30758 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY. "
CITY OF CUPERTINO I BUILDING.ELECTRICAL. PERMIT NO. 3 0 7 5 8
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-..MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDI.NGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
e)JL— Ct 141- -2-
OWNER'S
OWNER'S NAME: PHONE: CO rA T RSNAME: LIC NO:
I!� ^r / 91.4 . NIC CONTROL#
�ARCHITECT/[iNGINEfiR:i LIC NO: ADDRESS: /�� ❑, .
U S4 U 4,
CONTACT PHONE: T)0"-2e,_ I VS" 1.(P BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT.
ED ' MECH
❑ LUM
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I heruhy affirm that 1 am licensed under provisions of Chapter 9(commencing JOB UES ION
w0Z with Section 7")of Division 3 of the Business and Prof inions Cade,and my license is RF_SIDENTIAL:
FK(y� in full force and effect �0 PERMIT ISSUANCE
<-U License Class Llaa (aJ eF1(n.'u ❑SFDWL ❑KITCHEN REMODEL
F ZW Dare /.� Comrvcto ,'�' u APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING REPIPE
ARCHITECTS DECLARATION ❑MULTI"UNIT ❑STRUCTURAL
Z p m Z 1 understand my plans shall be used as public records PANELS MODIFICATION
OZ-`"+0 UP T0200AMPS ❑INTERIOR [I CHIMNEY REPAIR
[-4 t:W LicemW Prol'essi...I '- 201-IC00AMPS IMPROVEMENT
�Yfa OWNER-BUILDER DECLARATION OVER IDOGAMPS ❑BA ODEIBEPAIR [I DEMOLITION
C C 6 1 hereby affirm that I am exempt form the Commetor s License Law for the
{tadd a.U. following reeom.(Section 9031 5,Business and Pmfcvions Coal,Any cay m,i m, SIGNS ELECTRICAL HEk
W a p y which requires a permit to construct,alter,improve,demolish,or repair any slrucmr,
F•^rn; mit he licensed
p,aluantto res provisions
fur Contractors
License aw(Chaptem SPECIAL CIRCUIT/MISC
p. that he is licenud pursuammthe provisions of the Commctors License Ww(Chapmr9
00 (commencing with Section 7")of Division 3 nl'the Busine,and Pmfexsions CoJc)or TEMP.METER OR POLE INST MR L: -
A.a c W Ihat he is exempt therefrom and the basis for the alleged exemption.Any violation of BLDG/ADDITION ❑DEMOLITION
X^LL Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES '
u'..y nm more than five hundred dollars($500), IMPROVEMENT ❑FOODSERVICE
' O FlI..sowncr of thepmpcny only employees with wages as their tole cofpenswion, SWIMMING POOL ELECTRIClit
, IMPROVEMENT
F• wiDda Newurk.ane thes0ucturc rs not intended or ufferedfor sale(Sea 1044.11usiness. COTTER
1, co and Professions Code:The Contractors License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvmncws are not intended or Offered for NEW RESIDENTIAL P.LECTR SQ FT.
sale.IL however.the building Or improvement in sold within one year of completion,the _ SQ.FTFLOORAREA $/SQ.FI'.
ser-bar-
uilder will have the burden Of prdving that he did not build or improve for p
Elseofs.lc). • I•
7 1,as oviaer or the pmperty,am excluovely contracting with licensed coal...I m TOTAL: / ,. A /
construct the project(See.o an Business and Professions Code:)The e%daemon, Li fix./l Y
e se law Joel not apply a an owner of pmpeny who builds or improves daemon,and QTY. PL IN MIT FEE
who commas for such projects with a cnntmetogs)licensed pursuant to the Conlrectors
License exempt
L
1 an exempt under See ,B&I'C for rcm
Nis on PERMIT ISSUANCE.
Owner Datc ALTER-DRAIN&VENT- TE (EA) VAL
WORKIRSCoMPF.NSATIONUFCI.ARATION BACK I1-OWPROTLLT DEVI H
I hereby ff de Penalty f perjury one of the bellowing d I tons:
❑ Ih e d maintain t Certfct fConscnt m wifmsu foW kr:Carmen- DRAINS TUJOR.ROOEARF.A. STORIES A ' TYPECONSTRUCDON
satin . provided f by Section 37M fine Labor Code,f the Pedurmance of
work far.which this per i t is iotiedFIXTURES-PER TRAP
1 have and will maintain Workers COmper-oan Insurance,as required by Section
3108 of the Libor Code.fur theperformanceofthe work for which this permit is issued. GAS-IiA.SYSTEM-1 INC.4 OUTLETS IXC�GRpg11 3 Es® APN
My Workers Compensation Insurance carrier and Policy ngmber arc:
rri ]YIV1ii 1��pUCtly t
Cuer: Policy NO.: GAS-IiA.SYSTEM-OVER 4(EA) L
CERTIFICATE OF EXCMI'GON FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR BQjIT)INCsIpIQ1El
(This section need not be completed if the Permit is for one hundred dollars(S 100) GREASETRAP
ur le"') PLANCHECK MBE
I ttr fyth b pert f b kf h'hih'p 'I. ...ed lshvll SEWER-SANITARY-STORMFA.200 IT.
not employ y pc y .t Mc subject t the N k Co pcn ENERGY FEM
Z
sation Laws ofCalifismia,Dam - WATER HEATER WNENT/ELECTR
Z �.
Applicant GRADING FEE.
y NOTICE TO APPLICANT It.after making put,Cortillemeof Exemption,ywr should WATER SYSTENVTREATING
a ; become subject to the Workers Compensation provisions of the labor Code,you must SOILS FEE
W
forthwith comply with such provisions or this Permit shall be deemed revoked.
WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.FT PAID
a
Date
U C I hemby affirmat there is a construction lending agency for the performance or
construction Re Et a
the work fur which this not is i.emee 15ec.31131,civ.C.)
Lender's Nume /, �1 TOTAL:
U Lenders AJJma T7 'DOTAL:
} y I madly that 1 have read this application and state that the above information is BUILDING PEE
m
.` F' t/t correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERM IT FEE
'U Z building conswction.:nd herebyauthonre representatives of this city to enter upon the SEISMIC FEE
abovementionedproperty for inspection purposes, PERMIT ISSUANCE
(We)agree to save,indemnify and keep hess the Ci,of Cupcnino against ELECTRIC ITE
wml
liabilities,judgments,costs and expenses which may in any way accmc against said City ALTER OR ADDTO MECH. 4
nsequcnc !lire granting of this pvomt. PI
APPLIC UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,(x)0 CFM)
SOU REGULATIONS. " ECHANICAL PEE
AIR HANDLING UNIT(OVER 10.600 CFM) C AX
Signawrcnf ApplicwUCOmmcnv t� I' Date EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant Or future building Occupant store or handle harardivis material HEATING UNIT(TO 100.000 BTU)
u.defined by the Capistrano Municipal Code,Chapter 9,12,and the Health and Smote
Cole,Section 25532(a)'I HEATING UNIT(OVER 100,000 BTU) I
❑Yes E]NO VENTILATION BAN(SINGLE RESID) PAIL`/may [f/
Will the applicant or future huildin t use equipment or devices which Dme Receipt a
PO dby the
4alp BOILER-COMP(3HP OR 110.000 B'I'IF
emit haxarJous air contaminants as defined by the Buy Area Air Quality Management ,
OTAL:
Distract?
❑Yes Fl No BOILER-CONIP(OVER 100,000 BTU)
I have read the havudounnaterials mquircmerla under Chapter 695 of lire Cali-' - AIR CONDITIONER ISS ANCEDATE
Forma Heald!&Safety Code.Sections 25505,25533 and 25534.1 underannal that if the NEW RESIDENTIAL MECH. SQ.ET.
building does not currently have a larval.that it is my responsibility In notify rhe Occupant _
of the rcyniwmentx wM1icM1 mu l it ma pyi+u.is<uance'd n Certificate nr Occu�ayr
Owner or aathmaed agent Data TOTAL: ISSUED BY:
OFFICE