30582 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMITNO. /N O r.. ^ —
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 3 5 L
BUILDING PROJECT IDENTIFICATION
BU QINO A�RESS: MSETZ SPV'I S nuv'� SANITARY NO. A/P7lFP�L�JICATION SUBMIT/PnASL DATE
N' 'S NAME: /y' C, PHONE: W CO/yt/R/q�C1' S N MG J7 •—
.— "1�.�'i 9 "� ' �t/ m��/G. NIC CONTROLp
1RCH1TECf/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUD-DING PERMTT INFO
❑ Consultant Fees Paid by Applicant(Initial) L ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION 'Cn"' � f ^ ❑ ❑
QTY. "ELECTRIC PERMIT FEE JOB DESCRI ION
1 Hereby ).f that 1 em licen.md under provisions of Chapter Cork, 9(commencing p: L .,
:W2 with Section?it affa Division lotthe Business and ProfcssionsCdc,endm licenseis
Y RFSIDEN?!.al•
-uO ijn fall oenseoree and effect. PERMIT ISSUANCE
U U L'ita, Class Il Lic.p ❑SFD M ❑KITCHEN REMODEL
?a` Dea ECTSCo.,,.nor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE PIPE
.gym ARCHITECTS DEC ON PANELS ❑MULTLUNIT []STRUCTURAL
v�Z 1 underamnd my plans shall be used as public records MODIFICATION
.E� UPTO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
W
Licensed Professional 201-HIWAMPS IMPROVEMENT
5f; OWNER-BUILDER DECLARATION
3w6 I hereby affum that 1 am exempt from the Contractors License Law for the OVER 10BOAMPS 11BATH REVQDELIREPAIR ❑DEMOLITION
S U fallowing mann.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL %THER
T
^O y which Lequims a pima,m construct,aper.improve,demolish,or repair any structure ro 109 i G�An,a Ar
printo its iuuane,also acquires the applicant for such pemduo file a signedammmem SPECIAL CIRCUTT/MISC Jl.LH ✓SI��L
1� the he is licensed pursuant to the provisions of the Contractors Lima.Law(Chapter 9
i7C0 (mmmencing with Section 7f1110)of Division 3 of Ne Business and Professions Coca)or TEMP.METER OR POLE INST. COMMERCIAL;
.m that he is exempt therefrom and Ne basis for no alleged exemption.Any violence of
< Section 703 IS by my applicant for a pcdnit subjects Ne applicant to a civil penalty of POWER DEVICES 0 NEW BLDG/ADDRION ❑DEMOLITION
Z y ruroom om than five hundred dollua($500). ❑TENANT ❑FOOD SERVICE
:SpQ 0Laa owner of the property.or my employees with.,as as their sale compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work and the structure is not intended moBcrad forsale(Sm,7014,Busineas �O ER
3 m and Professions Code:The Contractor's License law does not apply to on 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 am Hat intended or offered for NEW RESIDENTIAL ELECTR SQ FT
We.U,however the building or improvement is sold within one ycutdcompletion,the SQ.FT.FLOOR AREA 5/SQ.FT.
owner-builduwill have Ne burden of proving that he did not build or improve for par-
pose of s �F ' ^
ide.). /S Y
❑1,as owner of the pmpeny,am exclusively contracting with hcenmd mintumnou i TAL
construct the projut(SCC7014.Business and PmfessuOns Coda:)The Contractor L �.'.- +T'" 'S'"' OCr '/
cavae law does Har apply m tit owner of MCIxnY who bolds or improves thereon and Q7'Y F>^, p, }1 PLUMBING P 'Sj,FEE'+� 1 O ��V
abominations for such projects with acontractons)licensed purtuua to the Contractms rych C r �^s' k.b'..:.. y
LiLice.am exempt ander Sac. ,B&P C for this teazon
PERMITISSUANCE l
Owner Date ALTER-DRAIN&VENT-W ATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penalty of perjury cove of the following dacluations:
I have and will London a CeHfimteofComent to self-imure for Workers Comped. DRAINS-FLOOR,ROOF,AREA.GOND. STORIES TYPE CONSTRUCTION
satia..m provided for by Section 37M of the Labor Code,for the pMou
mnce of the
wock fm which this amdt is issued. FIXTURES-PER TRAP
❑1 have aM will maintain Worker's Compensation Insuranu,as required by Section
3700ofthe Labor Cade.for the pe timmaceorthe work far which this pemth is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
Worker's Compematian Insurance reedierand Policy numbereROCC GROUP APN
Ca :
Cartier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF10N FROM WORKERS'
COMPENSATION INSURANCE GREASFl1NDUSTRL WASTE INTERCEPTOR i ',-qr^;i:v :;BIIIDINO DNLSION FEES' J - tr+
(l3nxsectian rtecd natbe completed ifthe permit isfmone hundred doll=(1100)
or Im") GREASE TRAP PLANCHECK FEE
I,any and amount to
Performance of Nework
minewhich thoth,W.permit,kc.'Cimips issued,I shall SEWER-SANITARY-STORM EA.2W FT.
mi employ any person de any rummer su ss to become subject ro the WorkerF Comped- ENERGY FEE
Z
Applicant
of Gliforwa Date
ZO Applirmt WATER HEATER W/VENT/ELELTR GRADING FEE
.N. NOTICE TO APPLICANT:If,stir making this Cenifcate of Exemption,you should WATER SYSTEM/TREATING
Y ' become subject to the Workers CompetitN..provisions of the Labor Code,you most SOILS FEE
fmthwdh comply with such previsions or this permit shall d domed revoked. WATER SERVICE
Z CONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL PCMB. $Q.FT. PAID
J 0 Thereby affirm Nat Nert iseconawction lending agency for Ne performance of conpl#
the work for which Nis pcmds is issued(Sec.3097,Civ,C.)
Lenders Name TOTAL:
L.J Lendda Address TOTAL:
yI certify that 1 have read this application and smm that the above informdom is .. _ _ BUILDI G E
LA correct.I agree m comply with all city and county ordinances and state laws mlaung to Q?y, MECHAMCAL PERMIT - FEE
..) Z buildingcnvnmmion.andheremez (tome Lives offfi to enmr upon the SEISMIC FEE
above-mentioned property for inspection inoses. PERMIT ISSUANCE
(WOrigmamsave,inde...f n kee0 hadnm sthe Ciryof '.Pcr no,'mmn ELECTRIC FEE
liabilities,judgmcros.costimile.nenses hichmayim nywayacc agamosaid Gay ALTER OR ADD TO MECH.
in consequence of the granting of this pe 't PLUMBING FEE
APPLICANT UNDER ,ANDS IN' .L 'ITH LL RUN-POINT AIR HANDLING UNIT(TO IfI,(X)U CFM) MECHANICAL FEE
SOURCERE T V. _
AIR HANDLING IINR(OVER
Ia.UIXI CFM) CONSTRUCTION TAX
Sig Pplicrn/Co ter Date EXHAUST HOOD LW/DUCT) HOUSINGDIRIGATION FEE
IL RDOU ATER D SCLOSURE
Wdlth pImantorfuwmbut cyan mm or handle hasaedous..led.] UEATLNG UNrr M Ion"BTU)
as Iran.by the Canadian Municipal Cdc, In 9.12,end Ne Hwlth and Safety
Code,Section 25532007 HEATING UNIT(OVER 100.000 BTU)
❑Yes (]No VENTILATION FAN(SINGLE'RESID) PAID
Dam ReceiptIf
{ Will Ns applicant oruntie building occupancy useequipmentManagement
BOILER-COMPOHPOR100,000BTU)
emit hevrdous err conmmirmnts es defined by the Bey Area Av Quality Menegcment TOTAL.
a[l?
❑Yes ❑No ' BOILER-COMP(OVER100,000BTU)
I have Land the boundlessmaterials Laquirtmrnta trader Chapter 6.95 of the Cali- AIR CYINORIONER ISSUANCE DATE
fmNa Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.IT.
building does not currently have a amann that it is my responsibility to notify Lite mcupant
of the requirements which must he met prior in issum of a Certificate of Occuprcy, ,
Owner cr i uthorired'ant Dem TOTAL: ISSUED BY:
OFFICE