29666 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILDING-EILECTRICAL PERMIT NO. L^^ ^6
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL xVJ lL�/ lhJ
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANTrARYNO. APPLICATION SUBMITTAL DATE
OW MF.: - PHOyyEL �� COM1TRACCOR'S NAME: LIC NO:
NIC CONTROLp
A TF /E G EF ' LICry� „ ADDRESS: ❑
CONTACT. _ PHONE: BUILDING PERMIT INFO
b' „fAlC�j ❑ Consultant Fees Paid by Applicant(Initial) BLDG - ELECT PLUMB MECH
�I 7rf* �V a I?� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE -
1 hereby affirm that Tam licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
w0Z with Section 7000)of Division 3 offs,Business and ProfieVacna Code,and my license is .RESIDENTIAL:
Fyw� in full force and effort. PERMIT ISSUANCE ❑SFDWL [3 KITCHEN REh10DEL
6UU License Class Lisp
tFa 4I DateContractor APPLIANCES-RESIDENTIAL. []ADDITION ❑PLUMBING RE PIPE
G ARCHITEC'SDECLARATION ❑MULTI-UNIT El STRUCTURAL
�Fu,z I understand my plans shall be used as public records' s PANELS MODIFICATION
Z 4 UPTO 200 AMPS
I-[?,tW Licensed Professional - ❑INTERIOR 'El CHIMNEY REPAIR
201-IgNIAMPS IMPROVEMENT
Ck�a-,1 OWNER-BUILDER DECLARATION OVER UM)AMPS ❑BATH REMODEURF.PAIR 0DEMOLITION
S C W d I hereby affirm mm I am exempt Imre the Contractors License Law for the
x 3 d U .following reason.(Section 703 1.5,Business and Professions Code:Any city or county SIGNS ELECTkICAL ❑OTHER
41 h,y which requires a permit to construct,alcor,improve,demolish,or repair any structure
prima,its lesuvn,,,msomquirm the applicant frreuch permit to file asignedstetemmat SPECIALCIRCULUMISC. i
Fa y that he is licensed pumuantto the Provisions of The Contractor's license Las,(Chapter 9
tailaQ�O (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE IN'SL COMMERCIAL .
Q.=0 y dfm he is exempt therchoor unit he basis for the alleged exemption.AnY violutinn of E3 NEW BLDG/ADDITION ❑UEMOLI'1'ION
4• Section 7031.5 by any applicant for a permit subjects the applicamm a civil penalty of POWER DEVICIS
W , r . ❑TENANT OFOODSERVICF.
F=Qnut more than five hundred dolhmrx(551X1. IMPROVEM17NT
IT Las owner of the property,army enmployees with wage;as their sole compensmion, SWIMMING POOL ELELTRI
p.,� will doshewmic.andthemoretureisnotintindedmuffercdforsale Sec.70x4.Business ❑OTHER
3 m and Pm(csximns Code The Cammcmrs Licerae law drus not app1Y to an owner of OU'TLF.TS-SWITCHES-FIXT S
,property who builds or improves thereon,and who docs such work himself or Through
hits town empinycc..`prmsided thin such Improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ
sale.If,however The building or improvement is sold within one year of completion, SQ.FT.FLOOR AREA S/SQ,FT
er-builder will have the burden mf proving that he did not build or improve for put-'
pose of staled.
❑L as owner of the pro ,pa am exclusively coenciing with licensed contractors to TO' L:
xtitmct the project 040,Businnys vnd Pmfesxiuos Grade:)The Commemh Li-
exaseLawJc a cto an owner of OroMnY who builds or improrcsthcaan,and QTY. PLUMBING PERMIT F' -
whocommcfsfurs, injects with a commmogX licenwd pumountto The Contractors -
License Low PERMIT ISSUANCE
❑lam ex m S -.B&PC for eason
I 4POwner Date ALTER-DRAIN&VENT-WATER RAJ VALUATION f
WORKER'SC 1 iN ATIUN ULCLARATION .BACK PLOW PROTEGE.DEVICE (�„
sea yul Erre under t lyre(perjury ane of Ne following Juavminns - `o 00
•(]Ihavemtdwillmaintaina - mfica,ofCmnwnt to self-insure for Workers Compen- DRAINS-FLOOR.ROOF,AR EA.COND.
suflon,as provided for by Section 3700of ton, ub
Lar Code,far The performance of The STORIES- TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as acquired by Section
3700 of the Labor Code,for the perfrrm:mce of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS UCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number ora:
Came, Pal icy No.: GAS-EA.SYSTEM-OVER 4(EA) -'
CERTIFICATE OF EXENIM]ON FROM WOR KERS'
COQMPEITSATION INSURANCE GREASIANDUS HU_WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section rte nbecompleted if the permit is for hundred dollars(511X) GREASETRAP q
or
less.) PLANCHECK Irlil: 73 /S•
I certify Tito n anRomrnanceort,tob -fmwib: is permit is iesuN.l shall SEWER-SANITARY-STORM EA.200 FT.
not employ am man munncrsn azmh tone sub let fin Ne Wmkec'Compare ENERGY PEE )I !
lotion lawns t WATER HEATER WNENTMLECTR
Applicanf GRADING FEE
z y NOT ICH a m NT:If,of is ;akin this Cenilicate of Exemption,you should WATER SYSTEM?REATING
a becomes jocf m Ne Workers C pensadon provisions of The Labor Code,you must SOILS FEE
Curfhwilh comply with ouch pnrvis nc ter this permit shall be deemed revoked. WATER SERVICE
a O $-3- 77
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FC PAID 97.3
V 0 Ihcreby nfEmvsm there isemw
nsction lending agency far the peri mm�
inecnf _ m —Receipts /Co.
D. F. din work for which this permit is issued(Sce.3197.Cie C.)
Lender's Name TOTAL:
V Lenders Address TOTAL:
r a 1 cenify that 1 have read this application and state That the above information is BUILDING FEE
FTA correct.l agree to comply with all'cify and coumy ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
C.) Z building construction.and hereby msodze aprewnutives of this city m enter upon the SEISMIC O
alcove-mentioned property for inspection purposes PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against IiLECfRIC Eli
liabilities.judgmen .costs and expenses which may in any'way accrue against said City ALTER OR ADD TOMECL
in onseque f e granting of this permit PLUMPING -
APPLICA ' DERSTANDS AND "ILL CO PLY WITH ALL NO 1-POINT ALR HANDLING UNIT(TO 10,gX CFM) AIr
SOU C RF'MATIONS. - — MECHANICAL
GAIR HANDLING UNIT 10,0(111 CPM)
CUNSRUC10TA
Sig a of pl icanUCon emr - Duo EXHAUST HOOD(W/DUCT) n . HOUSING MITIGATION FE '
HA 1 DTIGA
OLS MATERIALS DISCLOSURE .Lw
Will the applicant r future building occupant store or handle hazardous material HEATING UNIT CFO 101030 BTU)
tax defined by the Caperton Municipal Code,Chapter 9.12,and the Health and Safety - '
Code,Scaion 25532(x)? - HEATING UNIT(OVER 1110,(X0 BTU) CITY I IF tat fr'm (Yl \V1
Yes Nm PAIDS
vENTLLATION PAN(SINGI.Ii RES ID) part kccci a
Will one applicant or future building occupant use equipment or devices which. BOILER-COMP(3HP OR 100.000 BTU)
age
m t haa:uJaus air romaminonu as Jested M1y Ne 16sy Arcs Air Anality Manment TOTAL:/V4
;lE
DisVi[17
❑Yes O�Vo BOILER-COMP(OVER I01000 B'TU)
ONDII
AIR RESIDEN'FIA
4n �mly
xismaterialsrequiremam under Chzpfer 6.95 of the Cali- ISSUANCE DATE
hrmix HWC,Secfionn 25505.25533 and 25534.1 understandthat ifNe NEW kESIDENTIAI,MCCII. SQ.PT.bulldinghave a tenant That iti. ynx,,si ,1hy,arm yth ec'memsof themost be tprior once, 'coif a y.
thitnual agent I Olue, TOTAL: ISSUEDBY: D,��
OFFICE