30146 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. - PERMIT NO. 30146 O 1 4{l•�!
a,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJEC9'IDENTIFICA'I'[ON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
07Z 8 E.. E 54#-V
OWNER'S AME' PHONE: C(IMRAffOR'SN MIi: - LIC NO:
e_0.fF1� — N/C CONTROL#
0ES S UyVI I
4RCHITECT/ENGINHER: LIC NO: ADDRESS: ❑
J, Z.
COFH'ACP. PHONE: _ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) - BLDG ELECT PLUMB MECH
❑ ❑
LICENSED CON'1'RACIY)R:S DECLARATION X ❑
QTY ELECTRIC PERMIT FEE
1 hemby affirm that I am licensed under Provisions of Chapter 9(commencing
JOB DESCRIPTION
1-t with Section 7n00)af Division3ouM1c 9usincav and Professions Code,and of license is
a W O in full force and effy�t. 1/- PERMIT ISSUANCE RESIDENTIAL
QF.U� Liccnu Class ( — Lica Lti?1� I ❑SFT3WL ❑KITCHEN REMODEL
Nz Dam Conwcmr AI'I'LIANCI3S-RF.SIDF.NTIAL ❑ADDITION IUMBING RE-PIPE
(.Ota RCHIT[LT'S DECL TION PANELS
❑MULTI-UNIT CI STRUCTURAL
zo`2?g lundernundmyplanzshallbeuseds,pull records MODIFICATION
ONF^0 UP'102(NIAMPS
Licenmd Professional ❑INTERIOR ❑CHIMNEY REPAIR
201.1000 AMPS
Q .J
IMPROVEMENT
OWNER-BUILDER DECLARATION
C Q 1 hereby affirm that i am exempt from the Contractors License Law for the OVER 1010 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
sS O 6 U following reason.(Section 7031.5,Business and Pmfeszium Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
F 0.O y which requires a permit to construct,alter,improve,demolish,or repair any structure
m� prior to its issuance.also requires the applicant forsuch permit to fiieazigaed antitumor SPECIAL CIRCUIT/MISC.
6 that he is licensed pursuant o the pmvisions of the Contractor's License law(Chapter 9
I 1� O (aommrnmin,with Section WNN)of Division 3 ofthe Business add Professions Code)or TFMP METER OR POLE INSI'. COMMERCIAL
a o YY that he is exempt therefrom and the basis for the alleged exemption.Any violation of EI DEMOLITION
Seetion]031.56 an a liar fora ❑NEW
NANT ADURION
not mate than live huml ddollars 5500) tt mbjene the applicam totcivil penahy of POWER DEVICES ❑TEANT ❑FOOD SERVICE
E=G Las owner ofthe pmcerty.ormy employees with wagesm their ote compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
y.p.. will do the work.and the structure is not immndedoroffed for sale(See.7044,Business []OTHER
a3 and Professions Core The Comment,',License Law does not apply m an owner,of OUFLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees.provided that such improvementsart not imeodeJ or oRered for NEW RESIDENTIAL ELECTR SQ FT.
sale.ILhoweveathe building in improvement iszold withinone year of completi %,SQjT.FLOOR AREA $/SQ.FI'.
ser-builder,will have the burden of proving that he did not build or improve for .is 4sp /t D
pose of sale.).
❑ I,as owner of the properly,am exclusively contracting with licensed contractors to TOTAL:
construct the project(See.7(W.Business and Professions Code:)The Contactors Li-
cense
i I AUC 3
ensel.am does not apply to an ownerof pniperny who builds or improves themon,and QTY. PLUMBING PERMIT FEE 199
who rmoracts for such projects with a contracmrp)licensed pursuanuo he Commemr'it r�
Licence law.
❑1 not exemptPERMIT ISSUANCE UV_ 0
under See. .B&P C for his mason w �'VYth,
OwnerALTER-DRAIN&VENT-WATER EA)
Data VALUATION
WORKER'S COMPENSATION DIECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of he following declarations:
❑I huarmal will maintains CertifiamnfConxnnoself-insurefor Wnrkcr's Compen- DRAINS-FLOOR,ROOF,AREA,CONE).
satien,ex provided for by Section 3]INE of he loder Code,for the perfornme a of he STORIES FTw rk for which this pemur is issue. FIXTURES-PER TRAP
E] 1 have and will maintain Workers Compenxaion Insurance,as rtgvid by Section
37M of the Labor Codmie.fur the performance of the work for which this pert is issued. GAS-EA.SYSTEM-I INC.4 OUTLETSOCC GROUP
My workers s sensation hormone counter and Policy number are'
Carrier: Policy No.:MN✓Y. 25IRg2-1 GAS-EA.SYSTEM-OVER4(EA)
CERTIFICAT OFEXEMMIONFROMWORKERS'
COMPENSATION INSURANCE GRF,ASMNDUSTRL WASTE INTERCEPTOR
or It's.)This_eenion"red not he competed it'the pcGREASE TRAP
ruit is for one hundred dol Isrs($Hill) BUILDING DIVISION FEES
I certify that in the performance ofhe work for which this twordis issued,1 shall PLANCHECK FEE
not employiny person in anynwnneranaam heemnambject m he Worlacor Compen- SEWER-SANITARY-S'i ORM EA,200 FT.
Z cation laws of Califomia.Date ENERGY FEE
0 WATER HEATER W/VENT/ELECTR
z NOTICE
GRADING FEE
N NOTICE TO APPLICANT:If,after making this Ceniticam of Enemprion,you should WATER SYSTEMUREATING
IZ become subject m the Workers Compensation provisions of he labor Code,you mus
ai forthwith comply with sarh pnwisions or this permit shall Ac deemed revoked. SOILS Flip
RJ Q WATER SERVICE
a
az CONSTRUCTION LENDINGAGENCY NEW RESIDENTIALPLMB. SQ.FC PAID
L, Q I for by which
tr that his Permit
issnd(Sec.3W7.Cis, agancy In, perlinmmnm of Dom cipn#
fA F he work for which this pertain is issue)(Sec.J09],Civ.CJ
Q U Lenders Name
ULetdcrk Address ] 1 'OTA1.:
Fp. I certify that 1 have real this application and state hat the above information is
(Z) correct.I agree to comply with all city and county ordinances and state laws refining BUILDING FEE
U n tmetiun.wtd hereby to QTY. MECHANICAL PERMIT FEE
Z baildi
g cons yauharize representatives ufhis city locator upon the SEISMIC FEE
above-memioned pmscnY for iropection purpnes.
(WO agree¢)save,indemnify and keep hamJes the City of Cu rtinou t PERMIT ISSUANCE gains ELECTRIC F
in
thecosts and expenseswhichmay in any way accrue against ante City ALTER OR ADD TO MECH.
A APPLICANT
UNDERSTANDS
of his D WILL
PLUMBING ME
APPLICANT 11NDGRSTANUS AND WILL II'LYWITH AI-I.NON-POINT AIR HANDLING UNIT ITO to,"CFM) LV
SOURCE REGULAT )NS. � n CO� I __Ct6
/i`�// k'/C/^.. MECHANICAL ME
AIR IfAND1.INC UNIT(GVHR IgIIINI CFM)
CONSTRUCI'IONTAX
Stg;tre of Ap caHAC RDD Dane EXHAUST HOOD(W/DUCO
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION P.
Will ylineCptain.ial or forumbuilding o.Chapter 9.12,
handle Health material HEATING UNIT(TO 100.1]00BTU)
as defined byline Cupcnino Municipal Code,ChaPmr 9.12,and the Heath and Safely
Cale.Section 25532(u)? HEATING UNI T(OVER 100,0110 BTI])
❑Yes CI No
VENTILATION FAN(SINGLE RESIDE PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt fe
emit harallous air contaminants a defined by the Bay Area Air Quality Management SCOMP OR 100.000 BTU)District? TOTALYea EDNo ER 100,000 BTU)1 have mad the hwardous materials requirments under Chapter 6.95 of the Cali-hmiu Health&Safely Code,Sections 2.5505.25533 and 25534.1 undemhad hat if he ISSUANCE DATE
buildingdoesnmtwmntlyhesxa remnLthatit is myresprmsibilitymirchflharecupam ECH. SQ.FC
of the requimmems which must b,met prior issuance of n CeNfiare nf(kcu,sar,
Oag
wner or ernamedent Data TOTAL: _ f.,SU,,BY �77jtr.Z, 1
OFFICE