30949 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO. 30949
BUILDING DIVISION APPLICATION/PERMIT PLUMPING•MECHANICAL
BUILDING PROJECT II)EN'TIFICA'1'[ON
BUILDINGADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
ZO�100 �/moi j�it•✓%S 0 �
OWNERS NAME: - -( PHONE: CONTRACTOR'S NAME: • LIC NO:
• Q� �M� s / NIC COM'ROLk
ARCHITECT/ENGINEER: LIC NO: ADDRESS:
CONTACT. - PHONE: BUILDING PERMIT INFO
A /^ ` • / `y��� ���/.a� ❑ Consultant Fags Paid by Applicant(Initial) BLDG St ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION / QTY. ELECTRIC PERMIT NEE ❑ ❑
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB ESCRIPPION
g o O
goo with Section 7fNX)ofDivision 3 mi Business and Professions Cole,and my license is
PERMI'nSSUANCE RESIDENTIAL:
W• in full force and effect ❑SFDWL ❑KITCHEN REMODEL
QU�j LicenxeC ass ��� Lic.M— APPLIANCE'S-RESIDENJAL []ADDITION ❑PLUM BING RE-PIPE
0n Date Cnnimmrr
GGA CHITECTS DECIARATIO ❑MULTI-UNIT ❑STRUCfURAI.
oe
PANELS
PJ ns Z I understanJ my plain shall Na used as Public accords MODIFICA'T'ION
ozf.2 UPT02WAMPS (D INTERIOR CCHIMNEY REPAIR
F.4J("' Licensed Professional 201.1000AMPS IMPROVEMENT
XRf+j OWNER-BUILDER DECLARATION OVER IINN1AMI'S (D BATH REMODEIJRP.PAIR [I DEMOLITION
0.' Q 1 herrby off!.,that 1 am exempt from the Comment's License Law for the
fe 30.F following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL COTTER
C 1�O oe which fayuim a permit to mmusiO,aloe,,improve,demolish,or repair any soucturc
prior to its issuance,also requires the applicant for such permit to file a signed saterMm SPECIAL CIRCUITMISC.
>.V the,he is licensed pursuant to the provisions ofthe Connaut's License Law(Chapter H
W
no (commencing with Section 7000).&Division Sof Ne Businessand Professions Code)or 'TAMP.METI3R OR POL131NST. COMMERCIAL
0. m that he is exempt therefrom and the basis for the alleged nempion.Any violmiun of C NEW BLDG/ADDITION C DEMOLITION
V• Section]03 L5 by any applicant for a permil subjects the applicantto a civil penally of POWER DEVICES
P„ } not more then five hundred dollars($500). ❑TENANT [I FOOD SERVICE
C Las owner mfthe property.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is not intended contend for sale(Sec.71N4,Business G OTHER
W end Profusions Cede:The Convectors License Law does act apply to an owner of OUTLETS-SWITCHES-FIXTURES u
0.3 pmpeny who builds or improves thereon,and who does such work himself or through
his own employers,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ FT.
mIe.ILh.wncr,the building orimpmvemem is mlJ withinone year nfamoplctum the SQ. OUR AREA SdQ.FE
owner-builder will have the burden of proving that he did not build tar improve for pur OR '26 e
ofooleJ. /1
❑I,as owner of the properly.an exclusively enalructing with licensed ceriumonto nL: C/ (g
consul the project(Sao.7W,Business and Professions Code:)The Grmncmrs Li- / U
cense Law does not apply to an owner of property who builds or improves thereon.and QTY, PLUMBING PERMIT E rVurCHj,Ity
who contracts for such projects with a c.ataaom(s)licensed pursuant to the Contracture
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. .B&PC for this mason
Owner Dam ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 herebyuffvmunder penalty ofperjuryone ofdue following decimations:
C havemid arovide for
ea ..37M of be Labor
Code,fart a Wader's Comperee DRAINS-FLOOR,ROOF,AREA,CORD. 72 ir)cq5)
radon,as provided far by Section 3]00 of the IAM1mr Code,for the perfomtance of the ST( IES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
37M of the lAbor Code,for the performance of the work for which this pandit is issued GAS-PA.S YSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Worker'. trpens In• u c dPolicy nu
Writelel10N Nn.: mGAS-L'A.SYSTI?M.OVF.R4(PA)
CERTIFICA'EOFEKEMPf1I NIRO ORKI:RS'
COM PPls'SATION INSURANCE is on GRF.ASFJINDUSTRL WASTE INTERCEPTOR
(Thiseninn need not he mmplemd if the perodtlm for one hundreddollars($1(Y) BU ISION FEES
or Iessd GREASE.TRAP PLANCHECK tMest
I cenify that in the performuice ofthework forwhich this formal is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
mol employ any person in any manner su q in jjubjec jr the N'mm,a Cnmpem ENERGY F.
safimi Lnwsof California.Data s` 'L 1
y�y O Applicant WATER HEATER W/VENT/ELECIR GRADING
flV) NOTICE TO ARPLICANII ICaRenmaking this Ceniftcam.f Fienjusur,you should WATER SYSTP.MTREATING
(• 1"" became subject to the Wurkcr's Compensation provisions of the Labor Code,you must SOILS FEE
forthwith Comply withmuch provisions milli.,permit shall he deemedreveked. WATER SERVICE
CONS'I'RUCI']ON LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FC PAID
U O I hereby affimt that hem is o umnruai.n lending agency for the performance of Dam Receipt If
t
thiv,(, e work for which this porton is issued(Sec.3097,CC.)
O U Lenders Name TOTAL:
L>a Landers Address TOTAL:
TomT... Lis 1 cenify that 1 have read this application and state that the above information is BUIL TNG FEE �.
F-i (4 correct.l ague to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERM IT PEE
U building aouslmctiou,and hereby nuthmize representatives of this city to enter upon the SEISMIC Mf3
above-item...it property for inspection par mses. PERMIT ISSUANCE
We)agree to save,indemnify and keep h:umless the City of Connection o,mraj ELECTRIC IEE
Iiabilities,judEmenls,costs and expemoswhich may many wayuccomagainsf said City ALTER OR ADD TO MECH.
tRR' nit. PLUMBING PEE
AP .ICANT U��.D W 0 WITH ALL NON-POINT AIR HANDLING UNIT(I'0 10,001 CPM)
MECHANICAL F[E
SOURCG REGULAT�.. _
AIR HANDLING UNIT(OVER 10,IX1 CFM) CONSTRUCTIONTAX
Signature of plica Dam EXHAUST HOOD OODUC) HOUSING MITIGATIONEE
t HA RD ATLRI S SCLOSU
Will more building am oto anAle hazurAous mnmrinl IfGTING IINII'OO IW,O(NI BTU)
as Amined by the Ca"
Muni ,L .12,nal the li alth sad Safety
Code,Se 25532(.):' HEATING UNIT(OVER 100,0010 BTU)
C Vex [3 No
VENTILATION PAN(SINGLE RESIO) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt is
emit hazanlo is air contaminants as defined by the flay Area Air Quality Management BOILER-COMP(311P OR I WAN)HU)
Oinri
TOTAL:
nT
El Yea Misr, BOILER-COMP(OVER 100,0110 BTU)
I have nail the haradousmaterialsmimovarems lmder,Cloprr 6.95 of the Cali iAIR CONDITIONER ISSUANCE DATE
fomia Hullmh&Safety Cede,Sections 25505,25533 and 255M.I understand that if the N13W RES IDENI'IAL SUCH. SQ.FE'.
building does not currently have n tenant.that if is my responsibility to family the necupant
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE