30997 APPLICANT TO FILL IN INFORMATION WITHINIRED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERFIIT NO. 30997
x O 9/N /N
JM
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL J{
BUILDING PROJECT IDENTIFICATION
�SIUILDTNG ADDRESS: L SANITARY NO. APPLICATIONSUBMUETALDATE
0`100
/VCR-rH TANTv 1 'KQ�
�yyN� 'S NAMLG 1 PHONE L I- NTRACfOR'S NAME LIC NO:
v A` C IC NO: - ` DD ICO.-JCC SNC GLI !, a NIC CONTROL♦
RCHITECf/F�` 1,1
3 op-016 Ave 06r-,- d 324 a
COM��AC7VL �•`� PHONE: p BUILDING PERMIT INFO
r�-1� �SO tlgf� �7/�-a•(i 700 Consulut Fm Paid by Applicant(Initial) EIF,Cf PLUMB MECH
96 LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
. IM1etmy aft 1Mt lam littnscd order Po.isiam al Chtrper9(cu mercin, JOB DESCRIPTION
FO=Z with Section 78(18)ofnivision 3 ofthe Business mad Professions code,and my liatuc is RESIDENTIAL
1- in full tome aril fl I •�r� PERMIT ISSUANCE
y,W ass A �al (o L/�r /p ❑SFDWL - ❑KITCHEN REMODEL
<U�j Date Contrast, WCQ SNC APPLIANCES-RFSIDLMIAL []ADDITION ❑PLUMPING RE-PIER
F�ISI Ove cSDF.u- _
N y� ARCHITECTS DECLARATION ❑MULTI-UNR ❑STRUCTURAL
Z c!!�- 1 ondentmld my Pld^•xhu0 be us 1 as public records PANUS MODIFICATION
p Z:]� UP'T0200AMPS ❑INTERIOR [I CHIMNEY REPAIR
IJcemed Prefeexiunal Ni-1000AMPS IMPROVEM Xr
;. OWNER-BUILDER DECLARATION OVER IOg1AM15 ❑BATHRPNODHIAU I AOLITION
ytxy C < I hereby of irou that 1 am exempt from the Comrixmr's License Raw,for the
W a O following aesun.(Scetio i AD U5,he,inexs mxl l'mfcuinns Cody:Any chy w moot, SIGNS FI rC`1RICAL. []OTHER
_
0
413which rrywraea'Pennll to convtmct,alter,impmc,dc
vma,hsh,or repair my my yo- ure
FSO prim to its ustaone,rho mryire the applicant for arch Permit to file a siyvil mrentent SPCCIALCIRCUIT/IISC
f }
Bou be la licxnsed Pwatmt to the Povisiom of tole Cca xtar.Liceme Law 1471uper9
p0 (commencing with Seefton 9100)of Division 3 of the Bulli ncsx and Pmfeuiens Cody)or DWR METIER OR POLL INS, COMMERCIAL
a Na hem esemP Iherefrnm anal the basis for the wcgcJ eaentptinn.Any violaism of ❑NEN'BLIXHAODITION OLITION
yu'�+ Section703"byany appliam f«apvnlit aubjap Ne alglicant toanvil pcmlry of POWER DEV] 3
LL1-rir ❑TENANT ❑ SERVICE
va snare than fire hundred dollars 153007.
-F-Z>` IMPROVEMF.YI' '
��Q ❑ Luownerof the bcsuroca myemployecx woffere ri,r lc tele 04,1.8 ioe. SWIM L[LCCfRIC
will G,thc worts,mal thc4rucwreisrxv imnvhN or offered farwlu(Sm]TUC,Hueilwu ❑09NIiH
and Profoxions Code:Ther Cnnuacu,a,Licen.sc low di tall apply to m owner of OUTL HES-FIX'NRF_S
PopmD who baBds a ttrtpmvn ucreon,arta wlto clue,%such uVok BimacU ac dun-.1. IF
hey own employee,art idW dart such imPovemenu true,p intendnl or olfacd for NEW FSIDFNrA SQ FT.
mile If,hnweveothe huildinem improvement is sold within on.,-of n,tnpinim,Nc SQ.FT FLOOR AREA SISQ.FT
—ltilde,w,It MVelhebirclim rtaringthat bedidnutbuild aintpmveIn, Iry Pq
pue
F1 1.m owner of the pmWty.un esch,"velY caw>nh0g with liceasd contmvtou m TOTAL '
a,natrect the,project(Sec.700.Busitcss and Profcvvioru Code:)The Cmluxtors Li-
xLaw does not ,1yK,-,onerofpropmty who builds or imProvcs thert.,u,and QTY. PLUMBING PERMIT FEE
whucmtrvets fm such projays with acontranot(x)licensed Pursuvnt to the Cnnuvcmr's y ^�
nw law. PERMIT ISSUANCE
Flamm
Uf II
leacpNcc
tmxar . ,11P11or1,c,umn lrY
Lia
ALTER-DRAIN de VENT-WATER(EA) VALU
Owner 'Lhlteof alL�/t
WORKER;SWFIPFNSATION DECLARATION i BACK FLOW'PROTECT.DEVICE
Nei (9
I Neiftrm uMe penalty of perjury arle the, ttcLvuimo:
❑IM1rv'eertd will muintainaCerifate,AComens to self-insum far Wiskers Campcn- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPECO 'TRUC'DON
Baum,as Provided for by Section Srtp of use Labor Code.fit the pMbmtarce of the
wort for which this Prntdt ix iueN. FIXTURES-PER TRAP
I have d ve awill rounnu n Workv'x comprnvum Inwrattt,as u,bmed by Section
3]Wofas,L3tafibbea Co,lee..foorplbe PrMu mmarce ofRe work fee massail
which this pe runt is . GAS-EA.SYSTEM-1 INC.J OUTLETS OCC GROUP APN
my/ Lemaca'^7C L`vi+G we cvrxrPattd olicy PNwy numlmr�ygr_ O� GAS-FA.SYgTEM-0VER4(EA)
o.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASF/INDUSTRL WASP:INTERCEPTOR
UIL N V ION FEES
(ThasectionmW mtbernmPlned'Jthe Lr'Genn Mfarae hutM,eJ dollars(SLIM)) GREASE TRAP
or les..) PLANCHF.0 r
anify that In inmy..nffeof the wohfoi which 0h is the Wisenni Col�11fen.- SEWER-SANITARY-STORFt EA. FT.
tort emPbY my Patron in any mannas so a,to become subject m the M'orken'Compeer- PN2RGY
Z atm laws a hliftania.late WATER HEATER WNFNTIELECIR
O Applicant GRAD] FTE
NOTICE TO APPLICANT,IC after mai ng l hi x Cmifcateuf laemption,you nhould WATER SYSTEM EATING
I"' ^ bem.Glib SOILS '
jM, the Wo la po Ca ere,or u t pmvivions of a loom Coale,Yet must
forthwith cmryly with sttM Posiakmmthispmnit shill be deemed rtvokcd. WATER SERVICE
7.Z CONSTe is,rmNLENDINGAGENCY NEW RESIDENTIAL PhMII. SQ.FT. PAID
U Q i,farw which
cry cro tvis twist uaitml Cing egelu:y forth perfumtmttof Dote RttciPM
W. F" 1-mer
rk for which Nix pumit is isslaJ lSx.31H'I.Civ.C.) TOTAL
1sMer1 Nvnc
O alenhrAddtcav' - 'IUTAL
Im
:
ei(y that 1 horeedvpp
ve eal thin licaoon and sense 1M1et be ehwe infm nmtatiivBUILDING FEE' �
y curmch 1 agrm m comply with all city atld caanty oNinmee vrd sure laws relating to QTY. MECHANICAL PERMIT FEE
V z building convrvetion,olid M1tteby luthariae reprmluuve of this city to rnte upon the SEISMICFEE
above-hemi t a{any fm impcniam putpxca. PERMITISSUANCE
(We)agree it, mu
save,btdcnify W tap hmleu the City of Cupmino agaitu0 ELECB
prIC ECB
liabilities,judgments.ensu and cxIsmyes which nary in my wary tame agiustmid CityALTEROR AUD'TO MECH.
in cuccuence of the' ein,of 1M1i,Permit PL
ataUMBING FEE
APPLICANT UNDERSTANDS AND WILL gOMPLY WITH ALL NON-POIT AIR HANDLING UNIT(TO 10000 CFM) MECHANICAL PEE
SOURCE
PBG' ATI DNS.
l7 'AIN HANDLING UNIT(OVER 10,000 CI M) CONSTRUCIIONTAX '
SuRraturre of EXHAUST HOLD(WIDUCD HOUSING MITIGATION
HAZARDOUS MATERIALS DISCLOSURE
W/I the applictrnt an forte building occupant arae tr hanAe hnunhmr material I]RATING UNIT(TO IBOOK)BTU)
v defined by the CuPcuim,MmLi,I Code,Chaple,9.12,and the Hcalth end Safety
Cak,._SV"n 25532(02 II EATING ON IT(OVER 100.000 BTU)
RT*cs ❑No
!ice VENTILATION PAN(SINGLE RFSID) PAID - Dae Raeip 0
Will 0c ur,caKnt or famre huildmg by he,B uxe Area
Air u a Management
which
emit luvuralousvr cumm�lwnt nv alcundl hY the Bey Amv Ah Quality Mana,cttant 11011.1?N-COMI'(7HPOR III),IM100TU) TOTAL:
Di uci BOILER-COMP(OVER 1mox)BN)
❑Ye, n
I have real the hen ,],Kva cWeiiaLs myulrcuents utldhr Chapter 11.95 of the Cali- AIR CONDITIONCR ISSUANCE DATE
Tania IlcalOh&SafctY CWe.Satitxts 25503,25577 and 25534.I uMmlarld tau if IM NRiW RESIDENTIAL MECH. SQ.Fn
banding cltrremRy ha.e tenon,.then itu teapausibilitY to notify 0heoavpan
d0a wT' prior m' afaCrni�te of
Owncror zd lyem Dene TOTAL: I ISSUED BY:
OFFICE