/ s NIC CO ROLA
0RC 3 ENG 'ER: -_ LIC NO: ADDRESS: ❑ �'
DILI
Owe
CONTACT. T♦•FV x PHONE: - BUILDING PERMIT INFO
4r"y 1e;4 q/5. Q0
0`/_w ❑ Consultant Fees Paid by Applicant(Initial) BLDG EELEECCT PLUMB MECH
LICENSEDCONTRACTORSDECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm mm 1 ant Beamed under provisions of Chapter 9(commencing JOB DESCRIPTION
004Z
�00 with Section d al of Division7of the Business and Professions Cstde,mW mylicenu is
PERMIT ISSUANCE. RESIDENTIAL:
CW mfullforeeand eRect. VAFDWL ❑KRCHENREMODEL
LissaxQU Dole. Class Com APPLIANCES-RESIDINTIAL pODITION C1 PLUMBING RE-PIPE
OF Dam Contmctd
hg..7 do ❑
ARCHITECTS DECLARATION PANELS MULTI-UNIT ❑ CT
STRUURAL
Z p ern r� I understand my plans shall be used as public records A MODIFICATION
OZ—� UP TO 200 AMPS El INTERIOR ,/� ❑CHIMNEY REPAIR
�y�W Licensed Professional 201-10MAMP5 6 jp$PROVEtifPT�
sl OWNER-BUILDER DECLARATION OVER IIXp AMPS [� EMODEI/R AIR. El DEMOLITION
09 G L hereby aEcm mat I am exempt form the ContracmA License Law for the
x�4 C 6 UF following as .(Section 7031.5,Business tad Profession,Cade:Any city or county SIGNS ELECTRICAL OT
W a 0 Na which requires o permit to constmm,alter,impnrve,demolish,or repair any nmcwrc
m❑ ptioutihslss...ce,also requiresihe.ppliamm forsuch permit to file.signed statement SPECIAL CIRCUR/MISC. /�—T &
). that he is licensed pursuance the provisions ofthe Convecmr's License Law(Chapters r•�t-.
GAO (commencing taint Seclian7IXp)of Division3 of the Business and Professions Cude)rr TEMI'.METI3R OR POLE INS , COMM
th /1
at he is exempt therefrom odd the biwis far the alleged exemption Any violation of ❑NEW BLDG/AD61llUN ❑DEMOLITION
edo Section 70115 by any applicant for a Permit subjects the aPpli.o'ta.civil penalty of POWER DEVICES TENANT ❑FOOD SERVICE "
y not mare than five hundred dollars($500). IMPROVEMENT .
xx< C]I,as owner of the property,or my employees with wages as their sole compensation, SWIM M ING POOL ELECTRIC lo
g.Q will do me work,and the swaum is not intended or offered for sale(See.7B .Business ❑OTHER
and Professions Code:The Contractor's License Low does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
L pmpeny who builds or improves thereon,and who does such work himself or through
his own employees,provided Nat such assovemems are not intended or offered for NEW RESIDENTIAL ELECTR SQ
v1e.IL however,the building nrimprovemem is sold within one yeundcompl¢tion,the - SQ.PC FLOOR AREA $ISQ.IT.
er-builder will have the burden ofpmving that he did nen build or improve fiction. O � _7�Tka
pose of sma). - A 'Z1 _V 1
ns owner of the property,em exclusively connecting taint licensed contractors to `Ike ��p ]
con a does not
(plytoa owner
rof property
rop Professions Code:)improves
Li- (�+TIY`1`
c mlmmus finmapplymanownerofpropenywhen„w4sorimproveeCore0n,and QTY. PLUMBING PERMIT PEE
who contracts forsuch pmjeas taint a conmacton(s)licensed pursuant to the Camractofs
Limns La PERMIT ISSUANCE
❑lam ex under sec. ',B&PC for this r anon
ALTER-DRAIN&VENT-WATER(EA). VALUATION ”
caner Data
WORKER'S COMPENSATION UECLARAI"ON BACK PLOW PROTECT.DEVICE I(�
1 hereby affirm under penalty of ps jury one of the following dcel.rmimns: {r Y CA,
O l have and will maintain a Certificate of Consent to self-insure forWarker's Comism- DRAINS-FLOOR,RODE AREA,COND, STORIES TYPE CONSTRUCTION
ration,as provided far by Section 37M of the Lather Code,for e performance of the
work for which this permit is issued. FIXTURES-PER'IHAP
I] I have and will maintain Worker.Compensation Insurance,as required by Section ,
3700ofine LaborCNe.forte performance ofthe work forwhich this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
OCC.GROUP APN
MysCompensation Interstate carrier Policy number am
Carrier.
Policy No.: GAS-8A.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRBASFANDUSTRL WASTE INTERCEPTOR
B D ISIONFq?ES
(This sectionnced not be cnmpletW ifine permit is Tanana hundred dollars(f1001
GREASETRAP
or less.) PLANCHECK1fK tICUD I
Ii,any mminmeperf....a, ..mebecomewhicht India W i kam' ashall SEWER-SANITARY-STORM EA,200 FT.
not employ any person in any manner sn es ho become subject India Workeri Camper. ENERGY PEE aasse
Z stairs Laws of Califomia.Data WATER HEATER WNENTELECTR
z Applicant - GRADING FEE
fj) NOTICE TO APPLICANT.If,after making this Certificate of,Exampiion,you should WATER SYSI'EMUREATING
a' became subject to me Worker's Compensation provisions of the Labor Code,you must SOILS FEE -
foNtwithcomplywithsuchpotskinn,orthis patent shall be deemed mselod! WATER SERVICE
ItsQ
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMD; SQ.FT. PAID Date R rei ted
T hereby affirm that them is a construction landing agency tiuthe Performance of i
L1� rho work for which this permit is issued(Sec.3097,Civ.C.)
LTr F Lenders Name TOTAL:
V Lenders Address - O
0. L. BUILDING TEL' L •/a
I certify Thal I have read this apphriahm and Stam mat me above information is
W mvect.T agree ut mmPly with of airy and county ordinances and ata a laws reining to QT'g MECHANICAL PERMIT FEE
V 4 building constructions add hereby imhmize representatives of this city to enter upon the SEISMIC FEE
above-mcmioned property for inspection imp ssa. PERMIT ISSUANCE }'1
(We)agree ,,save,indemnify and keep harmless the City of Cupertino assured ELECTRIC FE L`•
liabilims,judgames,costs and expenses which may in any way accme against said City ALTERORADDTOMECH. PLUMBING
in consequence of the graming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 10.000 CFM)
SO RC. ULATIONS. - ^ MECHANICA EE
/J_ � / AIR HANDLING UNIT(OVER In"CFM) CONSTRUCTIDNTX
Sign of ApplicanVContrecar K'`+ Data EXHAUST HOLD(WMUCD HOUSING MITIGAT6UEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ascupant thoracic handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cale Chapter 9.Q.and the Health and Safety
Code,Section 25532(.17 HEATING UNIT(OVER 101.0110 BTU)
❑Yes ONo VENTILATION PAN(SINGLE RESID) PAID Data Receipt.
W ll the applicant or future building accup ow use equipment or devices which
mit haranhou air contaminants as di ftrcd by the Bay Ana Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) TOTAL:
DisWa?
❑Yes No BOILER-COMP(OVER I Tough BTU)
I have mad the harardaus ntherialt requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
humin Health&Safety Ca a.Sections 25505.25533 and 25534.1 understand Nut if me NEW RFSTDENfIAL MECH. 'SQ.Fr.
buildingd ro Oy haveamnnnh.tb iti pmsibilihymnotify the mcupum a
afm 7 nth which must be prix ¢sofa Cenifcnm�TFWt�te ■v)
sea A0ft__J
Owner or aflumcd agent Dam L: ISSUEDBY:
OFFICE