30866 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY "
CITY OF CUPERTINOBUILDING-ELECTRICAL PERMOPND, f] O p,�C
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J O 6
BUILDING PROJECT IDENTIFICATION
RUILDINGAUDRF.SS: �� SANITARY NO. APPLICATION SUBMITTAL DATE .
6 - - y
O N R'SNAME` Alit- PHONE: as CONTRACTOR'S NAME: LIC NO:
.iik --43r-81
Y/ NIC CONTROLp
RCHI 't l'/ENGINE : MC NO: ADDRESS: ❑ v -
C21
UNT PHONE: BUILDIN6 PERMIT INFO
O n/ / ❑ Consultant Fees Paid by Applicant(Initial) ,D E ,CT PLUMB MECH wt
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm chat 1 am licensed under provisions of Chapter 9(commencing J613 DESC IPTION
C`feZ with S.tiun]000)of Division3ofthe Busincssaad Prafessimn Crede,andmyliccnseix
W O O PERMIT ISSUANCE- RESIDENTIAL:
ge W F- in full farce and effect. ❑SF WL [I KITCHEN REMODEL
U License Class Liep
6 U APPLIANCES-RESIDENTIAL DDITION El PLUMBING RE-PIPE
F a a Date =.tremor
E,Om ARCHITECT5IlEC1.ARATION PANELS ❑MULTI-UNTf ❑STRUCTURAL
zOyZ I understand my plans.shall be used as public records .MODIFICATION
O z4—a _ up rO 200 AMPS . El INTERIOR ]CHIMNEY REPAIR
r-4tW Liehawd PmfeWhimil 201-IOW AMPS IMPROVEMENT
Y W< OWNER-BUILDER DECLARATION OVER HKdh AMPS ❑BATH REMODEUREPAIR ]DEMOLITION
GL 0.'Q I hereby specific,1 am exempt from the Cession,Cock:
License Law for the
3µF following reason.(Section 7031.3,Business and Professions Code:Any city or county SIGNS EL RI A ❑OTHER
y which requires a permit to cures me ulmc.improve•demolish, file
repair any twnurc
EN�q
prior toslits censed e.also pursuant to the mecant for suchPermitLicense Law
(CIhrement SPECIALC T/M.
f } that he is licensed pursuant w the provisions of the Commences License Ww(Chupmr9
S CC CO (commencing with Section]W()mf Division 3 of the Business and Professions Code)or TEMP.SISTERO T. COMMERCIAL
a L p Ss that he is exempt thcrcfmin and the basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
� :2LL Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVI
u7�o" ❑TENANT ❑FOODSERVICE.
�z6not more than five hundred dollars($500). IMPROVEMENT
F7 I;asownerof the property,or my employees with wages as chcir sole compensation, SWIMMING POOL ELECTRIC
9p ,will do the workand the structure is not intended or offered for sale(Sec. ,71VWBusiness
I„ []OTHER
W 3 m and Profess inns Cole:The Contractor's'License Law does not apply,,an owner of OUTLETS-SWITCHES-1'IXTDRE$ v
property who huilda or improves thereon,and who does such work himself or through
his own employees,provided that such improvetuents arc not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however the buildirri-imprnvemcnt is sold within one}ear nfmmpluion,the SQ.FT.FLOOR AREA $/SQ.FT.
owner builder will have fife burden of proving that he did not build or improve for par-
ryne of sal
❑ has owner of the property,am exclusively contracting with licensed contmmurs m J L!
oexmue,the projar(Sec.70th,Business and Professions Code:)The Cummnors Li�
cemse Ww doss not apply to as miner of property who builds orlmproves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a come dogs)licensed pursuant o the Commercial's
License Law. PERMIT ISSUANCE
I] I um exempt under Sec rt
B&P C fortis reason
Owner Ume ENT
ALTER-DRAIN&V .R EA) VALUATION
J
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECI'. . :VICE / C •�
I hereby affirm un der penalty of perjury ane of the following declarations
] Ibaveandwill maintain aCenificum of Connnun sell-insure for SVorker's Cnmpcn- DRAINS-FLOOR,ROOF.ARE D. STORIESTYPECONSTRUCTION
cation,es provided for by Section 3700 of the Tabor Code,for the performance of the
work fur whicbthmit
ie per ;,is sued FIXTURES-PER TRAP '
FI I have and will maintain Worker's Compensation Insurance.as requited by Section
37W of am Labor Code,for the pimmurnanceof the work for which this pernit is issued. GAS-EA.SYSTEMIINC.JOUTIP' OCC.GROUP ANN
My Workers Compensationlnnce rarha sho lsolicy numhr am
e :
Carries Policy
Policy No.: GAS-EA.SYSTEMOVER J(EA)
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
BU31W.QIVESION,FLLS
TTht,oshion need mot becmmpkted iOhe pcnnit is foroae hundred dollars(51000 GREASETRAP
sir les,) PLANCHE K
1 dfythal' th p ro of the kf hichthi p 't issued.1 hall SEWER-SANITARY STORM EA.200 FT v
.of empty off Cu,,cn at.any
lmn ratasl become auhjccl1 th Workers'Cmnpcn- - - ENER FSE
Qz otintl WATER HEATER W/VENT/I:LECIR
Z Q Apph t Ill
ti NOTICE T(.)APPLICANT.If,aner making This Certificate of F.xemptinn,you should WATER SYSTEM/TREATING
a ' becmn,subject to the Workers Compensation provisions of Ne labor Code,you must 'r FID
foMwith comply with such provisions or this permit shallM drsmexim,.ked. WATER SERVICE'CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FLDateV O I hereby aRrm that there is a conswction lending agency for the perfannance ofthe work for which this permit is issued(Sec.309].Civ.C.).
0 UWaders Name ex
TOTAL:
Lk1 Lenders AddressY' 1 certify that 1 have read this application and stem that the above infomfmion is -Vat] correct 1 agreem comply with all cityand county oNinance,end state rows relating u{ QTY. MECHANICAL PIERMIT FEEU Z huildiagenneWame.and hereby muthnrizc mthesentmoesofthircity lm enterupn the F
ahovo-..eme mod properly for inspeeuun mv,w,. PERMIT ISSUANCE(We)agree to save,indemnify and keep harmless IM City of Cupenido against I FEE
liubilitiusjudgmemscosn and expenses which may in any way accoutright nstsaid City ALTER OR ADD TO MSCI I.
in consequence of the gotming of,hi,permit YLUMBIN FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 C17M)
SOURCE REGULATIONS. MECHANI LEE[
I AIR HANDLING UNIT(OVER 10.000 CFM) CONS'TRUCT'ION TAX
Sigmwte of ApplicanVConmacmr, Data EXHAUST HOOD ONMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO IW,f111B BTU)
as defined by the Chicane,Municipal Code.Chapter 9.12,and the Health and Safety
- Code,Section 25532fidI HEATING UNIT(OVER 100,001[1 BTU)
Ye ❑N
- - VEMILAI'ION PAN(SINCI.I:RI,SID) PAID Date Ncsc'plk
Will the applicant or future building cup t use equipment or devices which
th dax err corm ms ms defmdb ih Bay Qualil Management BOILER-COMP(3HPOR I(M."BTU)
�mis�m te r y y g TornL: r
❑Yes ]Nm BOILER-COMP(OVER 100,00l)BTU)
I have read the hazard.,materials AIR CONDITIONER
my 25533 an under Chapter6.95 of Cali- ^SSJJaN DATE
fomiagdox,&SaRre Cale.eations25505.is myandrnsil, IufdematfQ thatif the NEW RESIDENf1Al.MECH. SQ.FL (Cpa'r [YIJ
of themgstimmenet cuwhichently have be met prior
ismyof a Can eonoGfy ancy.
of fife requirtmencs which must be ma prior of issuance of a Certificate of Occupancy. '
I. Owneror aulhoo,ed agent Date — A ISSUED DY:
OFFICE