30323 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES--USE BALL POINT PEN ONLY -
CITY OFCUPERTINO BUILDING-ELECTRICAL PERMITNO. �O
BUILDING DIVISION APPLICATION/PF,RMIT PLUMBING.-MECHANICAL
BUILDING PROJECT IDEN'TIF'ICATION
323
BUILDING ADDRESS: SANITARY NO. , APPLICATION SUAMI'CI'AL DATE
W.""TE ,
PHONE: C Xr CIO S AME: LIC NO, /Z- f `CONTROL#
EER: LIC NO: L ADORES p ,
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CONTACT: . PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB � MECH
❑ El ( ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEF,
I hereby o lon that I licensed under Provisions of Chapter 9(commencing JOB DESCRIPTION
�QZ with Secy n9000)ofDv 3 fthe Businessand Professions PERMIT ISSUANCE f:.ions Cade and my license is IDEA 1
O _
AL
�(yF in full(r un Cs SPDWL ❑KITCHEN REMODEL
Q U U Lice se Class Lie.p pppLIANCPS-RESIDENTIAL ADDITION ❑PLUMBING RF PIPE
P Q d Damow:
Cum t
g�pm ARCHITECT'S DEC T PANELS
❑MULTI-UNIT [I STRUCTURAL
Z O,nZ 1 nears d my plans hall be ed as public rac NsMODIFICATION
OZ4— UPTO200AMPS ❑INTERIOR El CHIMNEY REPAIR
FW Lmcansed Pnd..emed 201-1000AMPS - IMPROVEMENT
OWNERBUILDERDECLARATION OVER AMPS
C Q 1 hereby affirm that I am exempt from @e Contractors License Law for the . OTHER
❑anBATH REMODEVRFPAIR [i DEMOLITION
3iXV following reason.(Section 9031.5.Business and Professions Code Any city or countIOWy SIGNS ELECTRICAL s ip
tel11 N which require.,a pennil la mmnucl,aIle,.improve,denudish,or repair any structure
���^�' prior,.its is...nee,a6vnectuosihe applicant for such pennil,.rile o signed slatenient SPECIAL CIRCUTUMISCr
�y that he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter 9
1 0 (commencing with Section 7")ofDivision 3 ofthe Business and Professions Coultor TEMP.METER OR POLE I.NSE COMMERCIAL:
d L c C that he is exempt membrum and the baste for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^u• Section'/031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
^m ❑TENANT ❑FOOD SERVICE
not more than fve hundred dollars($SIX). IMPROVEMENT
^ Q ❑.Lav owner ,and pe,froc vex ourayceswithwagefor it,(Sele compensation. SWIMMING POOL ELECT RIC
Ste will do the work,and the xtmmumis not imm�Jed nrortered for sale(Seb.91W,Bu,ioess ❑OTHER
W m and Professions Code:'Time Connactor's License Law does not apply n an owner of OUTLETS-S\VITCHIS-FIXTURES
L 3^ property who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECfR SQ FT
sale.I I hosecven the laid;ngmon,..vemont is sold withlnone year of emumlctiin,the SQ.IT.FLOOR AREA $/SQ.FT.
owner-huilder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑h y
as owner of the pomer ,am exclusively contracting with licensed contractors to TOTAL:
construct he Inject(Sec.l(Wk,Business and Professions Cale:)The Contractor's Li-
censeLuwdoes notapplyto anwourofproperty.,his buildsorimprovastheater,and Q1 Y. PLUMBING PERMIT FEECEIVE
who contracts for such pr Jcces with o emanations)( licence ,.d pursuantthe Contractor's
License Ems. PERMIT ISSUANCE
❑I an exempt under Seo. ,B&PC lot his re..
Owner Dale ALTER-DRAIN&VENT-WATER 4 vV ION
WORKER'S COMPENSATION DECLARARON BACK MOW PROrEC..DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
•❑I havcand will frainmina Cenificaleuf Ccosennnsdf-in.vere for Workc,,Cnmpen- DRAINS-FLOOR,ROOK AREA,COND.
sation,as Provided for by Section 3/W of the Labor Code,for the performance of the CONSTRUCTION
k for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Lma,Code,for the pefforman,aof the work for which his permit;sowed. G_AS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP APN
My Work yy's Cyy pp.�nsad a W...06y,,..frier and Policy th umhcr of:
Cartier:/a ImA rn�/V Policy No.: GAS-EA.SYSTEMOVER4(E.A)
C RTIFICA'1'F: E%EMPTION FRO 'ORKERT
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This udion need not he completed ifthe cetmin is for one hundred dollars is 100) GREASEIRAP
or less) PLANCHECK FBI;
larify the arme peflornmanc.oOlot wodfim,xnelo do,pennit i,Issud,[,hall SEWER-SANITARY-STORM G.210 VE
nor employ any pc—a in any manner o as sm le ,ebjad ran the Workers Coun,n ENERGY FEE
z ,Z sation laws f Cahfomiou Da a WATER HEATER WNEM'?:LGCfR
O Applicant GRADING FEE
4NOTICL TO A LICANT:If,ab¢r mnkin this Cdnilicam rf Exemption,you should WATER SYSTEM/IREATING
7 become subject to the Worker's Compensation prevision,of Ja Labor Code,you mist SOILS FEE
Cr forthwith comply with such pmvi.siotoordii, ooru,h rhe deemed ra mod. WATER SERVICE. -
0
U Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ,Fr. PAID - Dae Receip
U Q weak
w ichaffirm that is sued( ca,i 0 lending agency(robe perfannounce.f
the work fa which this permit is issue)(Sec.3119'!.Civ.C.) _
0 1"'V Lender,Name OTAL:
Lender's Address - TOTAL:
I certify mat 1 have read misapplication t d start Lha the above infirminum is BUILDING FF.F.
[— y r pp ice ion ac
N building 1 agile to comply with all city and county ordinances and slam laws relatingto QTY MECHANICAL PERMIT FEE
UZ building construction,and hereby authorize represenmtiva nbnhis ciry to enter upon me SEISMIC FEE
above-mentioned property for inspection purposes. PERM II'%ISSUANCE
(We)agree to save.Inden afy vad keep harmless Joe Cil,of Cupcnino r,moELECTRIC FEE
Iiabildies,judgmenu.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MF.CI I. PLUMBING FEE
I. nscyuence if,ha graming of Nis .i,.
_ /
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNITG70 10.000CFM) MECHANICAL FEE
S URCE REGULATIONS. -
AIR HANDLING UNIT'(OVER 10,00)CPM) CONSTRUCTION TAX
«of App aanV ommaor �1 1 etc EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS ATERIALS DISCLOSUR
Will the applicant or future building occupant store or handle hazadous material HEATING UNIT 070 list 1BTU)
as defined by the Cupcnino Municipal Calc.Chapter 9.12,and the Health and Safety
Code,Section 25532nd! ,,,...non''' HEATING UNIT(OVER Io),00JBTU)
f❑Yes o - VENTILATION PAN(SINGLE RESID) PAID
1 Date Receipts
Will the applicant or(.lure building y the Bl use equipment or devices which
hazardo
; us air comaminanu efi
as dneJ.by the Bay Arca Air Quality Menagemem BOILER-COMP(JHPOR I00,000 BTU7
TOTAL:
Distnetl yyyyN � BOILER-COMP(OVER IUU.W)BTU)
I have read the haranous materials mquarmems under Chapter 6.95 ofmhe Cali- AIR CONDITIONER ISSUANCE DATE
brain Health&Safery,Code.Sections 25505.25533 and 25534.1 ondersmnd thm if the NEW RESIDENTIAL MECH. SQ.Fr. J Z
building does not conendy mve.n.m.that it is my responsibilityto notify the occupant
of rcqui«,.anis wMe mull met#ninon . mlauf a Cenifcale
L9J u ISSUED BY:
otlecd agent 1 a TOTAL:
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OFFICE