30686 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMD'NO. JK^ O 6^6
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL IF/S VX`FJS
BUILDING PROJECT IDENTIFICATION
LDINGADDRESS. SANITARY NO, APPLICATION SUBMITTAL DATE
!09 /�u,1fezr fw!
I ! f 14ee•
IVV*R'S NAME: PONEC NTRACfOR'S NA s:
WU 67— /6 we ^ c°vR°L«AI) l' LIO
C .'RNGINF
I LIC NO: ADDRESS. ❑ (V LA,y.J1
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSFI)CONI RACT(IR:S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
aOz wou Senna7")ofoi.i.ion 3 ofthe Business and Professions Code,and my license JOB DESCRIPTION
F W_ in full force and eff cu, PERMIT ISSUANCE RESIDENTIAL
QUI. License Class Licq ❑SFDWL ❑KITCHEN REMODEL
a 4 L Dam Contractor APPLIANCES-RESIDENTIAL -ADDITION F1 PLUMBING RE-PIPE
1-,pto ARC[I I BUTTS DECLARATION PANELS LJ MULTI-UNIT ❑$TRUCTURAI.
z O in z I understand my plans.,hull he used no public records
. MODIFICATION
FNFO UP TAM AMPS 0INTERIOR ❑CHIMNEY R PAIR
__W Licensed Pmfesetonal 1-IIXp
Q 20AA1P5 IMPROVEMENT
���,� OWNER-BUILDER DECLARATION OVERIBBBAMPS
W Q 1 hereby affirm that I am exempt from the Contractors License Law for the ❑BATH REMODEL(REPAIR ❑DEMOLITION
3 G U following reason.(Section 703 1,5,Business and I'mfsions Cale:Any city or county SIGNS ELECTRICAL ElOTHER
OyQ which acquires,a permit m crmsnbet,alter,bniaxwe.demolish,or repair any ewemrc
prior to itsissuance.also requires the applicant for such permit to file a signedstatement SPECIAL CIRCUITIMISC.
C�6E that he it licensed pursuant o the provisions ofthe Contractors License Law(Chapter 9
IyCpO (commencing with Section OgXl)of Division3 of Ne Rastas and Professions Code)or TE METER OR POLE[NST TE
A r
6 X n oC that he is exempt therefrom and the basis for tM1c alleged exemption.Any viulaima of ❑NEW BLD /ADDTfIDN�0 DEhfOUT10N.
I.�y Semon 7(131.5 by any applicant li,rapermn subjcros the applicam mucivil penalty of PO iR ;VICES ❑TEN 'qT
nm more than livebunJreJdmllud(551Xp. ❑
MP FOODSERVICE� ❑L as owner of Nm
e property,Or my employees with wages as their sole compemion, SWI OLE ' RIC p��p^yR
Wca p. will do the work,shad the structure is not intended orofferal formic(See TkIaL Business ❑OTHE •R a«XI I`n a.�
d3 ce and Pmfe"inn.Code:The Cmaracmrs License Law does not apply to an owner of OUTLETS-S IT '-m RES Cry'Y v
property all,,builds or improv.thereon,and who does such work himself or through y
his own employees,provided that such improvements are not intended or offered far NEW RES] IA C SQ ET. C LV� .N
sale,ILhowever,the building or improvement is sold within one year of'completion.the SQ--FT�FLOOR AREA gJSQ.FI'.
-builder will have the burden of proving that he did not buil)or improve or
par-
probe ofsale.).
❑1,m owner of ct pmpeny,am exclusively contracting with Tcontmnon m
nsWa
cothe project(Su.0(194.Business and Professions Cw1eO The he Commctors Li.
cense Law
o,1011not apply u,anowner ofpelar( who iro,edds Orimpmvcc Chum,and QTY. PLUMBING PERMIT 17EE
whenseLaet'lirt such projects will ncommcum(s)liwnsed pununntmlhe Conimdmr'x 1.�• LJ.
License Law, PERMIT ISSUANCE l•
❑1 a nits a. .B&P C for this reacnn
Owner ALTER-DRAIN&VENT-WATER(G)
Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 herebyaffhm under penalty u,perjurynucofthnfnBOwiny Worker
Co ,
and will for
rection 37M of Conanto rCod,fortnsuac lin Worker's Ce of the DRAINS-FLOOR,ROOF,AREA,COND.
.wuoham provided for by Section 3]00 of the Labor Code,for the porfommnce of the STORIES TYPE CONSTRUCTION
wok far which this permit is orW. FlXTURES-PER'IRAP
❑1 have and will maintain Worker's ante Of the
Insurance,which required by Satinn
MY WfNelaton Cematior thepedormancer and Polis,mousrat
t his permit is issued. GAS-F.A.SYSTEM-I INC.90UTLETS
My Workers Cnmpanwtinn Insurance carrier and Policy number are: OCC.GROUT' ANN
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEINDUSTRL WASTE INTERCEPTOR
or les.)
(This section rad not he completed if Ne permit is for one hundred dollars(SI WGREASETRAP) BUILDING DIV[ ON FEES
I certify that in the performance ofthe work for which this mit is isued,[,hall NCHECK PER �.
not su to on t PL SEWER-SANITARY-,
suplo, Y person in any nmm�u m as to boson c subject mi the Wrnkers'Comlxm STORM EA.21X)Fit ENERGY PEE
Q z wfmn Lows of Colifomia.Use
Z O Applicata WATER HEATER W E IFUELECTR
-s Z71 GRADING FEE
NOTICE TO APPLICANT:IL alma making this provisions
of of Exemption,you should WATER SYSTEM,TREATING
i� become mbjm m Ne Worker's Compensation provisions of the labor Code,you must
. forhwiN comply withsich Potomac,-orthis.pvra it'bell be deemed revoked. SOUS FEE
WATER SERVICE - -
5z CONST RUCTION LENDING AGENCY NEW RESIDENTIAL PLNB. SQ.FT PAID
UO l hereby affirm that drcre is a construction lending agency for the performance of Dat Receipt I
F' the work for which this permit is issued(Sec.3097.Civ.C.)
U Leaders Name
Lenders Address TOTAL:
Fa I county Nut I have read this application and state that the above information is L BUILDIN
AW
fq correct.I agree to comply with all city and county ordinances and state laws renting n, QTY, MECHANICAL PERMIT
building construction,and hereby immunize representatives ofthis city toenter also.Ne I FEE SEISM[ F .f/1
above-mentioned property(or inspection purpisse,s. PERMIT ISSUANCE V
(We)agree to save,indemnify and kap harmless the City of Cupertino again• ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accme against said City ALTER OR ADD TO MISCH.
In consequence of the granting of this permit. PLUMBING FEE
APPLICANT,UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT('r.Io,odd CPM)
SOURCE REGULATIONS. MECHANICAL FF
AIR HANDLING UNIT(OVER]BOOM CFM)
CONSTRUCT.. AX
Sgnamre nfApphcaHAC Rcmr Dam EXHAUST HOOD(W/DUCp
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITI ATION PEE
Will the applicant or fmure building occupon store Or handle lmrardaus material HEATING UNIT(TO 100,000 BTU)
as def neJ,by the Cupertino Municipal Code.Chapter Y.12,and the Healed and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100.000 BTU)
E]Yes ON.
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant nr[marc building acupanl msec equipment nr devices which Uate Receipt«
mit had6 Yom sir contaminants as defined by Nu Bay Area Air Quultry Managanent BOI I.ER-COMP(3 HE OR 100,000 BT U) -
(aTt
Dishin?x TO L:
❑No BOILER-COMP(OVER 100,000 BTU)
Ldc�s
av the hmzhdnus materials rryuimnteno under Chapter 6.95 ofthe Cali- AIR CONDITIONER
L
Safety Code,Sections 25505,25533 snit 25534.1 understand Nat if the ISSUAN E DATE
t currently haemucoom,that it is my resrymsibility to notify the occupant NEW RESIDENTIAL MRCH. SQ.Pr.
rots which must be nett prior to issuaceofa Ceui feats of Occupancy.nzed.,car Date ( L
ISSUED BY:—�L�/✓
OFFICE