30232 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY . '
CITYOF
CUPERTINO BUILDING-F.LECTRICAI. ' PERMIT NO. O^ /"S
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L L
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
O '2•\ R-OL6
OW R'S NA PHONE: CONTR CTOR'S NAME' LIC NO: NIC CONTROL#
10606.- K
'\w P CHITEC'UHNGINEER: LIC NO: ADDRESS:
4QNTAC. PHONE: - BUILDING PERMIT INFO
% - Consultant Fees Paid by Applicant(InitWp�_ BH I M .LSF Gcy� PL MECH
S LICENSED CONTRACTOR'S DECLARATION QTy, ELECTRIC PERMIT FEE _TG,f7S'
1 hereby attire that I am licensed under,ono,k o of Chapter 9(commencing QTY
JOB DESCRIPTION
0 Oil with Section7000).f Division 3ofthe Businesaand Professions Code,and my license is RESIDENTIAL'
Op ;.full forceandeffact. PERMIT ISSUANCE
FU IrI]] License Class Lic.# ❑SFDWL [I KITCHEN REMODEL
W<G Dam Comm APPLIANCES-RESIDENTIAL RGnDITION C3 PLUMBING RE-PIPE
F-pr� ARCHITECTS D TIONCMULTI-UNIT ❑STRUCTURAL
1 understand m lens shall t o used b Ns PANELS
Z0-7j YP MODIFICATION
OZ—Q UPT02WAMPS C3 INTERIOR [3 CHIMNEY REPAIR
1-ed Lic.uJ Professional 20MODDAMPS IMPROVEMENT
OWNEWB ER N OVER I"AMPS ❑BATH REMODEUREPAIR El DEMOLITION
d' 6 1 hereby affirm that 1 am i from a Co c e Low far the
3 L V following ueasom(Senion"/031.5, student t ode: or..my ❑OTHER -
WWW which nes a rmit to eoasuuct.a fish, m swewrc SIGNS ELIiCfRICAI.
that he
slcense cromm requires he the xis c rein usign ret cm SPEC IALCIRCUIT/MISC.
} the mens licensed pmsuam m the provisions o e C no er
06�CC (comm ise xempto Sereftoor and the
Division 3 of e i d c TEM P,METER OR POLE INST COMMFRCIAIy
a y o p( that io is b therefrom and the basis for me aIleoption.
cut t.Any all ❑NEW BLDG/AUDITION ❑FOOD SERVICE iCro V. Sermo7031.5 ve any applicant for a00). subjatx Ne cwtmo pc of POWER DEVICES
Bat mare than five hundred dollars($500). ❑TENANT ❑FOODSERVICE
� C OLas owner of the property,or my emplayeeswith wages asth'r c no ING POOL ELECTRIC IMPROVEMENT
t FF will do the work,and the strucwre is not intended orofferrxl forsele l c. ,Rusin []OTHER
and Professions Code:The CnmmnoYs License Law docs cwt apply t men Of1TL WITCHES-FIXTURES
property who builds or improves thereon,and who dswx such work himull'b t h
his we employe.,provided tom such improvements are not intended or nffc W ID ALECTR' SQ PT.
sule.ILhnwever,darlumldiall improvement;s sold within onsyearofemudetion. / Q.PL FLO EA $/SQ.PT
owner-builder will have the burden of proving that he did not build or improve for pur-
s
Is
soltv6Y ♦ VVl /�!/�
o ner of the Property,ae exclusively cantwcting with li.nsW anntmnmsI O�
c
con
toe project(See.7044,Business and Pmfesxions Cade:)The Contrwtor's Li- pp�k �pL B
caosa Law dams not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE IIS W
who ren mcu forsuch prolan&with acontmnons)licensed pursuant to the Cotnractels
License law. PERMIT ISSUANCE
�I ren exe�pt under$¢. ,B&P C fo this re n
a areata ALTER-DRAIN&VENT-WATER(EA) /s A
WORKER'S COMPENSATION DECLA 2ATION BACK FLOW PROTECT.DEVICE CITY ,.
1 herebyaffirm KERpenaltyofperjuryoneofthefollowing ded+mtions:
(have anJ will mainmina Cenifink of Conxnt tc self-insure for Worker's Cnmpen- DRAINS-FLOOR.ROOK AREA.COND.
tenon, provided for ho Section 37W of the Labor Code,for the performance of the STORIES TYPECONSTRUC71ON
work r which Nis pcmtit is issued. PI%TURPS-PER TRAP r
E]I have
e end will ode,fon WweCR Come ofthe w rkfor we,.required by Section 11
My ofthenion Labor Code,forInsurncecarhe rier and
work for con: permit is iswed, GAS-EA.SYSTEM-1 INC.4OUTLETS OCC.GROUP APN
Caner: sCompensation Insuwnce.rrierand Policy number ere:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER4MA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR BU .D ISION FEES
(This section need not ho,conadcual ifthe permit is fornne hundreddollersf5100) GREASETRAP
or less.) PLANCHECK PER,
I certify Net in the performance ofthe work forwhich this permit is issued,l shall SEWER-SANITARY-ST ORM EA.
200 FT.
not employ any person in anymanner w m ecome to bsubjen w the Workers'Cnmpen- ENERGY FEE
Z cation laws of Califchu.Date
Z O Applicant WATER HEATER WNENT/ELECTR GRADING E
fn NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
abecome subject to the Worker's Compensation provisions of Ne labor Code,you must SOILS FEE
W forthwith comply with such provisions or this Permit shell M deemed revoked. WATER SERVICE
Q
Z) CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
LJ 0 I herehyaffirm thonhcre iso construction lending+gency for the perfuna...f Dat Receipt#
H the work for which this permit is issued(Sec.3111 Civ,C.) .TOTAL:
O LeMers Name
LU[I Lombes Address
L, I unify that I huve read this application and awte that the above information is BUILDING F L
L. VV)r correct.I agree to comply with all city and county ordinances and state laws mlaringur QTY, MECHANICAL PERMIT FEE O
V z building construction,and hereby authorize reprerenwtiver of this cirym enter upon the SEISM IC FEE
above-coutiancd proper for inspection pu
lasOa PERMIT ISSUANCE p, ELECTRIC FEE
(We)agree to cave,indemnify and keep harmless the City of Cupcnst s against
in
oft
,costs and expenses which may in any way accrue against said City p
in consequence of the geeing of this penniC ALTER ORAD PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLI I I IT 10,IXpC v
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING CF CONSTRUCTION TAX
Signawreof AppliesnUContractor Data EXHAUST HOOD(W HOUSING MITIGATION E
HAZARDOUS MATERIALS DISCLOSURE
Will she applicant or future building occupwt store orlowele hawdous material HEATING UNIT( TU)
as defined by the Cupertino MunicipalCode,Chapter 9.12,and the Health and Safety
Ctde,Section 25532(0)? HEATING UNIT(OVER 100,000 BTU)
❑Yes F7 No VENTILATION FAN(SINGLE RRSID) PAID
Uaid
Will the applicant or future building occupant use equipment or devices which
o havWuus air suarninanu as defined by the Bay A.Air Quality Management BOILER-COMP(3HPOR 100,000BTU)
Outdo? TI L'
❑Yes ON. BOILER-COMP(OVER 100,000 BTU) -
I have reed the hmardous materials requirements under Chapter 6.95 of the Col. AIR CONDITIONER ISSUANCE DATE
famie Health&Safety Code.Seetions 25505,25533 and M534.1 undcrswnd that if the NEW RF,SIOENTIAL MECH. SQ.PT.
building docs net currently have a tenant,that it is my rcaponsibility to notify the occupant
of the hurricane.which must be met on,to iasuance of a Certificate of occupancy.
Owner or authorized agent - Date - T L ISSUED BY.
OFFICE
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