S2930 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELRCTHICAL PERMITNO.
BUILDING DIVISION APPLICATIONIPERNIIT PLUMBING-.MECHANICAL
BUILDING PROJECT IDKNI'Ih'ICA'1'[ON
BUIIDINGNIDRF_SS: SANITARY N I APPLICATION SUBMI'PI'AL DATE
5 Z. 4U -FI c('T`'
OWNER'S NAME: IPHONE: CONI RACTs S Ni , :oLIC NO.
NIC CON IkOLp
N: x �• yYb- �6 , owl �,
ARCIIITECT/ENGIN'EER: "LIC NO: DRI: ❑
CON TACT,- PHONE: BUILDING PERMIT INTO
DIE....bunt Fees Paid by Applicant(Initial) BLIO ELF.CI' P1,UMB MF,CH
LICENSED CON]RAC10RS DECLARATION QTY. ELECTRIC.PERMIT FEE
I hereby of irm that I am licensed under PtnVlsluns Of Chapter 9(ammnricag _ JOB DESCRIPTION
OC)Z with Scainn]0Io)of Divi' nlof I nesemtd Professions Code.and my license ix RESIDENTIAL:
M: p �, . FERMI"TISSUANCE
C'F in Nll fomo.nd cff.,yy.,,�r C SFDWL ❑KITCHEN REMODEL
¢UU Lmen.m Class--49S-/—I.ir Of APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBI,NG RE-PIPIT
ti 6 a Data =15�', Cnnwcmr
ARCHIL HUI`S DEC1464AI'1 EIMUTATUNIT ❑STRUCTURAI.
Z Iundcmend myplans,halltouvd5c
as pubrcoords I'ANF.LS
Z OyMODIFICATION
OZ-�, UP TO NIOAMPS ❑INT17RIOR O CHIh1NEY REPAIR
[F4F'W L¢cnmd Prnl eOmrnl 301-RXXOAMI'S IMPROVEMENT USWIMMING POOLS
-� OWNER-BUILDER DECLARATION
C¢ 1 hcaby a[tinn Nm nm exonpt from Ne Gm¢aaar'e license Law ties the OVER 11XXIANIPS ❑BATH RFMODEIIREPAIR 0 DEMOLITION
XO C U following rwaoa.OS.rtian 9031.5.Rusincss mrd Profession.Cad,.Any city or county SIGNS ELEC TICAL ❑(ITIIER n
u:3 C H
Qwhich requites a r
pemit alma ur coronet. improves re
demolish,or pair any nacmAre
prior to itsa,also equin,sth applicant fsuch permit file a:'gmd statement SPEC]AL Cl RCUITIMISC.
$�} but h I n:dpurw n the Fan i,ion' f t C Imclor,9' I ,00"Pler9
at C, (commencing with Section 7W)of Di vision 3 of the Business and Professions Code)or TEMP.METER OR POLE,INST. COMMERCIAL:
d y e C that be is exempt thvrchn o and the basis for the alleged rxeninion.Any violation of NEW BLDG/ADDITION 0 DEMOLITION
uk.=w Section]031.5 by any applicant for a permit subject,the applicant nr acivil prnalty of POWER DEVICES q TISKT ❑FOOU SERVICEot m
narc than five hundred dill...(S500k CEMENT
❑ 1.111 owner of the property,or my employees with wages as their colt asupetrsatlon, SWIMMING POOL ELECTRIC,
F ,ilido Nework,ara lhcoormais not imendedoroRercd farsale(See.]0,W,Insimess U;,ER
and Professions Gdc The Contractors License Law dons nm apply m an-wr of OUTLIifS-S WITCHES-FIXTURES
Propcny who holds Or improves there....trod who does such work huusclfm through
his own employees,provided that such fmpmvcmemh are not invaded or offered for NEW RESIDER[JAL IJSCTR SQ PI'.
,.10.If.hownr. m
'cJN buildo,or improveent is sold within oneycarnf completion.me SQ,IT FLOOR AREA 5/SQ.F1'.
crbaildar will I,-the burden of proving that ha did nal build nr improve fur pur-
pow m salad.
❑ I..s owner of the progeny,am exclusively xclsively contactingra
with licensed comcmrx m TOTAL
on.nmm the p get(Secs RIg1,Nuxincxs anJ I'rafcxxion,.Cndcp'Iln Conaunor',hi- -
cars,law docs not apply to an ow net of prnpcny who builds nr improves Nerenn.and QTY. PLUMBING PERMIT FEE
whocarracts for such projects with a contrmorr(s)licensed pusuanuo the Conamen's /� ///-.�
License Line / pT;RA11'I'ISSUANCE .1/ /_-± S
❑lam esempl..d,,Sec. .B A 1'C for his re son '+ ✓ U
ALTER-DRAINR VIiNT-WATER(ITA) ILl) VALUATION
Owner Dvlx ,,�//
WORKERS COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE: + APR 15 1999
. I hereby affnr under Farr of perjnty one of the following deduafams:
I haveand will nwtnafn aCerificamafConsenao.self-insure tin Workers Compvn- DRAINS-FLOOR,ROOF.AREA,COND, STORIES TYPE CON.' "PION
sation,asprovided f r by Section 3]00 of the Lulaor Code,for the pefforamence of the
work[or '1 the p I 1 PINT URES ['ERTRAP By
❑ Ih d.,If s t W k :c p I . q ' dbys t o ,n �1----_.__
3700of the Labor Code.for the serfom ce of the work for which this permit rxssued, GAS EA.SYlTEM-I INC.i OUTLETS (/ -OCC.GROUT'
My Wnrkc F �7`satly�Ins'!{�.cy.urtirrand PnlicY numRe pE
Cuvier F t,>LY__L�_PulicY Nn.:Nf+L 9p'L 91.03 GAS-L'A SYS'I'LM"OVIiRO(IiN
CEH'II CATEOEISM[O I NPROM WORKERS' GREASUDNDIISTRL%VAST E IN'1 ERCEPTOR
C(IMPENSA'1'ION INSURANCE BUILD]NG DIVISION IFES
Ilhkore,.inn need nut beeompleted if he -rt is unone hunrlrtWW
coll—IS I t GREASE TRAP
or Ic,cl I'LANCIIECK 14i1i
Iccnifythul fihcpcd'ormanccol thewa,khrr whichihispamil,i,,OIL[eaall SEWER-SANITARY-S'FORM PA.2001-1
not anploy any person in any manner so as to th con re subject to the Workers'Conopep, ENERGY PCIS
Oz sation Law,of California Date %%'ATER HEATER W/VIiNTMITICTR GRADING THE O APPlicam
(n NOI'DCF,TO APPLICANT':IL alter m.king Nis CeniOcmc of Exemption,you should WATER SYS]EMG-RIiAI'ING
a ; bccnme subject to the Workers CmmPewmin I pmvi im,of the Labor Code, sat must SOILS ILL:
fanhwith comply with such provision,or this permit shall hedecmed mvoksl WA'I'IR SERVICE
1z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMU SQ.IT PAID
U 0 IIt...by.frim that there ishcnn,amctiou lardin0 agen9 hmhcpcefmnauccof Dac Receipt OF
LS. - the work for which this cooks issued(Sec.3097,Civ.C.7CV
0 11'U Lender's Nine TOTAL":
r UU Lender's AdNcss TOTAL:
L1 1 cenifY that 1 have rend Nis applicminn and,taro that the a6nx infnrnrmion is ItU1L IN -
F-' ta) correct I agree m comply with all city and county ordinances and state laws relming to Q1 y. MECHANICAL PERMIT FEE
U Z mundEng emt.lmermm.and hetwya,dtmiu reP emarvea of Ni,citytn an,,,pan the selsMl sB
,Mrvomentioned Propcny for inspection pngnms. PERM]I'ISSUANCE
(We)agree in save,indemnify and keep homeless the City of Cupertino against L'LECI' IC GEIi
IiuNdide,.iudgaam..eaels and OO,T ewhist.may immry way accrue apninst said City AIA Idn OR AUDto MI?CII.
in I'LUhtli GIEIi
consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNTI(fO III,IXOCFM) MECIIANICr ,IEE
SOURCE REGULATIONS. /J f
4 /f i AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUCTION TAX
S t hhcnd AppllcmWCo ana,1r J Umc EXHAUSTHOOD(W)DUCT) HOUSING MI'1'IGMION IFR
HAZARDOUS MATERIALS DISCLOSURE
Will thempplicanlnr turn,huildingacrupantsnnr or state hmanktw mai DEAD NG ON IT(TO 101,000 BTU)
Code,Sw bathe Cu, ren MOnici Fail Cali Chapter 9.12,and Ne health and Safety
,wry BEATING UNIT(OVER IIXI,IXXI R'TO)
�Yu rr VId`D[LA'TION I AN(SING I,it RES IDI PAID Uwc Rcaclp,v
• Will the applicam m future huilding arupam use equipment ar den'ica which ROILER-COMP(311P OR 110,000 BTU)
count hmnrinus air comunntanre ax dchneM by the Buy Area Air Quality Mmmgement TO
Di,tnci! BOILER-COMP(OVER 100.000 B'IU)
E)It's �w
II' l he h.unu,ni as,ineanualand Chapter h)50Ne Cali AIR CONDI'I'IONER ISSUANCE DATE
Forma Haalih&Safety Code.Section%25505.25533 and 255W 1 understand that if the NEW RESIDENTIAL MECH. SQ.IT.
fu ld'Ing—cNoot illi t t th t Y :pore bill I to the cvwP.nl L(/ - �• /
f the".,rcne whah moa bet tpn ofuC rlf t f(kavp'ncy
Ihndecd ugcm
Dom TOTAL: ISSUED BY: P
OFFICE