30594 (2) APPLICANT TO'FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUH,DING-El'ECTRICAL PERM]T NO. 3 0 5 9 4
Bt
DIVISION APPLICATIONAPERMIT PLUMBING MECHANICAL.
ILIlILO1NC PROJECT IUt:YTIt'ICA'1'ION'
BUILDINGADDRESS: ( SANITARYNO. APPLICATION SUBMITTAL DATE
lo156 Mfk�'buN Lrl
OWNE NAM2:_Cad ^�n HO B:^^ CONT CTO
CNAM NO: BIC CONT ROLN
RCHITEDENGINEER: f7 aG LIC NfO:VV ADD ' S vl-5 �1 u/ ❑
CONTACT: PHONE: / / BUILDING PERMIT INFO
�Ifl 1/�� /'� ��C/ � ❑ Consultant Fees Paid by Applicant(Initial) NLUG ELECT PLUMB MECH
Y Y / ❑ fi4� ❑ ❑
LICENSED CON'TRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FETE
1 hereby affirm tha I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OW Y with Sectlon70001nfDivision J.nnc e.xmexs and rofdxxb,mcoda amd my licrnsen RESIDENTIAL:
W 00 PERMIT ISSUANCE
F+Ul- infull and effecrG /O ��/�� ❑SFDWL ❑KITCHEN REMODEL,
Pzz QUU Licrnu Clan Liceden APPLIANCES-RCSIDIN IAL ❑AUDITION ❑PLUMBING RV.PIPH
e ^� /" l�l'k inn DECLARA 1 N PANELS ❑MULT6UNIT C3 STRUCTURAL
Z O m Z semneks tlutn sb 1 he uxcJ as public records MODIFICATION
UI'T021XIAM1'S
OZ�`n ❑INTERIOR ❑CHIMNIiY REPAIR
F4FW Li eased Prof.M 2M-1(Xk)AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER I(XIOAMPS ❑BATH REMODEUREPAIR ❑DEMOL'1'ION
E C m 6 I hereby from that 1 an exempt from rhe Comment's License Law for the .
x606V folio .(Section)011.5.Busire,sand Professions Cedc:Any city.,county SIGNS ELECTRICAL -1 OTHER YE a_�
la a W N which¢tattoo a permit ,,nmvoct,alter.improve,demolish,or repair any structure
F.Ory Y� prinmoia issuances atm rryuires the epPlicam for such permiuollea signM sm¢ment SPECIAL CIRCUIT/MISC.
E� that he is licensed pursuant to the provix;onset the Contractor's Lieenm Law(Chapter 1)
Iyp0 (commencing with Section]0(XBnfDivisiunJofthe Brearessard Pmfessiam CMgo, TEMP.METER OR POLE INST COMMERCIAL,
a 11 c that he is exempt therefrom and the bast,,for rhe alleged exemption.Any Arlalmo of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^, Section 7031.5 by any applicant for a permit subjens the applicant to a civil penalty of POWER DEVICESVIZ FNANT ❑FODD SERVICE
non more then five hundred Dollars(b5fgp.
I..Z> IMPROVEMENT
=Q I,as owner of the pmpeny.mmy empinymx with wages as their sole enmpemsation, SWIMMING POOL ELECTRIC
wt. will do the work.and the structure is not intended mothered for sale(Sec.IIW.Business ❑ THER
Wm and Pudessiuns Cale:The Contractors License Law does not apply m an owner of OUTLEI;S-SWITCHES-FIXTURES
a 3 property who builds or improves Iberenn,and who Jens such work hire ch or though
his own employees,provided tha such imp r..career,am not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
.]a.If.however the building or improvement is sold within one year ofconipletion,the SQ.FT'FLOOR AREA SISQ.FT.
owneT-builder will have the burden of proving that hedid not build orimprove forpar-
Isneof saleJ.
E]onaacrt
1,as owner of the property,am exclusively contracting with licensed contractor,to QCa�
uhe p jJ(IMand uacm
ect(See 70,14.Business Professions Cede:j The C.nrSEP
's Id- '(996
rOme .aw does.rn apply n,;m.wne,ofpropeny who huilds or impose,lhercon,and QTY, PLUMBING PERMIT FEE s7s7
who contracts for such pmjws with a<nntmnor(s)licensed pursuant to the Contractor's
License law. PERMIT ISSUANCE
❑1 am exempl anter Sec. .B&P C fur this reasiaa
Owner Uale ALTER-DRAIN&VENT-WATER(EA) VALUATION
WOR KER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 ha mby affirm under penalty ofperjury one.f the following Jedaradons
❑ Ibuve unJ will mainminu Cenil irate of Consenno sclGinsure for Worker's Compere- DRAINS-FLOOR,ROOF AREA,GOND. STORIES TYPE CONSTRUCTION
scion,as provided for by Section 37M of the Labor Code,for the pie fmmzace of the
work for which this permit is issued. FIXTURES-PER THAI'
❑1 have and will maintain Workers Compensation Insurance,as required by Section
37W of the Lser Code.for the peifnnm.arrof Ne..,it for whichthis permit Ls issued GAS-E:A.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers yy��ernt��tion Insurance nsue came,sad Policy number an:
Cartier: �I9-C/ Policy No: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASFIINUUSTRf.WASTF.INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
('pd,section need not be enameled if the permit is for one hundred dollars H IW) GREASETRAP
or less.) PLANCHECK FEE
Icenif diad in thepeRonnuneeofthe..,it forwhichthispe,mit Nismed.lshall SEWER-SANITARY-STORM F.A.200 FT.
not employ any person in any manner ser as In become mhjed m the Worker,'Compere- ENERGY FEE
Zsan i Law"of California.(late WATER HEATER W/VENTMLECTR
O GRADING FEE
2 Applicant
pl NOTICE bj APPLICANT:IL atter making this provisions
o of Exemption,you should WATER SYSTEM?BEATING
abecome stbject y the Worker's re Compensation provisions of the talon Cede,you moa SOILS IIiC
� forthwith armply with such provisions nr this permit shat be Deemed evoked WATER SERVICE
Q
Uz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.FT PAID Date Recc t a
C) p Ihemby vffirm mmthere isac.nstrvaion lending agency 6rthe performance of
Pthe work for which this permit is issued)Sec.3097.Civ.C 1
Lambe,Name TAI"
IDL( Lenders Address TOTAL:
1 certify that 1 have read this application and state that the above information is BUILDING Phis
is
Hcorrect.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V building construction,and hereby authorize mpresenutives of mix city to enter upon the SEISMIC P,
above-mentioned property for inspeninn putunex PERM I'1'ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC :E
liabilities,judgments.costs and expenses which may in any way accrue agai rest said City ALTER OR ADD TO MECH. PLUMBING FEE
in cnnscqucnce of ing.f thi'F`permit.
APP .AN DERSTA DS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON]I(TO 10.(M CI'M)
MECHANICAL 'Eli
SOUR N
23 / AIR HANDLING UNIT(OVER 10,000 CFM) CONSTHU ION TAX
ignatureofA IwnttDarterator ✓ Date EXHAUST HOOD(W/DUCT} HOUSIN ITIGATION FEIi
HAZARDOUS MATERIALS DISCLOSURE
t eapplicant or France building occupant store or handle haralloas material HEATING ON]'I'(TO 100.000 BIU)
ax defined by the Cupertino Municipal Code.Chapter 212,and the Health and Safety
Cede,Section 25532mP 14EATING UNIT(OVER 100.000 BTID
E]Yes QN. VENTILATION FAN(SINGLE RESIDI PAID
Date R<
Will me u Bam m efar..buildingt use aimtont n,devices which
emit hazardous avcontaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3H1'OR IOO,IIW(ITU) To L:
District? / BOILER-COMP(OVER I W."BTU)
❑Yes
AIR CONDITIONER Lve
I have mad the naaardoa 6.95 that
calm ISSUA EUATE
forma Health&Safety e.SecVii�255U5.2SSJJ unJ 25534.I understand Ihnt if the NEW RESIIILN'TIAI.MECH. SQ.PT.
buildmgJcesnmQQnn t lyhave atetr 6lha it is my re,wasiailoyto reify the occupant
of the mluirem do, I as,b I prior to issuance ofaC�i'le O%EP my.
Ownermau rized,gen ate TUl'AU ISSUED BY: V
OFFICE