30528 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
[i,�GWDING
ITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO 30528
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL
_ BUILDING PROJECT IDENTIFICATION
ADDRESS: SANITARY NOAP PLICATION SUBMITTAL DATq x 6A6
W��GG�1 PHONE: CONTRACTOR'S NAME: LIC NO
N/C CONTROLp
f1 CHITECT/ENGI LIC NO: ADDRESS: ❑
1 GIG
107V ti W
C NTACT. .T QI PPHONES:,N� L� BUILDING PERMIT INFO
LLC-V-- 1AAF ` ` {1ONy4 { 1aP ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE A
1 hereby affirm that 1 me licensed undo pnwi,ions of Chapter 9(commencing ]OB DESCRIPTION
�kgZ wish Section7000)ofpi,iuion 3 ofine Ravines,and Prnfesshms Code,and my license is RESIDENTIAL:
WOO PERM IT ISS DANCE
FKm� in full forcemtdeffeel. _, k OSFDWL [I KITCHEN REMODEL
tub 4cense Class Lic.p AI'PLIANCLS-RESIDENTIAL DITION El PLUMBING RE-PIPE;
an,u] pate ConnectorLL D. ARCHITECT'S DECLARATION ULTI-UNIT ❑STRUCTURAL
ZOo-Z l understand my plem,lall be used as pant is accords PANELS MODIFICATION
UP FO 200 AMPS [I INTERIOR El CHIMNEY REPAIR
F[�, uw1 Licensed Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER I ant)UILDER.m the omnedi OVER INXI AMPS O BATH REMODEUREPAIR ❑DEMOLITION
1 hereby arfrn that 1 a.exempt o-um me comra,mra License Law for the
10.f O M U following res-it(Section 9031.5,Business and Nor..ma,Code:Any city or county SIGNS ELECTRICAL ❑OTHER
00'3 lti y which reyuires a permit 1,cm,trm%alley,improve,demolwh,nr repair any structure
L'-u,O� prion,its issuance.al......me,iheapplicant faster Permit,l i to a,ignedsmtemem SPECIAL CIRCUIT/MISC.
SSS T that he is licensed pursuant In the provision,ofthe Gmwcmr's License Law(Chapter 9
(commencing with Section 9000)of Division 3 oftbe ,sine„and Prowsoions Code)or TEMP.MUTERORPOLP. COMMERCIAL:
d p,m ev that he is exempt therefrom and the basic for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
at to Section 9031.5 by any applicant for v permit suhjects the applicant to it civil Penalty of POWER DEVICES El TENANT ❑FOOD SERVICE
.,it mom room five hundred dollars($500).
Zpy>' IMPROVEMENT
F-a' 0Lothe woraRnepnesurnamnnycmpleyeeswitnered h,aleihec.compcnennn, SWIMMING POOL ELE IC
al Cwill dnthewons andthe heCouisnolintendedLaw
tunsal applyoairnne7044, r os [_1 OTHER
W�m and property
who
C,Nor The uses detreas End w Ino doe,not apply to an owner of OUTLETS-SWITCHES-FIXTURES
his o ny whooyes,or videdvth thsuch i and who dace such work himdee of m Inmugh
his own employees,the
provided that such imprrv ,sold w are not intended or offered for NEW RESIDENTIAL ELEC'TR SQ FT.
sale If,h Ih b ild n6 r'mp � um IJ within one Y' f pl ll,n the SQ.IT.FLOOR ARCA 8/SQ f,'
erb 'IJ 'lib with make fp persons Ind d'd shuts p f rpur-
°w iq
1.a. fct See ty I . ely t tingithI J t n: m
cense t theproject(Sec o an Business and Professions Code)Th Contractors L-
whoemmicLaw sfnot apply manowner otpr,penywcensclasoritnprovcContondor's,and Y. PLUMBING PERMIT PEE
who canvass for such prgjecty with u eomrvemr(s)licensed pur,mm o-:the Qmlmemr'S W
License Law. PERMITISSUANCE
0 I am enuipl under Sec. .B&P C ha this reasonLAG
ALTER-DRAIN&VENT'-WA'T'ER(EA) 0, DON
Date 1
WORKERS a lyefESAn,on DECLARATION HACK FLOW PROTECT.DEVICE 4 6
Ihueby ufOrm unser p,wlty of perjury one,(the following Acclamtiom: ` �
I have and will maintain a Certificate of Comento.self-insure for Worker's Compcn- DRAINS-FLOOR,ROOF,AR G.COND. STORIES TYPE CONSTRUCTION
ood,as provided for by Section 371X1 of the Labor Code,for the par ormanee of the -
work for which this permit i,issued I FIXTURES-P
0 1 have and will maintain Worker's Compensation In.mmnce,as reyuired by Section
3900 of the Labor Code.for the performance afthe wnrk for which this permit is i„ GA EM-I INC.40UTL OCC.GROUP APN
My Worker's Compensation Insurance:mnicr and Policy number are: (V`►,/
Cartier. PolicyN . GAS EA. Y�T� - VER 4EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRE R1lildyclDIVISION FEE
This section need not be completed if the permit is(nnme hundred dollars( ) GREASETRAP
car les,.) PLANCH �—
Icemfy that in theperfermixe ofthe work forwhich this Permit is issued,l,ha11 SEWER-SANT RY ,STORMEf FT.
not employ any person in airy manner su a,m become subject,the Wuludl Compcn- ENERG
Z satins Laws of California Date
zO Applicant WAT TER E GRADING FEE
NOTICE TO APPLICANT:IC after making this Certificate of Exemption,you should WATER SYSTEMIT'R
F been.,subject in the Workers G.mpensvtion provision of the Labor Code,you.aa SOILS FEL?
forthwith comply with smliprevisionor this proan,hall be dee.edrevoted. WATER SERVICE
� z CONSTRUC'T'ION LENDING AGENCY NEW RESIDUNTIALYLMy. PAID Datc cipt
U O I hereby affirm that mere is a construction lending agency for theperfmmance of
Fr the work for which this permit is issued(Sec.3U9],Civ.CJ TOTAL.
O ULender's Name (\�,
Lender's Address {
I certify met I have rwA this application and site that the ubavc info uralion is BUILDING FEE,1VI 01k,
.F.ro!Icorrect.I agree to comply with all city and county urdircuces and,tam low.relvting to QTY. MECHANICAL PERMIT PEE
U ',Z building convtmction,and hereby authorive representative„fthis city member upon me SEISMICFE �-V
move an uoured property for in,p ounin purpoxcs. PERMIT ISSUANCEG !�
(We)agree m save,indemnify and keep harmless the City ofpe
Curtino iddinl ELECTRIC �P. V
liabilities,judgments,costs and exonams which may in any way ucemcugerst said City ALTERORADDTOMECIT
in twit oc of the granting ul this permit PLUMBING F
a
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANIC LFEG
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRU TAX
Signature of ApplieanUContmctor Date EXHAUS'THOOD(W/DUCT) HOUSING MITIGATI FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the upplicame,future building necupunlaoreo,handle hrealous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupcnine Municipal Code,Chapter 9.12,and the Health and Safety
Coda Sett a 25532(01 HEATING UNI'T(OVER 100,000 BTU)
O Yes 0Nn PAID
VENTILATION FAN(SINGLE RESIU) pate R cipt b
WiII the applicant or future building me.pur use sCmu mere or devices which
thanardoue air commainant,odefined by the Bay Area Air Quality Management BOILER-COMP(3HP OR IINL00U NTE) TOTAL.
and9
E]yes 0Nn BOILER-COMP(OVER 100.000 B'TO)
AIR CONDITIONER
I nave read A,Safety
hazardous ore,Ssuers 55alsrequirements,253a underChapter1 and 695 or that Carie i/ }SSI/A E DAT
fornix Health&Safety Cale,Sections 25505.25533 ons 25534,1 understand that if me NEW RESIDENTIAL MECH. SQ.FT. L,I{lj
building docs not commily have th roam,that it ismy responsibilityC In nilly the occupant
o[me rcyulrvnmms whichh must he moa prior n:issuanceuaissuanceoof[a enifiane of 0ecupaney.
Owner or aumori,ed age. Date T ISSUED IT)
OFFICE
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