30552 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BOMBING-ELECTRICAI, PERMITNO, 30552 5 5 2
BUILDING DIVISION APPLICATIONTERMIT PLUMBING-MECHANICAL. J
BOMBING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPI.ICATION SUBMITTAL DATI
OWNE ' MC: PHONE: CONTRACTORS NAME: O' LIC NO.
C1,46_—Vo-q
dt CII/A/ &-r.1er L O %/VO _ SIC COMROLN
NCHITECGENGINEER: LIC NO: ADDRESS ❑
oa sA22st, Aluc\
CONTACT. PHONE: BUILDING PERMIT INFO
• ❑ Consultant Fees Paid by Applicant(Initial) HI.DG EI.ECT PI.UMB MECH
❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
C x z 1 hereby affw thin[.to hcemed under ndPonom ofs Code. n my license
JOB UESCRI ION
y Ed ith Safall ran to70KKq.diffiec UivisionJof the Business and Professions Cale.and my license is RESIDENTIAL:
F O iceneClass-effort. - PERMIT ISSUANCE�� ❑SFDWI. ❑KITCHEN REMODEL.
�<U t,,) License Class Lick APPI-IANCIS-RESIDENTIAI• []ADDITION XWNIBING RE-PIPE
0. Dam Convector
ARCHITECTS DECLAMATION ❑MULTI-UNIT -'Cl STRUCTURAL.
z p r/=t 7Jy I ualersmnd my plain shall be teed m public records PANELS 'MODIFICATION
OZ=O UPTO�00AMPS [I INTERIOR ❑CHIMNEY REPAIR
rIo U4 Licensed Pndessanml - 201.1t}p AMPS IMPROVEMENT
��dd OWNER-BUILDER DECLARATION
ypd4'C4 Q 1 hereby affirm thin 1 an exempt fmm me Contractor's License Law for the OVHR,HMAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
W O�U following reason,(Section?071.5,Business and Professions Code:Any city or county ❑OTHER
a a SIGNS E IECIRICAI.
O which requires a permit to comwn,alter,improve,demolish,or repair any Smismas
��m�
poor o its i.ssmnce,also requires the applicant for such permit n File a signed Statement SPECIAL CIRCUIT/MISC.
.E p• that he is licensed pursuanun the provisions of are Contmerors License law Chapter
GO (con...nang with Section 70(alof Division3 of the Business and paressions Code)m TEM P.M11f ROR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis lot the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4• Section 707 L56y eny epplicmtfore permit subjcas the vpplicennoucivil penalty of POWER VICES
z pN„ rostrum than Five hundred dollars PS010. ❑TENANT [I FOOD SERVICE
a' ❑h as owner of the properly.or my employees with wages as their sole Mpensadon, 5 ING POOL ELECTRIC IMPROVEMENT
❑ will do me work,and the Structure,is not intended or offered for able(Sec.7044,Business ❑OTHER
L �_ and PmEbomns Code:The Conaacmrs Lice...Law does not apply to an owner d O L SNITCHES—FIXTURES
property who builds or improves thereon,and who does such work himself or through '
his own employees,providedthat such improvements arc not intended a ofered for SOW REST L ECTR SQ IT.
• seta.If.howeveu the building or improvement is Sold within one yea ofmmpletion,the SQ.FT.FT.00R AREA $/SQ,FT.
owner-builder will have the burden of proving thin he did not build or improve for pori
Pass of talo.).
I,as owner of the pnopeny,am exclusively contracting with licensed commmorn to TOTAL: .
construct do prej.1(See 70N4,Bmine,o and prnfcssinm Cods:)Tbc Convacmr's U.- r
cense I.aw does not apply to an owner of property who builds or improves thereon,and QTY. PL G P MIT FEE
who contracts for such(,injects with a commnogq licensed pursuant to the Cdnwnoes
License Law. PERMIT ISSUANCE•
❑Itnexemptunder Sec. ,B&PCforthismasan gip 161996
Owner Dam ALTER—DRAIN&VCM—WA TEA) _ VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
( ss xg
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintains CenifeamofComem to self-incurs,for Workers Compere- DRAINS—FLOOR,ROOF,AREA.COND. STORIES TYPECONSTRUCTION
sauon,as provided for by Section 37M of the f.eMv rm
Code,for the perfoance of the
work fur which this permit is issued. FIXTURES—PER TRAP r.
❑ I have and will maintain Worker's Compensation Insurance,as required by Sebum
37M of the Uhor Code,for the performance of the work for which this Permit is issued. GAS—EA.SYSTF-M-I INC.401117LETS OCC.GROUP APN
M Workeryy.{�.'pp inion Insure ce carrierand Folic number aR:I�C13
Gvncc /'TP\�nN✓�'�� policy NaY GAS—
EA.SYSTEM-OVI?R4(F.A)
CER'1'IFICATC OF EXEMPTION FROM WORKERS'
COMPENSATION W SURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section need not he completed if the permit is foram hundred dollars 1$100) - HUILDING DIVISION FEES
or less.) GREASETRAP pLANCHECK FEF.
I certify that in the performance of the work for whichods permit is ixsual,l shall SCWIiR—SANITARY—S'fORM EA.2W FT.
nor employ any Person in any mdnnerso as to become subject m the Wa keri Co.,.. ENERGY FEE
z,Z .tion laws of Calif son.Data
O Applicant WATER HEATER WNENT/HLF.CTR GRADING FEE
rq NOTICE TO APPLICANT:If,after making this Cenifcete of Exemption,you should - WATER SYSTEM?REATING
ahecome.bjam t the Workers Compensation provisions of the labor Coda you most SOILS FF.Ii
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE.
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIA1,PLM13, SQ.FT PAID Ln
U 0 (hereby affirm that is a communion lending agency for the performance of Dam cc
Li H the work for which this permit is issued('be '097,Civ.C.)
0 U Lender's Name AL:
Lenders Address
911 1 certify that I have read this application and Stam that the above intonation is A BUILDING FEE
Fr rA coned.l agree to comply with all city and county ordinances and stem laws relating to QTY. MECHANICAL PERMIT FEE
U. building construction.and hereby authorize representatives of this city to enter upon the SEISMIC
above-mentioned propeny for inspection pmpn.s' PERMIT ISSUANCE.
(We)agree to save,indemnify and keep hawless the City of Cupertino against PERMIT C E
Iiahilitics,judgmems,costs and expenses which may in my way accrue against said City ALTER OR ADD TO MECH.
in consequence of the Band of this permit. PLUMBING FE
A
NDE TA DS AND WILL COMPLY WITH ALL NON-POINT AIR I IANDLING UNITTO 10,000 CFM)
LAT S, MECHANIC FECe � AIR HANDLING UNIT(OVT:R 10,000 CFM) CONSTRUC TAXIicanucenun or '. Date EXHAUST HOOD(WIDUCI) HOUSING MITIGATIO E
HAZAR US MATERIALS DISCLOSUREpplicant or future building occupant store or handle hazardous murnal HEATING UNIT(TO 100,000 BTU)
as defined by the Cupcnim Municipal Cade,Chapter 9.12,and the Health and Safety
Code.Section 25532ho? HEATING UNIT(OVER I W."BTU)
❑Yes ❑Na
VENTILATION FAN(gINGLB RFSID) PAID
Ute Berri t p
Will the applicant or future building by are Bt use equipment of devices which BOILER—COMP OHP OR 100,00(,BTU
tis iet'! m air contaminants as defend by are Bay Arca Air Quality Management ( )
❑inrici! TOTAL:
❑Yes F7 No 1101LER—COMP(OVER IIN),(pO BTU)
l hove read the hn.Nmts materials rnryirenenu under Chapter fi.95 of the Culi- AIR CONDITIONER ISSUANCE DATE
ford.Health&Safety Code,Scenes 25505,25537 and 255]4.1 undmtand that if the NEW RESIDENTIAL MECH. SQ.PT.
building does not currently have a tenant,that it is my maponsibility to notify the occupant
of the requirements which must M met prior to issuance of a Coni Ficate of Occupancy.
Owner nr uuthorued uCcm Da¢ TOTAL: ISSUED BY:
OFFICE