30515 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 30515 O ^ l
5.1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
IINLIHNG PROJECT'[DEN'FIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICAIION SUBMITTAL DATE
v cs r [6
OWNER'S NAME: PHOlst ]NTRACroR'S NAME. '"1 LIC NO:
W
Ll/ t SrP"./ N/C CONTROL
\RCHITEC'I7ENGINF.ER: LIC NO: ADDRESS ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) I+LDG EIELT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
J hereby aninn[list I am licensed ander provl itar,of Chirpier 9(commencing JOB DESCRIPTION
G00 with Station)o00)of Division 3.f,he Rmitur—rd Professions Code.and my liccow,i RESIUENTIAL:
ca,p _ PERMIT ISSUANCE.
FIy full forcnmJ el I. L ❑SFDWL ❑KITCf1EN REMODEL
2 U License C as: s— 4 #commerce I a S - L G L
Q V APPLIANCES-RESIDENTIAL - ❑ADDITION ❑PLUMBING RE-PIPE
F Q W0. Datc t V
NF=y nRCHII'IiCI\S DEC].UEARAIION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z p m Z 1 understand my plans shall be used as public records MODIFICATION
OZ=i.Q UPI'02MAMPS ❑INTERIOR IMNEY RI?PAIR
[ �_w Licensed Professional 201.1000AMPS IMPROVEMENT'
.2+2 thereby affirm thwN um BCxcmp C, OVER IbX)AMPS ❑PAT'11 REMODEUREPAI ❑DI?MOLITION
Sc R DECLARATION
treat tire Contractor's License Law ror IM1e
y°x('paU following neawn.(Section 703 L5.Business and Professlum Cure:Any city or ceu.ry SIGNS ELECfRICA X ❑OTHER
LY 3 LL y which requires a permit to consumer,aIle,improve,demolish or repair any structure
prions itsissuance.alar requires the applicant for such permit o file a vignedswtemem SPECIAL CIRCUIT IS .
f(!{} that he is licensed pursu an to the pro rmons ofthe Convectors license Law(Chapter 9
¢W 00 (commencing with Section 70nq of Division 3 villa,Bovine+and Professions Core)nr TEMP.METER( POLECOMMERCIAL:
L 6 Ole that he is exempt therefrom and the basis for the alleged exemption.Any violation of - ❑NEW BLDG/ADDITION [I DEMOLITION
�m Section 9031.5 by any applicant for a permit subjects the applicant m a civil penahy of POWER DEVICES ❑TENANT ❑FOOD SERVICE
FZpma more than five hundred dollars(S5010. IMPROVEMENT
❑ 1 ns owner of the pmpenY•or my employ«s with wegcx av their sole compcnsa0on, SWIMMING POOL ELECTRIC
will do he work,and the...ncwre isnot amended ondfernl for sale(See.70,00,Business IQ
IQ w and Pmfe%siom Code:The Contractor's License law does nor apply to an'owner of OUT LEAS-SW HC FI" RES
property who builds or improves thereon,and who docs wcM1 work him%elf or IhrougM1
his own employees,provided Thal such impmvenemv are not intended or offered for NEW RESIDENTIAL ELF, R S
sale.If,however,the building or improvement is sold within one yearofmmphrion,the SQ.FT.FLOOR AREA S/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pun ,
pree m sure).
❑ L,as owner of IM1e properly,am exclusively contracting with licensed commemrs to L:
onerum the protect(Seo 9044,Business uad Pnal'esvinrvs Come,"rhe Convector's I t-
nme law Joe.,not apply r.im .are of propen,who builds we outdo..therms,and QTY. PLUMBING PERMIT FEE EP 16 1996
who a ithis s for such projects with,cormars fs)licensed pursuant o rhe Commnor'.s
License Law. PERMIT ISSUANCE
❑I am exeunder S . .B&P C for this reason -corralscorralsm
In t-,tl L,. l
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARAI'I ON BACK FLOW PROTECT.DEVICE
I hereby alEnn under penalty of perjury one of the Billowing declarations:
❑I have and will maintain a Certificate of Consents f-insum for Workers Compen- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
sation,as pros lded for by Section 3900 of Ibe Labor Calc,for the performance of the
work far which this permit is issued. FIXTURES-PER'TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of the labor Code,for the performance of the work for which this permit tv issued. GAS-EA.SYSTEM-I INC.4011TLETS OCC.GROUP APN
My Workers Comypee anon k, ace carn
✓k 1arier and Policy m rh
Carrier: S'TRy's- I—Vl •oliey No.:� o 10b--� GAS-EA.SYSTHM-OVIiR4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF:ASFJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This sectionneed..,hcmmpleted iOhe permit is horone hundred dollars($100) GREASETRAP
or Ica.) PI-ANCHECK FEE
I cenify that in IM1e performance ofthc work liar which this permlts issued.,shall SEWER-SANITARY-STORM EA.201 FT.
not employ any person in any manner m as to become wbjact m the Worker'Compen- ENERGY FEE
QZ onion laws of California.Data WNI ER HEATER WNENT/ELEM GRADING FEE
Z Q Applicant ✓ r
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you sherd WATER SYSIEM/TREATING
a berme tither a the Worker's Compcnsmian provi,i( I the Labor Onle.you must SOILS 103E
foMwith comply with such pawbions.1 this Permit shall be deemed revoked. WATER SERVICE
p" freir is.o IONLENDING leading agency
NEW RESIUENTIAL PLM B, SQ.IT. PAID
L) 17 Thereby affirm thauhem is econsumai.n lending agency for the performance of D e eeiprp
the work for which this porinit is issued(Sec.3097,Civ.C.)
Lt. Lenders Name TOTAL:
L) Lenders Address TOTAL:
y [CONSTRUCTION
DINGFE
[.. 1 ecnily that I have read this application and sate rbm he aMwe information is
fn conch.l agree to comply with all city and county ordinances and some law%adding to QTY MECHANICAL PERMIT FEE
V Z building construction,and berehy anthorvc represenmtivo'nf this citymener upon the MIC TEG
above-mentioned pmpery for inspection purpous. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino again. CTRIC
Iiahilities,judgmmats,cov¢and exper,esovoch may many way accrue againstsam City ALTER OR ADD TO MECH.
in consequence of the,taming of Nis penal. MBIN FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ALR HANDLING UNIT Cro Iojitto CFM)
SOUR ERE TIONS. F /j HANICALS
-•�-r AIR HANDLING UNIT(OVER 10.IX10 CFM)Signature.fApphanatiCommctm Da EXHAUST HOOD(W/DUCT) SING MD'IGATIO•FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle contents material HEWING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Cale,Section 25532(a)'7 HEA I'ING UNIT(OVER IFifths)B U)
❑Yes ❑N. VENT ILATION PAN(SINGLE RESID) PAID Dat. Rett- o#
Will the applicant or future building occupant use equipment or devices which
'mit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR 100.000 CITU) TOTAL:
District? HOIL17R-COMP(OVER 100.000 BTU)
[I Yes I]No
I have read the ha ssecke s mancrialsrequirements tinder Chapter ads of the Cali- AIR CONDITION UR ISSUANCE DATE
derstand
Tania Health&Safety Code.Sections hens 25505,—ay and 2 ithlay a amity the
that if the NEW RESIDENTIAL.MECH. SQ.FT,
building does nm cuncmly have a enet p roar ar ise my ce ofa Certificate
ramify the o'hopOccupancy.
m
of rhe rtquirtmenn which nun be neo prior m issuance of a Certificate of Qcu Wncy.
Owner or authorized agent Date I TOTAL: ISSUED BY:
OFFICE