30414 (2) a APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY
L
TY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO u q
4
BUILDING DIVISION APPLICATION/PERMIT ''PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 30414
O /141 /{
1
ILDING ADDRESS: 'SANITARY NO. APPLICATION SUBMITTAL DATE
iJ L—
NER'S NAME PHONE: CONTRACTORSNAMC: LIC NO:
r ` ^ , nT ST CO NIC CONTROL M
RCHITECDENGINCER: LIC NO: DRESS: ❑
8 l .oleo Lw
CONTACT: PHONE. - BUILDING PERMIT INFO
❑ Consultant Fees Pald by Applicant(Initial) BL ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEF?
1 hereby affirm that I..licatsed under provisions of Chapter 9(commencing AL' DESCRIPTION
a2 with Salto.?it aff Division3 of the Rosiness end Professions Code.end my license is RESIDENTIAL
�� ' fall Cleand effort. qq PERMRISSUANCE
License Class' Lic.N 67/13 T 8 OSFDWL 0 KITCHEN REMODEL
�6-u1 Dara Canttacm of led-r4gY APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
m
to ARCHITECTSDECLARATION
F'JPANELS ❑MULTI-UNIT ❑STRUCTURAL
2l)!/}2 IunderstnnJ my plane shell be used as public records .' MODIFICATIONO2 C UPT020f AMPS
1-131"' nue Professional ❑INTERIOR ❑CHIMNEY REPAIR
201-Iraq AMPS IMPROVEMENT
OWNEm exempt from
the RATION
yy I hereby aBlrm that 1 am exempt from the Contractor's License Law for the OVER IIMNIAMPS [:)BATH REMOUEUREPAIR DEMOLITI/�N A
'a!3SFU- followingreuan.(Section 0031.5,Business and Professions CWa Any cityorcounty SIGNS F.LF.CTRICAL 0OTHER �1 /-
Ya1l LL O which regattas a permit to cnmtruct,elteq improve,demaliilr,err repair any swewm QG
prior o its issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUIT/MISC.
y that he is licensed pummom to the p...ni.m.fthe Contmmora lime Law(Chapter 9
CC (commencing with Section?")of Division 3 ofihe Business and Professions Code)., � TEMP.METER OR POLE INST. COMMERCIAL
d y M C that he is exempt therefrom and the taxi,for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4%1 ay SectionT031,1byanyopplicant forapemut mbjeas Neopplicam toacivil penahyof POWER DEVICES ❑TENANT ❑FOOD SERVICE
} not mare than five hsndred dolears(55(10). IMPROVEMENT
C01,us owner of the pmpeny,or my employees with wagesns their side compensation, SWIMMING POOL ELECTRIC
will do the work,and twmte
he sure is not innded maff red fm sale(Sec.7044,Business ❑OTHER
and Professions Code:The Convertor's License Law does not apply to an owner of OUTLET'S-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT, -
aide.If,however.the building or improJemem is sold within ancycarofeimietti.n,the SQ.FT.FLOOR AREA S/SQ.FT.
owner-builder will have the burden of proving but he did not build or improve for pur-
copar0 1.a sowne TOTAL: 2 2 1996
Las owner of the property.,War B exclusively Prmmmins with licensed contractors i- AU G
consumer the project(Sec.?044,Business and Professions CswlcO'fhe Contractor's Li-
ranks Law does not apply mall owner ofProperty who buiedsori..proves.ler on,and QrV PLUMBING PERMIT F
who ermaacts for such projects with a contmctimo licensed pursuant to the Contmetors
Lean.Law. mal ( yj UU�Cft111Y
PERMIT ISSUANCE
0 1 em exempt under Sec. ,D&P C for this reason y'
Owner - Dote ALTER-DRAIN&VENT-WATER(EA) VALUATION_
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
I hereby alfimr under pendty of pe jury ane of Ne following declarations:
I have will and.r.na Certificate.(C.ramt1.self-insure for Warkera Creat®r DRAINS-FLOOR.ROOF AREA,COND. STORIES TYPE CONSTRUCTION
section, reviled for by Section 37W of the Labor CWa,for the performance of the
wor hichlhispermitisissued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as requited by Section
37M of the labor Code.for the performance of the work for which this peorm,is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Cc ion Inasmnce 'cr ectal Policy nutel
/ Carrier: /ti r2/n/♦� Policy No.:
GAS-EA SYST[M-OVER4(EA)
f/ CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREAS tVINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION MES('This sectioneardnot becompleted ifthe permit is Were hundred do[]..(SI00) GREASE TRAP
or leak.) PLANCHECK FEE
I.y...patin the anyaPerformunceaf thefir...imak for hjeet It,the W i le".Ossued,Isha11 SEWER-SANITA BY-STORM EA.200 FT.
I nm entpiny any partum in nny manner so arta hecnme subjca nr the WnrkcrC Camper- ENERGY FEF.
Z sation laws of Caeifomia.Date
WATER HEATER WNEM/ELECIR
Q Applicata GRADING FEE
y NOTICE TO APPLICANT:If,after making this Cenifcate of Exemption,you should WATER SYSTEMRREATING
hI� become subject to the Workerp
Workers Compe...Ead mvistm s of the Labor Cade,you most SOILS TEE
Wlis' Forthwith comply with such provisions,this permit shall be de.ntedrevoked, WATER SERVICE
Q 7z - CONSTRUCTION LENDING AGENCY NEW RfS1DENTIAL PLMB. SQ.IT PAID
V0 I handay.fifirsowhich
there issued(Secti0ro,Clending agency for N<perfnrmanceof Date Raeipta
W Fi Newark Ler which this permit is issued(Sec.31N],Civ.CJ
QLenders Name TOTAL:
WLender s Addrem - TOTAL: /
fy 1 artily that 1 have teed misapplication and stat.Not the about information is BUILDING FEE
cA comet.I agree in comply wit all city and county ordinances and state laws minting in QTY. MECHANICAL PERMIT FEE
U' building construction.and hereby authorise representatives ofthis city to enter upon the SEISMIC FEE
• above-mentioned property for inspection purpmcs. PERMITISSUANCE ELECTRIC FEE
(We)agree m save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs endeapa. a which may ma
y in any way receguast said City ALTER OR ADD TO MECH. PLUMBING ME
in comes urns, of coating of this permit.
APP[ DE T L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SD IC 'GUI S.
AIR HANDLING UNIT(OVER IQ00(l CFM) - CONSTRUCTION TAX
of ApplicanVContmcmr Date EXHAUST HOOD(W/DUCD
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will theapplicant or future hadding oecupum stare or handle hazadousmatedal HEATING UNIT(TO Ilk,"BTU) '
defined by the Caperton Municipal Code,Chapter 9.12,and be Health rad Safety
Cade,Section 25532(0)? HEATING UNIT(OVER 100.000 BTU) ��^
O Yea ON.
- VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Data _ Receipt H
mit heiardous air contaminants err defined by the Bay Are.Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
.strict? TOTAL:
EYes [D No BOILER-COMP(OVER,IWAW BTU)
have read the hasona nus materials requirements under Chapter 6.95 of the Calf- AIR CONDITIONER - ISSUANCE DATE
fonds Health&Safety Code,Sectors 25505,M533 end 25534,1 understood that if the NEW RFSIDENTIAI.MECH. SQ.FT.
building does not currently have a tenant.that it is my nopmsibility to notify The occupant
of the requirements which must be met in,to issuance of a Cenifcare of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE