30484 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO -. BUILDING-ELECTRICAL PERMITNo. 3 0 alL,�8 �I
- BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL• L�
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRP_SS: SANITARY NO. APPLICATION SUBMITTAL DATE
10 0 ► Lf AMY wiry Gv pg�rlJ,�va 1�.
'QWNER'S NAME: •lm k•'f1/
PHONE _ 383 CONTRACTOR O 'S NAME,: - I LIC NO:n
2 NIC CONTROLp
06M j
ARCHITECT/ENGINEER: LIC NO: ADDRESS: - i
o �'Z�' I
\/ CONTACT: PHONE: BUILDING PERMIT INFO
\/ ❑ Consultant Fees Paid by Applicant(Initial) BLOC Fa(F.[l PLU M i'CH
LICENSED CONTRACTOR DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed ander provisions of chapter 9(cmmmencins JOB DESCRIPTION
WOO with Swoon 7")of Division 3 of the Business and Professions Code.and my license is '
WOO O PERMIT ISSUANCE RESIDENTIAL:
F _ mfull force and ef(mt
y F, Lj ❑5 DWI. C1 KITCHEN REMODEL
QUU License Class Liga gppLIANCES-RESIDF.NTIAI. DDITION ❑PLUMBING RE-PIPE
un<i Date GSDECr
ARCHITECTS DECLARAI U ❑MULTI-UNIT ❑STRUCTURAL
Z O r/'Z 1 understand my plans shall be used as public records PANELS MODIFICATION
OZ-'� UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
u] Licensed Professional 201-1000AMPS IMPROVEMENT
S WNL OWNER-BUILDER DECLARATION OVER I(KKIAMPS C3 BATH REMODF.IIREPAIR C1 DEMOLITION
Q I hereby'affirm that 1 am exempt from the Contractor's License Law teethe
W 3 U following reason.(Section 703 L5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
y which rryuires a permit m construct, In,improve,demolish,or repair any numemre
F�•Oa prior to its issuance.also requires the applicant forsuch Permit o Ble a signed statement SPECIAL CIRCUIT/MISC.
E J that he is licensed pursuant o the previsions ofthe Commurnor's License Law(Chapter 9
(commencing with Section70(ad of Division 3 ofthe Business and Professions Confect or TEMR METER OR POLE INST. RD
-
a a p C that he is exempt therefrom and the basis for the alleged exemption.Any violation of 11 BLDG/ADDITION [I DEMOLITION
a6 te• Section 703 L5 by any applicant for a permitsabjecu the applicant to a civil penalty of POWER DEVICES
Foo ❑TENANT ❑FOODSERVICE
I,_,,Z} sol marc thatfeethundred praised or ($SW). - -
�SQp ❑Lathe owner k,the the somy,nemyemnneadeswithwagu^s their sale compcnsiness SWIMMING POOL ELECTRIC IMPROVEMENT
F will Jo thework,and thesomeoneCo eisoati License
dos not applyoan Business ❑OTHER
LL�1 m and Professions Cale:The Contractor's License Law Jces not apply to if or
of OUTLETS-SWITCHES-FIXTURE$
4'3.. hpropertyis own who builds or improves that
such improvements and who a such work himself ar Through
his own employeese provided Ihm such isoldwithin
arc not intended or altered for NEW RESIDENTIAL ELELTR SQ FT.
sales however ill have
improvementg th Id th non y f pl tfon the SQ.FT.FLOOR AREA 5/SQ.FT.
rte b 'Id ill have lh burden fpnwtng that did not build rir tpn for Pur-
pose f. I ). �
❑ 1 f the periy. .civ contracting .g with 1 J contractors i. A �./� l_ly] [V/ ��.•//
construct the project(See.]1004,Pusimss nnd Pmfe,axmns Code:)The Conann:ir's Li.
se Law docs not apply to an owner of property who holds or improves thereon,and QTY. PLUMBING PERMIT FEE ,� T
wbocommers forsuch projects wilbxcanamoso (s)I icunsed pursuant In the C^menet^r's
License Law. PERMIT'ISSUANCE
❑ I arnexcmpl under See .B&P C lir this reason A
ALTER-DRAIN&VENT-WATER(EA) I f f vA TUAj(lO
Own 'D I V ,
WOR RSCOMPI:NOTION UI CI AItAIION
y BACK FLOW PROTECT.DEVICE lis l U2 � �r
Ih bff nder penalyopep y llh following gJ f : r ( I�W- :x s
• ❑ 1 have and willmaintain a CenOrae of C tato:rIbir,mc for Worker s Coope.- URAI NS-FLUOR,ROOF,AREA,GOND. STORIES TYPECONSTRUCTION
satin as provided for by Section 3900 of the Lids Cook.for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Lalwr Code,for the performance of the work for which this pennir is issued. GAS-I:A.SYSTIFM-I INC/4 OUTLETS OCC ( AI'N
My Worker's Compensation Insurance carrier and I'nlicy number me:
Cartier Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF;EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - GREASUINDUSTRL WASTE INTERCEPTOR
U11. TNG DIVISION F}FS
(This section aced not be completed tribe Permit is fnnme hundred dollars($IfM1J GREASE TRAP
Ir
orlessJt is PLAN F:C .F
Icenify tBrsaw in Iscrifienname anymemberof he so ibekfor which this perthe Workers
ed.I shallCarrico- SEWER-SANITARY-STORM EA.200 FT.
ma employ any M^^^in Any mannersn e.ui:become subject to the workers'Carrico- ENERGY iE 19
ZZ cation Laws of California.Date WATER HEATER WNEN'DELECfR Y
Applicant a OR U G EE
.N. NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should WATER SYSTENITREATING SOLI
become subject to the Workers Compensation povisions of the Labor Cole,you must
Forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.EL PAID
UO 1 hercbyaffirmthat there is a construction lending agency for the lmrfomtanee of )ate Hecetp,#
the work for which this permit is issued(Sec.3097.Civ.C.)
OU Lendels Name TOTAL: `
U Liable,Address
r W 1 certify that 1 have road this application andstate that the above information is RUILDIN FEE
EcdA correct.Iaree m coral with all cit adcounts^ finances and state laws miming bs
g comply yon county ordinances s QTY. MECHANICAL PERMIT FEE SEISMIC EE
C„) Z building conswnion,and hereby amhorize repreunmives of thin city to enter upon the
above-vi'minned pmpeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harks
mthe City at Cupertino against ELECfR FEE
Iiabildies,pidgmems,costsand expenses which may in any wayaccmeagainst said City ALTER OR ADD TO MECH:
in consequence of the Bramin,ofthis permit PLUMBI G
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FE t
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
Signature of A,pIir.mK7mrasm, Date EXHAUST HOOD(W/DUCf) HOUSING MITIGATION IT
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant sore or handle hazardous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupenina Municipal Cale.Chapter 9.12,and the Health and Safety
Cale.Section 255321.1! HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑N�: VENTILATION FAN(SINGLE RESID) PAN
Dae Receipt p
Will the applicant m antra building by the B y A equipment or devices which
mit hazardous sic conmminanu as JelineJ by the Bay Arta Air Quality Manngmnenl BOILER-COMP(JHP OR 100,000 BTU)
District'
F1 Yes �No BOILER-COMP(OVER 100,000BTU)
[have read dtc hazardous materials m tx under Chapter 6,95 of the Cnli- AIR CONDITIONER ISSUANCE DATE
taco
fomia health&Safuy Calc,Sec5ons 255115,25533 nod 25574.1 u ideroand that if the NEW RESIDENTIAL.MECH. SQ.
building does nor Canemiy have a tenant,that 11 is my respmslbillty m notify the occupant
of the arranmm�cnts which mast be met prior to ostionce ora Cerrili^ate at Occupancy.
Owner or authorized agent Unix T ISSUED BY:
OFFICE