30994 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CCPERT]NO`. q BUILDING-ELECTRICAL. - •PERMITNO. 30994 O ^^ q
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. 3 VV 944
BUILDING PROJECT IDENTIFICATION
ILDING ADDRESS: t +, - - SANITARY NO; APPLICATION SUBMITTAL DATE
�'1Nv52ERISry1(o,-:Loviv�a� Laine G �pa �;F,a GA .gS014-
v I W1 A r�W,TG( �I[/H Z PZ Nt0�J Z•+ f�'�.RpC7,OR'S ME N V-110 I N/C.. CONTROL#
CONTACT.
CTIENGINEER: - LIC NO: Ott
t � � ❑ �.��
CONTACT.. - ,:PHONE: IlA40 TD-U4.30 BUILDING PERMIT INFO
4
Sable dIS 2.8 286o
d4l ❑ Consultant Fees Paid by A PP
Been[ nitiel OG ELECT PJL�UOyMfB�. MECH
LICENSED CONTRACTOR S DECLARATIONI,
I hereby affirm that Tom licensed under provisions of Chapte9(commencing QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
WOp with Section)000)aFDh3.f ife Business an Pmmssmn. a dmylicense ie PERMIT ISSUANCE RESIDENTIAL' .
F full force and effect.
�UV License Class Lic.# ❑SFDWL - ❑KITCHEN REMODEL
APPLIANCES-RESIDENTIAL
Dam Lic.If ter ' DITION El PLUMBING RE-PIPE
FDh ARCHITECT'S DECLARATION PANELS - MULTI-UNIT, r El STRUCTURAL
Z O a I understand my plans shall be usetl as public records . MODIFICATION '
OZ C UPT02MAMPS - ❑INTERIOR C1 CHIMNEY REPAIR
Licensed Professional - 20MOT00AMPS IMPROVEMENT
�./7 OWNER-BUILDER DE CLARATION OVER IWO AMPS' ❑BATH REMODEUREPAIR El DEMOLITION
■ I hereby.(Sectfifind the I am exempt Trani the C shoos o License Law for the
a a F following reason:(Samoa)onL5.Business and Professions Code:Any city or comfy SIGNS ELECTRICAL []OTHER[• which its issuance,
permit t n wet Iter, p demolish,lish or repair any Sween
ti Coon its also requires the Cpl' tf such permnt file a signed statement SPECIAL CIRCUIT/MISC.
[[[•pppp---� 7+
That he Itce:dPursuant t thepow of the C teacmrsL L' (Chapter 9
p0 (commencing with Section)WB) fDivision' 3 of the Bmadness andProf Code)or - TEMP.METER OR POLE INST. CQMMERCIAL,
tL a that he is exempt thomfinion and the basis t. for the al leged'exempe n Any violation of
Secti n'l03 L56 [I NEW BLDG/ADDITION - ❑DEMOLITION ,
y hundre dollars
the appli - nauavil penalty of POWER DEVICES ❑TENANT . (]FOODSERVICE
(,,,'ZZ•vN. not mare Nan loft huproperty,ndred or y Soo). IMPROVEMENT
G ❑Lo the work,
the estractur myemployees with wages xatheir(Sec.compensation, SWIMMING FOOL ELECTRIC -
willdothework,andr:no o isnot intended oreTala.arted l apply o acts came, ❑OTHER
L and Pmfessiuns Code:Tho.Conwetors License Law does not apply m an owner of OUTLETS-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 - SQFF
Fs
sale.If,however.the building or improvements Sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.FT. -
owner-builder will have the burden of proving that he did no,build or improve for Err- ,�� O '
pose of sale.). -
❑,L as owner of the Property,.m exclusively contracting with licensed contractors to �� a L
concoct the project(Sec.]044,Business and Professions Cade:)The Commctors Li- !'
aseLaw does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE '
who coarsen,for such projects with a comrecmr(s)Iicersed pmua d to the Connector's ,
` License Law. •. PERMIT ISSUANCE -
❑ model B&P C for this meson
OwnerData -
ALTER'-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE A' O
Ie byaffrm ander Certifyaf perj n fsom to a following arkers o _1 _
lh andwillforbinain37Certificate of The Labor Code.same
Workersce of the
DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
work f as provided for mi Section 3)00 of The Labor Codc,for the performance of the
_ work for which This anataiis issued. FIXTURES-PER TRAP '
❑I have and will maintain Worker's Compensation of
e Insurance,h required by Section -
My Wothe L.bmCode,for nthe InsuertormarccoRd Policy
for which this permit is issued, GAS-EA.SYSTEM-]INC.40UTLETS "' OCC ORO - APN
C. Workaia Compensation lnsarnnce carrier and Policy number ore:
Ceriee% Policy Na: GAS-EA.SYSTEM-OVER4(F,A) „
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR -
(Thismitlon need not he<bmploed ifthepermit is for one hundred dollars 1$100)
- IVISION PEES
or less.) GREASETRAP ' •,, -
PLANCHECK L
I certify that in the performance of the work for which this permit is Issued,Ishall cbl
SEWER-SANITARY-STORM EA. FT. -
not employ any person in any manner so as to become subject to N .
The Workers Comper- ENERGY
Z sation Laws of California.Date
O -- r FQL
WATER HEATER WNENT/ELECTR
O Applicant GRADING E
N NOTICE TO APPLICANT:11 after making this Certificate of Exemption,you should WATER SYSTEM/TREATING '
become subject to the Worker's Compensation provisions of The Labor Code,you must SOILS FEE '
forthwith comply with sudh provisions or this permitshall bedecmedrevoked., WATERSERVICE "
�L Q
CONSTRUCTION LENDINGAGENCY .. NEW RESIDENTIAL PLMB. SQ.FT. PAID
U Ihereby affirm that there is a construction lending agency for the performance of Date
LL F the work for which this permit is issued(Sec.3197,Cie.C) '
O U Lenders Name
TOTAL:
u] Lmamea Aadmas
Iy 1 certify that I have read thirty and court and stain that The above wsrmtamn is BUILDING PEE
r.t to bonen.I agree to comply with all city and county ordinances and smote laws relating he QTY. MECHANICAL PERMIT -FEE
U z ishooergcorshuction,pard hereby auction representative,of this cirymenter upon the SEISMIC PEE
rr above-mentioned property for inspection purposes. -
(We)agree m save,indemnify end keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
Iiabilhie,,judgrhents.casts and expen.which may in any way arcane ugairea,md City ALTER ORADDTO MECH. ,a
1 in consequence of the granting of this permit. PS.UMBINGF
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ''' AIR HANDLING UNIT 10,000 CFM) MECHANICA
ss SO tCE REGULATIONS: L
` 'AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCT IONTAX
Signature ol'AplicanUContractor Date EXHAUST HOOD(W/DUCT) ! HOUSING MITIGATIO FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Caperton Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)1 t HEATING UNIT(OVER I00,OW BTU)
❑Yes ❑No -
VENTILATIONPAN(SINGLERESID) PAID
Dem Receipt
kt- lual the applicant or future building occupancy A equipment or device.which BOILER-COMP CHIP OR 100,000 BTU)
#hazardous air contaminants as defined by the Bay Area Air Quality Management TOT
District,
❑Yes " QNo - BOILER-COME(OVER I00,OWBTU)
I hove read the hazardous materials ref iremems under Chapter 6.95 of the Cali. AIR CONDITIONER - I$ U CE AT
forma Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH: SQ.FT
building does not currently base.tenenp that it is my responsibility to notify the eccupunt - "
oftherequirmmtswhlch most be met priormissuence of.Cmifcma ofOceup.ncy.
r
Owner m imam ctl agent- - Date _ TO ISSUED BY:
OFFICE