30428 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY /p� ^/
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O O T L H
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, J
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
2- 9 A N , s r ,q G
OWNER'S NAME: PHONE: C RA /Q-R('S NAME: LICQNO:C
MCA r CR / JIAI NIC CONTROL
C AH HITECBINGINEER: LIC NO: ADDRESS
C M2 t.0 66 5. NA,,2
CONTACC ,�(( Q PHONE: ,' ,a BUILDING PERMIT INFO
4 0B — -7 6� (�O O 5Q Consultant Fees Paid by Applicant(Initial) _�[1. /,/(— BLDG ELECT PLUMB MECH
I`'� aCf q NS NTR � .gyp
LICENSED CONTRACTOR under S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby antro that I am licensed under Provisions of chapter 9 Rommenung JOB DESCRIPTION
MQZ with Section]IHNBof Division 3.1 he Business and Profession,Crde.aad my license s
FSB in full force and effect. PERMIT ISSUANCE RESIDENTIAL
aUU License Class L;c.if ❑SFDWL KITCHEN REMODEL
-ZW Dam Cmdrznor APPLIANCES-RESIDENTIAL [/ADDITION ❑PLUMBINGR6PIPE
Z pr/=/Z IunJeeaand mypl nRRCH]HCTS DECLARATION PANELS ❑MULT6UNIT ❑STRUCTURAL
shall be, as pub MODIFICATION
024—- UP TO 2q1 AMPS
l-.'n..F.W Licensed Professional INTERIOR ❑GHLMNIiY REPAIR
OWNER-BUILDER DECLARATION 201-IINq AM11PS IMPROVEMENT
Q - 1 hereby affirm that 1 am exempt from the Core...hr's Liccnsc Low fiat de, OVER 1030AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
Via$0 c.U following reason.(Session 703 I.S.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3
W'- which requires a permit to construct,alter,improve,demolish,or repair any swcwrc
�; fine to issu:mcc,also reyuirc.c the applicant for such permit to Rleasigned smtemem SPECIALCIRCUITMISC,
f y that he is licensed Forward native provision,ofdw Contrarian',License Law(Chapmr9
W.00 femnmencing with Station 70((Bof Division 3ofthe Ru.cimssand Pmfic,dms Code)nr TEMP,METER OR POLE DIST. COMMERCIAL'
a y m y that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DE,MOLITION
YX7 1ay Section 7031.5 by any applicant for a pcmtil subjects[he applicant to a civil penalty of POWER DEVICES
t more than five hundred dollars P$500)
❑TENANT ❑FOODSERVICE
?QC11,as owner of the progeny,or my employces with wage ax their sole com,ecmion, SWIMMING POOL ELECTRIC IMPROVEMENT
will Jo the werk,and the structure is not intended oroffered far sale(Sec 7044,Business ❑OTH17R
3 m and Pmfcsvionc Gdc:The Com......Llecnm Law docs ma apply in an owner of OUTLETS-SWITCHES-FIXTURES
progeny who build,or improves themun,.nd who docs such work hiinsOf Of...through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECIR SQ FT
sale If.however the building or improvement is sold within one yearn(completion,theFT FLOOR AREA $/SQ,W.
owner-builder will have the burden of proving that he did not build or improve for put. .
pose of n).
[:] o
I,as owner of the progeny,am exclusively contracting with licensed tanorsm
mwa
c s
et the project(Sec.]IW4,Business and Professinna CoJeq The Comactor's Li-
verve
i-c se law does not apply to an owner ofprogeny whobuildruriteprovecthereon.and QTY, PLUMBING PERMIT FEE
who contacts for such projects with a=ontraseembf licensed pursuant to the Contractor's JILL/// VVV V�
Liceoa Law.
I am exempt under Sec. ,B&P C for this reason PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATER(EA)
Owner Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK MOW PROTECT.DEVICE
I hereby aRno under penalty of perjury one of the following declarations: \ 1 1
❑Ihave amt.will mainminaCenifea,of Consent m.cdf-insure for Workers Compen- DRAINS-FLOOR,ROOF.AREA,CON I. l
cation,as provided for by Section 37M of the Labor Code,for the performance of the STORMS TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
n 1 have and will moinmin Worker's Compensation asamenee,as required by Section
37M of the Labor Cnde,to,heperfnummo=of the work for which this permit is issued, GAS-HA.SYS'GEM-I INC.4 OUTLETS DEC.GROUP-
My Worker's Compensation Insurance carrier and Policy number are: APN
Carter Policy No: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
(This section rrceJnm he completed ifthe permit is forma,hundred dollars 151(0) _ BUILDING DIVISION FEES
or less.) GREASETRAP PLANCHECK FEE �w
Toy any patinthc any
mf the work for subject
This the no Wisiss'Coinpr- SEWER-SANITARY-STORM EA.210 FT.r
not employ any Califon is any manner m as m become suhjen ro the Workers'Compen- O
,z cation Laws of California.Dale ENERGYFEE
O Applicata WATER HEATER WIVENT/ELECTH
z y NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you ahold GRADING FEE
a � become subject to the Worker's Compensation p WATERSYSTEM/I'HEATING
1 j, provi alas be,
Labor Cuda,you tend SOUS FEE
forthwith comply with such Crmvisimns or this Craton shall be deemW revoked.
UJ
Q WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ FT. PAID
L) O l hereby affirm that there is a construction lending agency forthe perfmmuncc of Dam Receipt#
W r the work tin which this permit is issued(Sec.3097,Civ.C.)
U Lenders Namc tt)TAL:
Unde's Address
Fy 1 certify Nat 1 have real this application and state that the above information is BUILDIN
to correct.l agree to comply with all city and county mahnances and sato laws relating to QTy, MECHANICAL PERMIT' FEE
V z nuildie,constriction.and hereby authorize represenmicv,of this city be enter jam the SEISM 1 .
above-mentioned progeny for inspecaaa pu'ser'. PERMIT ISSUANCE 4
(We)agree to save,indemnify and keep harmless the City mf Cupcnim against ELECTRIC FE
Iiehilitics.judgments,costs and expemee which may in any way accrue against said City ALTER OR ADD TO MECH.in consequence of the sorting of this permit. PLUMBINGI E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 10,0110 CENT
SOURCE REGULATIONS, MF,CHANIC LRE
AIR HANDLING UNIT(OVER 1),000CFM) CONSTRU
SignatumofAMficanlomammr Dote EXHAUSI'HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION
Will the applicant or future building rpcupam store or handle boarders material HEATING UNIT(TO 100,100 BTU)
as de0nd by the Cupcnim Municipal Code.Cmifer,9 12,and the Health and Safer,
Code.Section 25532bq? HEATING UNIT(OVER IOQWO BTU)
❑Ycs [3 No
Will he apt at termoutlining aemtetdevicesVENTILATION FAN(SINGLE RESID) PAID
-11 Date Receipt
is mit hazadous air contaminants as refined by the BayArea Air Quality Management
BOILER-COMP(3HP OR lIO,OW BTU)
District?
❑Yes ❑No BOILER-COMP(OVER 100,000 BTU) TOTAL:
1 have rod the hvnNous materials requimmcnts under Chapter 6.95 of the Cali- AIR CONDITIONER
Lamin Health&Safety Crile,Sections 25505.25533 and 25534.I understand that if the ISSUANCE DATE
buildingdoes not currently have.tenant that it ismyresponsibihtyr,notify theuccupant NEWRESIDENTIALMECIL SQ.Fn
of the requirements which mot he met gdot to iaauuna of a Comileate of O,,uDany.
Owner araathorncd agent Date T 'A
is ISSUED BY:
OFFICE