31378 iPPLICANTTOFILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PMMU NO. 3 7 O
BUILDING DIVISION ,APPLICATIONIPERMIT PLUMBING.MECHANICAL J o
BUILDING PROJECT IDENTIFICATION
ILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
/ S41kE 9Sbi�l oliq q,6
NCR'. NAME: �PJ T�SdCI CHONE %DA TORS NAME f / `Oe ^LICN
GIG-' lC J L NIC CONNTR(OOLL#
/ ORI:CT/I:NGINF[R: LIC NO: ADDRESS; ❑ �a�V�
//TT ffg .56 761 ArLe . San JhS'P (q
CONTACT: O: BUILDING PERMIT INFO
�) ❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELEQ. PLUMB MEC
-C- ht si i�uG 97 3678 �yufll �j{\ ❑
LICENSED CONTRACTOR'S DECLARATION
�Z QTY. ELECTRIC PFiRMIT FEE
1 hereby affirm that 1 a.licensed node,provishm.a of chapter 9 O'ommendn6 JOB DESCRIPTION
with Section 7")of Division 3 rfthe Business and Professions Code,and myliccnseis RESIDENTIAL:
F in full force and offu7. PERMIT ISSUANCE
aVZV
Lt.le Class Lit,# DSFDWL D KITCHEN REMODEL
y<1 ) Contractor API'LIANCFS-RISIOENTIAL DADDIIION DPLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT D STRUCTURAL
Z O h Z 1 rndemmld my plum shall the,told az public records MODIFICATION
O Z UP T02110 AMPS
Fa:E"W Licensed Professional E3 INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-III UROAS IMPROVEMENT "
L C=< I hereby affirm that 1 am exempt from the Combanoh License Law for the OVER 1000 AMPS D BATH REMODEUREPAIR D DEMOLITION
X O d U following reason.(Section]031,5,Balint"and Professions Gale:Any city or county SIGNS ELECTRICAL D OTHER
LL LLO yG which requires a permit m construct,aheq improve,Jemnlish,nr mpair any nmeturc
.F.yH.] Primmill ismonce,of-,recalls,thaapplicunt lo,such permit m Rleasignudsmement SPECIAL CIRCUIT/MISC.
� }a� that he is licensed pursuant to the provisions ofthe Comments License Law(Chapter 9
0O (commencingwilh Secliolh]0W)of Divi•inn 3oflhe Businessand Pn hesirns Coca)., TEMP.METER OR POLE INST COMMER IAL-
g,
A ,
a Xe that he is exempt therefrom and the basis for the alleged exemption.Any violation of
W u, Seclson7031.5 by any applicant for a fiction subjects the applicant m a civil penalty of POWER DEVICES 1 El NEW BLDG/ADDITION ❑DEMOLITION
f=Ct more than five hundred dollars($50)). ANT ❑FOOD SERVICE
D Las owner of the progeny,or my employees with wages as theirsole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
F will dmhe work,and the structure is not initialed or offered for sale(See.IIb4,Busineof s DOTHER
tai]`m and Professions Cade:The Contractor's License Law dols not apply man owner OUTLETS-SWITCHES-FIXTURES
propany who bo olds or improve,thereon,and who dors such work Imre#f nr through
his own employees,pmviderl that such improvnhmms arc not intended m offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.IL however,the building or iioprovenhent is sold within one year of completion.the SQ.FE FL(1DR AREA $ISQ.FT.
fir-builder will have the burden of that he did not build or improve for °
proving p pur-
❑p�eofsala.). YYY 2
1,a,t the p li the props(,am exclusively contracting with licensed nhrttmnors i- 0 2 9 199
construct La the project(Sean a amHolmes,,oft and Pnhfeao bum Code:?The,as polar, Li- /
onaelmmetsf not apply man with
ecofpmpeny whosedporimprovga thcreogors QTY. PLUMBING PERMIT FEE
whom Lars, insuch projects witharommcmrt)licensed pursuant Crnnactots
7
License law.
❑ Mum exempt under Sec. ,BKPG for this reason PERMIT ISSUANCE C 1Y OF Lauf Cnlll V
•
ALTER-DRAIN @ VENT-WATER(EA)Owner DaleVALUATION
WORKER'S under
P COMPISNSATION DECLARATION folATION HACK FLOW PROTECT.DEVICE
1hereby affirm underpenoltY le perjuryone ofthe followingdeclaration,: �a
❑ Ihava#rd.aide mammonarour 37W of he Ladtro sel6inwr'he Workers Ce of the DRAINS-FLOOR.ROpE AREA.GOND.
cation,os provided for by Section 3]00 of the lahor CWe,for the performance of the STORIES TYPE CONSTRUCTION
,which this nais issued, FI%TURFS-PER TRAP
w 1 have and will maintain Wmkets Compensation work
hi us ru,Na!t i Saaian
SI of the LaborCodhe perfnr '�r+(he dissilic for which lis permit is issueJ. GAS-EA.SYSTEM-I INC.40UTLETS
My Worker's Co.,.,pens. icr mcy Nicy number are: - ( OCC GROUP APN
@niers )Il lie No.: GAS-F.A.SYSTEM.OVGRJ(EA)
CERTIFICATE Oil FIT10N FROM WORKERS'.
COMPCNSASNTIONINSURANCE GREASEINDUSTRI.WASTE INTERCEPTOR
('ITissmtnn need nm be cnmpletW ifthepermit is for one hundred drllaa($100) BUILDING UI VISI. PEGS
or less? GREASE TRAP
PLANCHECK FEE
Loy say th:nin the outmynexa e,mlica tfie smbec nnevabjec,or Permithe W-Irrrissued, ,m-shall SEWER-SANITARY-STORM EA.200 FT,
not employ any person is any manner so as m become subjecuo the Workeri Compete 17NERGY PEE
Z unionaLaw.a of California.Dale
� WATER HEATER WNEN'1'/ELECTR
0 Applicant Z y
NO DUE TO APPLICANT,If,after making this Cenif icnm of Bnemption,you should GRADING FEF:
a became subject m the Worker'sCompenmtinn provisirm of the Lvhar Cade.you must WATER SYSTEM/IREATWG
frnhwimttun I th such SOILS FEE
0.
Q pywi provisions nr thi•permit shall the revoked WATER SERVICE
Uz CONS] isramRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ,FT PAID
VQ I far
rmthawrot i is#construction landing agency Tonic performance of Receiptp
W F the work for which this permit is iauN(Sec.3097.Civ.C.)
U 1o, dei Name
F p,
r LenJer' Address TOTAL: TOTAL:
I cenify that 1 have read this applical ion anA,rte that the shave information is BUILDING EE
Z bonder l agate to c n,and with all and erre,ordlnencea this crate laws reladng m QTY, MECHANICAL PERMIT FEE
V Z atracengammed proem for
authorizergpreunmtives of this city to enter upon the SEISMIC FEE
above-mentioned props(fnr inspection purposes. PERMIT'ISSUANCE
(We)agree m east,ondcaudyexpanses
and keep hay in an the City of Caperton,s against ELECTRIC E
inconsegjudgmentse granting ft his Permit. ALTER may in any way accme against said City ALTER OR ADD TO MECH.
consequence of the gloating of this pernhit PLUMBING B
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL 14 POI AIR HANDLING UNIT(To to,"CFM)
SOURCE EC)LAI'10'S. / ,jL� MECHANI AL FEE
�zZ 4i AIR HANDLING UNIT(OVER I0.000CFNU CONSTkU AX
Sign�0f Applhcv ,ntmcmr ✓✓���J//TTL LW Data EXHAUST HOOD(WMUCq
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATI( FEE
Will the.appllcunlor forme build..,ooulcom stere or handle hazardous material HEATING UNIT(TO 100000 BTU)
az defined by the Cupertino Municipal Code.Chapter 9.12,and Ne H.Ilh and Safcty
Codc.Sealirn 25532(0)] HEATING UNIT(OVER 100.000 BTU)
C3 Y" ❑No
VENTILATION FAN(SINGLE RMID) PAID
Will the applicant or future building cecupunh use equipment or devlttry which Dare Receipt
,coil hmnrdous air cammminams ac defined by'he[Jay Arca Air Quality Management BOILER-COMP IMP OR 100.000 BTU)
Distinct?
E3 Yr, DNo BOILER-COMP(OVER 100,00)BTU) 'IOTA
I have read the hrcoundous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
forma Health h Safety Coda Salton,25505,2.5533 and 25534,1 mdemand that if the ISSUANCE DATE
bulldingdoesnnt currently have atermnt,that all NEW RESIDENTIAL MECH. SQ,PT
y ceofaxCeniyto eodfythe curs,
rune myairemema wmgn mh61 he met ndnm n.i.awaneo oro cenf➢amc nr(>reap:hncr.
Owner or authorized agent Data
ISSUEDBY:
OFFICE