30694 (2) APPLICANTTO FILL'IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY _
CrrY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMB INC-MECHANICAL 30694
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS'. - SANITARY NO. APPLICATION SUBMITTAL DATE
1"2
OWN A PHO# CONTRACTOR'S NAME'. LIC NQ ,�kq
N/C .�CONTROLN
RCHI' LICN0, r �� ADDRESS. ❑ `�
742
CONTACT: PHONE: - - BUILDIN MITI/NFO
❑ Cam.]tant Fees Paid by Applicant(Initial) w BLDG ELECT P M
10
LICENSEDCONTRACTOR'SDECLARATION J 10
QTY ELECT YCPERMIT FEE
T Ixeny arram tool i am ranRd tar«pov;aiens of @ePtd v(mmmcaing JOB DESCRIPTION
�aZ in faSariun adp)o(Dlvia un Jofnhc Busircrsend Prnfcssiuns Cldc,end my liunv
L.,�O in full ince vnJ e,im. � PERMIT ISSU RESIDENTIAL-'
c�a..U�j License Class Lica WNL ❑KITCHEN REMODEL
In Z< Date Contractor APPLIANCES ESI L A DITION ❑PLUMBING REPIPE
ARCEM=S DECLARATION' � PANELS - ULTI-UNIT El STRUCTURAL
Z pv�'z� Iutdeavaod my plane shall he used as puM1lic rd:wJ. N' MODIFICATION
OZ +pop - UP T02W AMPS Ill"' ❑INTERIOR - ❑CHIMNEY REPAIR
N.,'31"'u,1 Licensed!Professional mmovomo F IMPROVEMENT
.�Y� ' OWNER-BUILDER DECLARATION OVER I00JAMPS ,❑BATH REMODELREPAIR 0DEMOLITION
a W Q I heuty alum that 1 am excerpt from the Contmcwr's License Low for the
a a.U following ruwn.(Smduti 90313,Buai.aM Pmfcssbtu Code:Any city or county SIGNS BW?CTRICAL R
a'Vr which rtynira a perrar,at cori ans,,intpNvc,dnuolith,or ar Wr any structure
1".m.0� do,In it,issuatwe,elwinquirestheappli.i fdach permit m fileavi8txd ev¢nx^f SPECIAL CIRCUITvUSC.
} that he is liceresedpulsuvnl to lis,Pr000nasofthe Cortactr's Licence Law(Claart9
00 (rovmtrnetn8withStsdun)0f1()ofDlvi.mn 3 oldie,Business anti Pmfcser.Cufde[
TEMP,METER OR COMMERCIAL'
d tox cxcmp d erefmm aril the nasi.for the alleged exnnption.Any violation of El BLDG/ADDMON�
on M 1DEMOLITION
Section 9031 5 by any app!cwt fora Pearrikoubjecis Ne,eppl I I 'I penalty of POWER DE - - -
ZN ❑TENANT ❑FOODSERVICE
not reare flosto Five M1UMRd Julien(55110).'
FS Qct (] 1 fthc poperty amycmply 'N 8nuthe pcnsai nn, $WIMA ELECTRIC . NIPROVEMEN'�A,e fT�'fIR7
wNllok the kud thertmelurtorrxotm aided RRdfw (Sc W Bus rcrs DOTTER. IAN IILDID
1 � and Pref (Ade:The CuaradN,License Law does apply'Ian revertra,of OUTI.; -SWITCHES-FIXTURES -
propertywinbwldswNmpmvcthuenn,tuna who down fiwork himselfwthrough ,rn iI
his own tmployca,pmvred that such improvcomar,are tial imcnddd or ofnacd for NEW RESIDENTIAL ELFCfR SUET -
mkJLhowever,nhe building mimpmv«rcmN..wlJ wilM1inone yrarufcxnpletion,the SQ.FT FLOOR AREA 9Q.Fr.
«-builder will have the burden.(provingthan he did out build or improve for par-
p se.f ale.). v
a corsstLarowner of nhe property,am ueluxively contracting wish licensedcontrvdws to y' 1
met the (Sec.c.91,4,Business and Professions Code:)On,Contractor.U-
1�cmclawdocs notapplya,nownerof,sou,scray wnobuild.orimpro,0hericar,and QTY, PLUMBING PERMIT FEE l ,
whom tracuforwcnpmjceedwilhaconaactot(s)IicensNpurwanttodhc Contr ors
leen PERMIT ISSUANCE `
int Aa oder Sec. ,B&P C Far Nis Teaser '
ALTER-DRAIN A VEN I'-WATER(EA) VALUATION
Llutc
WORKER'S COMPENSATION DECLARATION" 'BACK FLOW PROTECT DEVICE
Ihe¢hy Minn under pndty of pe7jury uneof the following dalarvinns: �� .,,�
[� Ihaveandwill malnWne CWirsicofConsedlosclf-inarefa WorkYsCeatpen- DRAINS-FLOOR ROOF,AREA,COND.' STORIES TYPECONSTRUCTION
vtim,es provided for by Seaton 37W of the Labor Code.for ate paff..o of Inc ' `M1
ssw«k fa which his permit is issued. FlXTURES-PER TRAP _
❑ 1 have ane will automation Worker's Compensation Imurmr<,as myuirdl by Section AI
39W ofthe Lasa CWe,forna,volarmarce none wurk for which this pemtil in issued. GAS-EA.SYSTEM-]INC.4 OUTLETS' 'OCC.GROUP APN
My Werker's Compensation ln.umncc Terrisand Policy numb« re:
en
Create, , BobyN, GAS-EA.SYSTEM-OVER 4(EA) j
CERTIFICATE OF EXEMPTION FROM WORKERS'- GRE,SEANDUSfRL WASTE UsITERCEPIOR
COMPENSATION INSURANCE u _ BUILDING DIVI NFHBS
(Thin section ancd tied be,coal ifdx permit it fw one hundred dollar,($100) CREASE TRAP
or less.) I PLANCHECK FEE Y
I certify not in dx trul twice critic riwk for which this Perron is issued,Idoll SEWER-SANITARY-STORM EA.200 FT.
rs
not employ any peon ne
in any manrm hem
es to coew. hject ne the WmkcrstCo.,.- ENERGY FEE
Z anion Lawsof CallGxnia Date
WATER HEATER WNfiNT/ELECfR
Z O ApplicvmN ' GRADING ME ,
rjJ NOTICE TO APPLICANT:If,after making this Certificate of EsemptLn,ya should WATER SYS ENIGEREATING-
I" hectare subjccn to tM WohcYs Cednpsnwtiun Provision,of the Lalwr Cock,you must SOILS FEE
fmhwidt cmmply with Rich povisims or this Remtn dura he domed revoked. WATER SERVICE
gz
az CONSTRUCTION LENDINGAGENCY ' NEW RESIDENTIAL PLMB SQ FT PAID
V 0 Ih«eby elimdnhat llM issedmnwdtn lending n8«dcy forth,p«fumtmxc of - Date . Receipt#
W w-d the work for which this pandit is iswed(Sec.3007.Civ,C)
Leaders Nem, - TOTAL',
IU ItNe,,Address v - -
lL 1 certify nar,1 have mad Ws applicatiea and sousohm ate ebeve infarretion is BUILDING FEE
N eoartetJ vgrzmemnply winh all city and county adinuree.and stn¢low.miming u' QTY. MECHANICAL PERMIT FEE
Q.7 ,z rL
NildmgcfmnaedPru,nnd lrrebyauthtrim apeRmmlives of this mtyto ennerurym rhe,, SEISMIC FEE
above-mcn0n agree
I. ave fain tally an pur,ha
(We,)agree to rave,indemnify and k y nennlm Inc City of Cupcnint agoinm PERMIT ISSUANCE ELECTRIC FEE
Ilabilitic,juJgarente.aunts and cxpanun which may in any way meagdnu aid City ALTER OR ADD TOMECH. PLUMBING FEE w
ctnnequencc of nhe ereming of nhi<prmil.
APPLIC UNDERSTANDS AND WILL COMPLY 1 TALI.NON,POINT AIR HANDLING UNIT(TO IU.l1W CFM7 MECHANICAL FEE
SOUR ERE NS. -
AIRHANDLINGUNIT(OVER10,0pUCFM) CONSTRUCIONTAX
Iokeralux,of pplicenVConhacmr -Date EXHAUST HOOD(WIDUC1) -
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building mcupant store or handle t.,,+rdeus n record HEATING UNIT(TO 100,000 BTU)
to deiamd by the Cu1u01no Municipal Code,Chapter 9.12,and the Health Rid Sturdy
Code,Section 25532(d? - HEATING UNIT(OVER 100,UW BTU) /
i]Yes ❑Ne VENHLATION FAN(SINGLE RESID) PAID _-7
Will thea licnnt or fuwR building t use n or&,vice.which Date Rwei N
pp goceheB Area
Air
BOILER-COMP OHP OR 100,000 BTU)
Nmol haeutddous air mmeminents v dapzl by the Bay Art Air Qua'IfY MawBeaaxnt TOTAL.
Distad?
❑Yes ❑No BOILER-COMP(OVER 100,000 BTU)
I have read the beard.materiels AIR CONDITIONER _
arydrwpnetuodcr Chapt«0.95 nchat Cali- SS ANCE DATE
fom'u Hicalts,does&Safety Gate,$Rnua ,thno is any and 25534.T tore uM nom if du NEW RPSIDElai MECH- SQ.FT
ofthe pdoesmNemrenth lust bawl pthato issuance ndnlhtylotxtifOeacvpvdf
of the raryirtarenls which mut be awl priwwisuana MaCcnlOcveMOavyu
(hxamnraudxai¢W agent - Ilmea
is ED
OFFICE