30269 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO BUILDING-ELECPR ICA L PL'RMITNO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL.
BUILDING PROJECT IDEN'FIF'ICAI'[ON 30269
.DING AD ESS: SANITARY NO, APPLICATION SUBMITTAL DATE
�NER7In
NAME: I'll NFy ` ACf N'SA "gy p �L L NO_ N/C - CONTROL #
•ARCHBTECTGINEEIC LIC NO: 6 RE' /IN/YCI�f'Y ��" ❑
CONTACT. - PHONE: (� BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLUg ELHCT PLUMB MECH
few\j' ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby arr to mut I ata licensed outer pn,elsltna tr Chapter ¢mm�,enei^g JOB DBSCRIPTION
COZ. with Section 7000)of Division 3 tithe Businecsand l0'nfwdaas Codgandmy license is - RESIDENTIAL:
F O full forte and effect. PERMIT ISSUANCE
cewr
in ❑SMWL ❑KITCHEN REMODEL
F6.�V O License Class Lic.#
I-zW Dam Canada, APPLIANCES-RESIDENTIAL ❑ADDITION 'El PLUMBING R&PIPE
ARCHITECTS DECLARATION PANELS
F.Orn ❑MULTI-UNIT C3 STRUCTURAL
z Oy7r. I understand my plans shall he used as public records - MUIPICATION
OZ— UPTO 200 AMPS
❑INTERIOR HIMNEY RI7PAIR
F 4Iu Lice dProfessional 201-I(XXIAMPS IMPROVEMENT
Oat lam eUILDERum the NA'T'ION OVER INMAMP$
1 hereby affirm runt 1 am exempt form the Contractors License Law for the El BATH RF.MODEIJHIiPA1R ❑DEMOLITION
531tv following reason.(Section 7131.5,Business and Pro1'evitns Cale:Any city or enemy SIGNS ELECTRICAL. ❑OTHER
LL which requires a permit to construct,alter,improve,demolish,or repair any structure
�LLO pduntita issuance.also rtquires the applicant(orsudh permiuo Rleasigned smmmem SPECIAL CIRCUITIMISC.
that he is licensed pursuant in the provisions tfthe Cnmmemr's License Law(Chapter 9
I+IapO (commencing with Section 7000)id'Division 3trnbe Business and Professions Code)or TEMP METER OR POLE INST COMMERCIAL:
E d e a' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�,rn Section 7031.5 by any applicant for a pernot subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
G
} m
n more than Ileo hundred dollun S500).
S ❑ Le the wortfmnepropcny.or myIinueeuswahwagcs astheiraolecompensatitn, SWIMMING I'(IOI.ELECTRIC
IMPROVEMENT'
a will dt the work,and the struelurc i...t imendW oroffcrcJ I'or tale(SecJ044,Business ❑OTHER
W and Professions Cale:The Contractor's License Law does not apply to an owner of OUTLETS-SWI'I'CllF -FIXTURE
property who builds m improves thereon,and who dors such some himself or through
his own employees,provided that such improvements ore not intended or offered for NEW RESIDENTIAL ELECTR S '!'f
sale.IL however,the building or improvement is sold within one years(completion,Be SQ.FL FLOOR AREA $/SQ.FI'.
owner-builder will have the burden of Forcing Nat he did not build or improve for par, .
pec of sale.). - o
❑I,as owner of the propany,tan exclusively contracting with licensed convectors in �" qEr i`i
consumer the prowl(See.7(44.Business and Prol'esslous Cuxl The Conductor's u-
cense Law does not apply m an owner of property who builds or improves thereon,mid QTY PLUMBING PERMIT who contracts for such La jcers with a contmetogs)licensed puriona to the Convectors /�ILicense Law. PERMIT ISSUANCE t/ ("1 am exempt under Sec. B&P C for this reason a/ a
Owner Date ALTER-DRAIN&VENT-WATER B: VAh 4 N
I hcrci afWORKER'S
rm under penally of perjury
oneofCLARATION BACK FLOW PROTECT.DEVICE � s `x'eCry«��
Y penally P 1 ryone of the following dedaratinne aF
Ihuve and will muintnin aCenilicate nfConsem to self-insurttm Worker's Cotnpcn- DRAINS-ILOOR,ROOF,AREA.COND, STORIES TVYC CONS'I'NUCTION
,;it r,as pmvided for by Section 37M of the Luhnr Calc,for the performm of the
work for which this panni,is issued. FIXTURES-PER TRAP
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
3700.1''he Lobo,Cale,for the performance.fthe work far which this p�efruit
tiiaasued GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP MIN
My Carrier.- Cpmpe alto lnsygnce simmer add Policy Policy No,LX tk`7/ d�� GAS-IiA.SYSTEM 4 IEA)
C./}LCEIDIPICATEEOOF EXEMPTION FROM W RKERS'
COMPENSATION INSURANCE GREASEONDUSTRL WASTE INTERCEPTOR
(This section need not becomplened If the permit is forone hundred dollar,I$Its)) BUILDING DIVISION FEES
m less.) GREASE.TRAP
I'LANCU[CB PEE
(certify that intic four anymannro the work as
lch ject to the Wialaux'ostedlshdl SEWER-SAN)LARY-STORM EA.2(X1 IPI'.
not employ any person in any manner so os to bcmme subject m the Wnrkerv'Cmnpem ENERGY FEE
O Zmoon lows of Califnmie.Date WATER HEATER WNENT/ELECTR
Z 0 Applicata GRADING FEE
.N. NOTICE bj APPLICANT:LL Co making this visions of
Exemption,you should
st WATER SY$TEM/1'REATING
a ' femme subject y the Worker's Compensation Permit
shal of rhe Labor Code,you must SOILS FEE
forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDEN'r1Al.Pi,MB. SQ,Fr. PAID
G0 Thereby af0nn Dam Receipt# -
W H the work for which this permit is Issued(Sec 3097,Civ,CJ
U Lenders Name TOTAL:
>a LLI Lenders Address TOTAL:
y 1 certify that 1 have read Nis application and state that the above information is BUILDING FEE
r h career.I agree to comply with all city and county oNinanees and state laws minting to QTY. MECHANICAL PERMIT FEE
V Z building convection.and hereby authorize representatives of this city to enter ulxm the SEISMIC FEE
above-mentioned propany,for inspection purixses, PERMIT ISSUANCE
(We)agree ro save,indemnify and keep tentless the City of Cupcnino against ELECTRIC FEE NO
Iiobilities,.ludgments,costs and expenses which may in any wary accum account said City ALTERORADD'I'OMECH,
ousequen of lheitualingofthispernin PLUMBING FEE
APPLIC NDERSTN IT. MPLY WD'H ALL NONPOIN'T AIR HANDLING UNIT('r01(1,0fx1CFM)
SOUR GULATI '71�/` MECHANICAL FEE
A {ail 9� AIR HANDLING UNIT(OVER 10,0(X1 CFM) CONSTRUCIONTAXSlif
natant(Appliemm ontmct Dam EXHAUST HOOD(WMUCT) HOUSING MITIGATION IEE
HAZIMU US MATERIA DISCLOSURE
Will the applicant orfrurobuilding x p:ml store or handle hazardous material HEATING UNIT(To 100,000 BTU)
to,defined by the Capetian Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532m)? .RELATING(INTI'(OVER 100.00013.1'Of
r-1 Yes []No
VEN ILLATION FAN(SINGLE RESID) PAID
Will thea applicant or future building t use equipment or devices which Date Receipt#
pp gby he
BOILER-COMP QHP OR 100,(100 BTU)
mit hazardous air conmminums as Je0nr1 by the Bey Area Air Quality Management
District? TOTAL:
❑Yes E3 No BOILER-COMP(LIVER 101000 BTU(
I have mail the hazallon materials requirements tinder Chaprer695 of he Cali AIR CONDI'T'IONER - ISSUANCED
foram Health&Safety Cute,Sections 25505,25533 and 25534 1 understand than if the NEW RES1DEN'I'IAL MECIL SQ.PP
building does nm c urendy have a mtmtn,that it is my respmslhlNy,m nmify tho wcupard
of rhe requirement which most be met prior to issuance tic Comocate of Occupancy.
Owner or malmaized agent Date TOTAL: ISSUED BY:
OFFICE