30476 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO, O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PRQIECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. AP PLICATION SUBMITTAL DATI
Com- �-mho l.� �
O ER'S NAME: PHONE:` CONTRACfOR:S NAME: LIC NO:
? M, - (3 Ill
NIC CONTROL
JHITECWHNGINEER: LIC NO ADDRESS: ❑
CONTACT. PHONE: 5� - BUILDING PERMIT INFO
�?A' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
�H 8 ❑ ❑
LICENSED CON'RACTOII;S UI?CLA ATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O0Z wilt Section 90(ho'Division3 ofthe Business and Professions Code and my licemes
x100 y PERMIT ISSUANCE RESIDENTIAL:
�ly in full force and effect. ❑SEDWL ❑KITCHEN REMODEL
QZW License Claa Coro APPLIANCES-RESIDENTIAL [ ADDITION ❑PLUMBING RE-PIPE
VFi Q 6 Date Commcmr
ARCED I ECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F,m PANELS
Z O'/pjZ IunJcmmrd my plans shall he used us puM1lic rcnads MODIFICATION
OZ—� UP TO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
[FHFuI LirenuJ Pndcssilnel 201-1000AMPS IMPROVEMENT
k.Ej OWNER-BUILDER DECLARATION OVER UKEDAMPS / ❑BATH REMODEUREPAIR C1 DEMOLITION
Q 1 hereby affirm that I um exempt from the Contractors Liccme Law for the
yx'3 LL U fallowing ma Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
kl ❑OTHER
which r,mres a permit m eeammo,alter,unprove,demolish,or rcpuit any xoumurc
F.0 prior to its issuance.also requires the applicant for tech permitto file a signed statement SPECIAL CIRCUIT/M ISC.
f�� that he is licensed pursoam to the provisions of the Courtrai License Law(Chapter 9 COMMERCIAL:
to 00 (commencing with Section!(IW)of DivisimnJof the Haziness ane PtofessionsCNe)nr TEMP.METER OR POLI:INST.
d d M C that he is exempt therefrom and the basis for the alleged exemption.Any violation of EW BLDG/ADDITIO,N' Q DEMOLITION
ern Section 1031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES ENANT FOOD SERVICE
t mom than live hundmil dollars($5(10).
E.
1 I'ROVEMENq'
=6 Lathe work,
ltd propeuy,onnycmployded withwned frsalei( ec.compensation, SWIMMING POOLELEGI'RIG
'SFO bill do the coons ands:no Coreis toe's Lienee Law does nal lady to an Business
R�1 maneerty who
Code:The Crnwacome License lawdadsmolapply slfowner of OUTLETS-,SWITCHES-FIXTURES �'Jr•
n 3 progeny who builds or improves Neuron,and who Ares such work deed or or through
his own oweve,the
provide)that such Improvements art not intended m offered for NEW RESIDENTIAL EL[CTR SQ FT.
sale,IChowcvdell have
ildinganimprovement is old withinlon wild or crmpldtfaathe SQ.FE FLOOR AREA 8ISQ.FT.
oaner-louldcr will have the huNen of proving that hd did not M1uiIJ or iinpmve for par-
you of tela). -
❑st as owner of the Sm.70,1 .B euess and Professions with Reins C enntraclars..o In�:
aveconstruct Inc project apply
loan
Business and y who ici CWP:i into Coohzemr's LF SEP
nulawd«srmapprojets.oath aofpropcny wcemeddsorimproves themon,mJ QTY. PLUMBING PERMIT FEE 31916
who dammers for such projects witherontmaor(s)IicenmJ pursoam to The Cnntrucmrs JJ 77�D
License I,aw. PHEMI'1'ISSUANCE
I an,exnnpt under Sec. ,B&ITC for this remon
Owner Dae ALTER-DRAIN&VENT-WATER(MMV L T�N
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE i�
\ I hereby affirm under penalty of perjury one of the following declarations: /� ✓�—
Ihave and will maintain aCertificateofCouxemit)self-imure for Workers Couni DRAINS-FLOOR,ROOF,AREA,COND, STORIES TYPE CONST RUCTION
,oton,as provided lin by Section 3901 of the I,uhor Cale,for line perfrrnance of the
work for which this permit is issued FIXTURES-PER TRAP
1 have and will maintain Wmkers Compenm..ion Insatiate,is required by Section
3100 of use tabor Coda for the do..of the work for which this permit is issued. GAS-FA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
47 Z
My Workers Compensation Insurance commerical Policy number are:
Comes Pnl icy No.: GAS-ITA.SYSTEM OVER 4(FA)
CERTIFICAi'IT Op EXEMPTION FROM WORKERS'
COMPI?NSATION INSURANCE GREAMU NDUS'1'RL WASTE INT ERCHVI'OR
BUILDING DIVISION IRifs
(This union need nm be compleed if the point is for one hunJrrd dollars ISI WI GREASETRAP or less.) PLANCIfECK
I certify Nat in the performance of d¢work for which this permit is toward.l shall
not employ any period in an to become the Wmkets'Cotn SOWER-SANITARY-SNRM EA.200 FT. ENERGY ITEE
yna nmmaa pen-
OZ sation Laws of California.Dam an WATER I WATER WHEN VELF.CTR
Z O Applicant GRADING FEE -
y NOTICE H)APPLICANT 11,after making this Cenilicatc of I?xcmplion,you should WATER SYSTEM/TREATING
become subject to the Workers Compensation Provisions of the Leon CWP.you mus.. SOILS FEE
Wforthwith comply with such previsions or this permit shall be deemed revoked. WATER SERVICE
ai
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. PAID
Z) Z I hereby affirm that there is a conswuction lending agency for the performance of Data Recdipek
{U& Othe work for which This permit is issued(Sed.300.Civ.C,)
toners Name
�a Landers Address TOTAL BUILDING FEE
certify rtify that I have read N
this application and state at else above information is
Er CO) correct,l agree to comply with all city and enemy ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z building concoction,and hereby authorize represcmntives of this city to enter upon the SEISMICFBE 12,LtLA�
Lt
above-mcmioncd property for inspection pupwse" PERMU'ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino again ELECTRIC FEE
Iiabildiesjidgmems.costs and expenses whid may in any way accrue againstsaid City ALTERORADDTOMECIL
inconsequence of the gaming of this R PLUMBING FEE
APPI DERSTAN ND ,C 1 LY WITH ALL NON-POR{T AIR HANDLING UNIT(TO 10.IXp CFM)
MECHANICAL FEE
SOU El I�,ATION\S.
V �L \ AIR HANDLING UNIT(OVER IO.OfN)CPM) CONSTItUC ION TAX
Signature of ApplicanlContmctor [`T/�a am EXHAUST HOOP UVIDUCT) HOUSING MITIGATION MEHAZARDOUS MATERI LS )ISCLOSURE
Will the applicant or future building oscupmnstom orhandlc hazardous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupcnino Municipal Code,Chapter 9.12,and the health and Safety
Code,Semon 25532(x)'/ _I� HEATING UNIT 1Ig1,dW BTU)
❑Yes ANn PAID
VENTILATION FAN(SINGLI?RFiSIDI Date Receipt#
Will the applicant or fwmm building by ths,Bd yu cqui it Qua or devices which BOILER-COMP UHP OR 100.000 BTU)
nY:hnzaNlus air commitments as Defined by Ilse Bay Area Air Quality Management TOTAL:
Domini? BOILER-COMP(OVER 100.000 BTU)
❑Yes No
(have read the hazaNnus materialQ01 . ms under Chapter 6r95 of the Cali AIR CONDITIONER ISSUANCE DATE,
fomi 1 ,amty Cak,Sections 25and 25514.1 undersand that if the NEW RESIDENIAL MECH. SQ.FT.
buil in9 utrendy ere tenant rcponsibiln,m notify Ne l¢vpun..10th ¢whic nvt rte nk sofa Cenifica f(
Ow um aonzed agcm I y IFUafe TOTAL: ISSUED HY,
OFFICE