30912 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. 30912 0 /A /N
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL JK `4J L
BUILDING PROJELT IDENTIFICATION
BUILDING ADDRESS:y � SANITARY NO. APPLICATION SUBMITTAL DT o P 4ia1r/
OW ,R w e //- 14/ PHONE: C RA R:S 4 f 4c1l".✓ I.IC : 0 NIC wCONTROL#
AR RI=R: LIC NO ADWr
CONTACM PHONE: HIJILDING PERMIT INFO
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Fees Paid by Applicant(Initial) BrLDDGG� ELECT PLUMB MECH
b Ka El
I'O
LICENSED CONTRACTOR CLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed ntder provision.of Chapter 9¢mnmencing JOB DESCRIPTION
too, with Section OWU)of Division 3 ofthe Business and Pr fessinsas Cade,and mylicense is RESIDE t D
FWO full force and eBect. PERMIT ISSUANCE
aUU Liccn.,c Class Lica D C( 05FDWL DO KITCHEN REMODEf.
aFQ WW Dme Commmor APPLIANCES-RESIDENTIAL ❑Aryp�DIITION 11 PLUMBING RE-PIPE
N HITECTS DELLA ATION ❑Y141111�A•IFG ._[]STRUCTURAL
Z O y Z I understand my plans shall be used as public rtcamis PANELS aelll[ 7lOq
OZ-1 uF TO 200 AMPS MOUIFlCATION
W Licensed Profewi...I II�,T�RIOR ❑CHIMNEY REPAIR
q XM_tl OWNER-BUILDER DECLARATION 301-IfgIIAMPS hMP�Rs fi'CN rr11^�I�/T
P:W Q 1 hereby affirm that 1 am exempt Irom the Cunaact ns License Law for the OVER I(OMIAMPS El REMODEUREPANI)b DEMOLITION
?P��O IL U following reason.(Section 0031.5,Business and Professions Code:Any city or county SIGNS ELfiCTRICAI. ❑OTHER
W O[ta-n which requires a permit m cnmtrva,altar,improve,demolish,ur repair any dre come
F'�m.] prior to its issuance.alsm requires theapphicamfor such permit to file a signed statement SPECIAL CIRCUIT/MISC.
} mut he is licensed pursuant o the provisions ofthe Conmictor's License Law(Chapter 9
aS (commencing with Section 0(MIO)of Division 3 ofthe Business and Professions CWs)or
p0 M oR POLE INST. fp COMMERCIALS
d d ey that he is exempt Therefrom and the basis for the alleged exemption.Any violation of
N Section 9031,5 by any applicant for apemnit subjects the applicant a cavil pmaky of IiR DEVIL y �• WBLDGIADDITION 11 DEMOLITION
1-Z} not more man Five hundred do]].(S5W). PANT [FOODSERVICE
Sap 0l,as Owner of the propeny,or my employees with wages as their sole compensation, SW POOL ELECTRIC I OVEMENT
F- will do the work,and the structure is notimended or offcrtdfor sale(Sm.OOW,Business OTHER
13 m end Professions Cade:The Conrramor's License Law does not apply to ua owner IT 3 OU1'LIns TCHES-FIXTURES
progeny who builds or improves Merton,and who does such work himself or through
his own employres,provided that such improvers ms are Oat intended or offered for NEW RESID ELECTR SO PT.
hale.If.however,the building or improvement is sold within one year ofcompletion,the SQ.ET.FLOOEA S/SQ.1T.
liter-builder will havethe bmJenofproving that he did not build or improve for pm- A OO
qts,uGulc.l. `/^i `L.
0 I.as owner of the propeny,am exclusively contracting with licensed contractors to T
onsuua the project(Sen.9(44,Business and Professions Code:)no Contractor's Li-
camelawdoesnotapplytoanownerofpropenywhobuildsorimprovesmenton.and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contmemrts)licensed pursuant o the CuntmRor's
License law.
❑Inmexemptunder .Ser. ,B&PCET,d rearom PERMIT ISSUANCE
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WOR KERS COM PENSNOON DECLARATION BACK FLOW PROTECT.DEVICE ��
I hereby affirm under penalty of perjury one i f the following dre
eclations: `
O l have and will maimana Cenificae of COnmm towlf-insure for Worker,Co.,.- DRAINS-MOOR.ROOT.AREA,COND.
satin,,,as provided for by Sectioibo
n 3700 of the Libor Code,for the performance of the STORE TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
0 I have and will armumin Worker'%Compensation Insurance,as required by Section
37W cut Labor Cose.for the performance ofthe work for which this permit is ismed.reGAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GRO ppN
My Worker',Compensation Insurance carrier and Policy number a :
Contact: Policy No.: GAS-EA.SYSTEM-OVER 4(E-A)
CERTIFICATE OF EXEMPTION ITtOM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(This section need not be completed ifthe permit is for one hundred dollars(S10) I LDI 'r DIVIMONEFES
or less) GREASETRAP PLANC C
Icenify that in the performance ofthe work for which this permitise,C Ishall
employ Law any person iaDa manner so nsmbecnnc.whjccun thu Wurkers'ComPcn- SIiWER-SANITARY-S'T'ORM EA.2IMI FT.
ENERGY FEE
O ,Z cation Laws of California..Date i+
O Applicant WATER HEATER WNENT/F.LECfR GRADING FEE
C NOTICE TO APPLICANT:IL after making this Cenifi<am of Boonton, you should
became subject m the Worker's Com r WATER SYSTEhf/TFtEATING
a Compensation somiisums of the Labor Code you must SOILS FEF;
W 1'onhwith comply with such prrvi,iuns or this permit shall he deemed revokedWATER SERVICE
z
UCONSTRUCTIDNLENDING AGENCY NEW RESIDIiNTIALPLMN. SQ.FT. PAID
C..1 0 Tfar which
That here isacd(Sol,iun len ding agency forth,perfunnance of Done ceipt#
C•t he Leaders for which this permit is issued(Secs 3099.Civ.CJ
F-� Lender's Name
O U Lcndcr's Addres TOT
FWOTA,:
C)a 1 cenify that I have real thirty had coup and Imre that the above information i, BUILT 1.
lin carrtecs.lagrcemcomply
and with all yauthriv county osaod rime law.vm upon
QTY. MECHANICAL PERMIT FEE
V,2 buildi-mentionad fosters hereby auttionpic representatives of this city mcnmr upon me SEISMI FEE
above-mentioned propeny far inspection puryaxes.
(We)agree to save,indemnify fail keepbamdcss the Cit f Cu vino f mna PERMIT ISSUANCE
Y o pe d ELECTRIC I>fi
incoities,joce,oftegranind of thisPes whichmayinany say az<me again,,said City ALTERORADDTOMECH.
nsequense ofthe granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-7DINT AIR HANDLING UNIT(TO 10,010 CFM)
SO RCE REGULATIONS. 1 ' I MECHANICALFEE
s_ Ia�
Si Nnn�
/l� AIR HANDLING UNIT(OVER 10,0(10CFM) CONSTRUCTIONTAX ).
gnammuf Applicant/Contmetor Date EXHAUST HOOD(W/DUCT) a
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE -
WiBtheappYcantorfuturehnJdingoccupantstoreorhandlehmardousmatenal H EATING UNIT(TO 100,000 BTU) `
f1 defined by the Capeni.O Municipal Code.Chapter 9,12.and on,Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,00 B FU) 1
0 Ye, 0 No
VENTILATION FAN(SINGLE RF.SID) PAID
Will the applicant or future building occupant use equipment or devices which Date - Re apt#
snit hmardous air comaminents as defined by the Bay Area Air Quality Management BOILER-COMP QHP OR 1 W,Op RTU)
Distdn?
TOTALYee [3No - BOILER-COMP(OVI:R I WAW BTU)
I have read We hazardous"imaals requirementx under Chapter 6.95 of the Cali. AIR CONDITIONER
forma Health&Safety Cade,Sections 25505.M533 and 25534.1 understand that if the ISSUANCE DATE
huildingdmes matennently have a moan,lhm it is my rcsponsibliny tomotify theaucupant NEW RF-RIDENTIAL MECH, SQ.IT.
of the requimmsnss which must be met poor to issuance ofa Cenificue of Occupancy.
Owner or euthnnzcd agent Date TOTAL:
ISSUED 13Y:
OFFICE