30898 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PER1viTN0 3 On p
p
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL O J O
BUILDING PROJECTIDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
q.-2_ 5 VVe6—Asisi 7/1 oZ t vgM
` OWN17R'S NAME: - - PH0NE: CONTRACTT OR'S NAME LIC NO:
pe�- Dec O . 1 _ NIC CONTROL
YCHMCT/ENGINEER: LIC NO: ADDRESS: !i ��C� ❑
7 U RSF2'<ge;tW f sa;
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB C
LICENSED CONTRACTOR'S DECLARATION OTY ELECTRICPERMIT FEE ❑
I hereby affirm that I am licensed under provisions of Chapter 9(commencing - JOB DESCRIPTION
00.'Z with Section 400(Bof Division Sof me Bnsiressard Professions Code,rd my license is �• RESIDENTIAL
IIOp . PERMITISSUANCC
�UUI fence and of�t'�
Licence Clejs,�tLic.# �71�0� -- ❑ WL. ❑KITCHEN REMODEI.
�Z {�r2 Al Convector �rrt4[_ APPLIANCES-RESIDENTIAL DION ❑PLUMBING RE-PIPI?
ARCHITECTS DECLARATION
PANES
MULTIUNIT ❑STRUCTURAL
0MODIFICATION N
2�Z
isuP'1'O4alAMPS INTERIOR ❑W CHIMN1iY RFPAIR��� lac d f.uo
aye f 0WNHR-BUILDER DECLARATION 201-11000AMPS IMPROVEMENT
yyy W 1 hereby uFri.that I am exempt bromine Command's License Law to,the OVER HM AMPS ❑BATH RR�EMODEL/REPAIR El DEMOLITION
$e a 0.F following reasquireon.(Section 9031.5,Rosiness vad Professions Cada Any city or..... ry SIGNS ELECTRICAL ❑ If'EgVg'T�
WW 14 y which res.psmom to construct,alter,improve,demolish,or repair any structure
Og pdor a its Nsuaatt..k.requires thertafmcant forsuch permit a file.signWsmmmere SPECIAL CIRCUIT'/MISC.
an that he is licamarad pursuant to the provisions offlic Contenders License Law(Chapter 9
00 (commncing with Section9Wl0of Division 3mfthe Redness and Profession.Codyor TEMP.METER 0R POLE INST.
that he eis exempt thefefoun and the husis Iia the alleged exemption.Any viobnion of NIiW BLDG/ADDITION ❑DEMOLITION
i� try Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICB.S
gg..z not more than five hundred dollars P$500). - TY CINU ❑FOODSERVICE
6 ElLas owner ofthe propnny,or my employees with wages se their sole compensation, SWIMMING M RIC "'�'N""'
will Jo the work,and me suucture is not In ended proffered for sale(Site 0044,Bmsiness ❑OTHER
0. and Professions Code:The Co inacun's License Law does and apply to an owner of OUTLETS-SWI - IXTIIRES
r property who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDE 1.ELE SQ FT.
sale.If,however the building or improvement is sold within one year fcompletion,'he SQ.FT.FLOOR AREA S/$Q.IT.
.-boilem will have the burden of proving that he did not build nr improvo for par-
you of sale.).
❑I,as owner of the property,am exclusively contracting with licensed continuous in
consumer the project(See.II44,Business and Professions Code:)The Contractor's Li-
amae Law doannot apply in un ownerof pmpcny who huilds or improves thereon,and QTY. PLUMBING FEE
who contracts for such Projects with a contractions)licensed pursuant o the Contractor's
License Law. PERMIT ISSUANCE
I am exempt under Sec. ,B&P C for this reason
Owner
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Doe /g^ '
WORKHR:S COMPENSKHION DECLARA'nON BACK FLOW PROTECT.DEVICE rA / /TS ''
I hereby affirm under penalty.(perjvrydneof the following declarations: _IY 2_0O
L] I have and will maintain a Certificate unconcern it,self-insure for Workers Comport- DRAINS-FLOOR,ROOF,AREA:COND. STORKS TYPE CONSTRUCTION
sod i,as provided for by Section 3700 of the Labor Code,for(e performmew of the (,
work for which this permit is issued FIXTURES-PEk'TRAP
❑ 1 hove and will named.Workers Compensation Insurance,vs inquired by Section \
37M ofthe LabrCale,for the performance ofthe work for which this Permit is issued GAS-EA.SYSTEM-1 INC.40UTLETS (K:C. R(GP APN
My Workers Compensation Insurance came,end Policy number are:
�Curricr: Policy No,: GAS-HA.SYSTHM-tJVBR4(BA) g•� j
CERTIFICATE OF I?XIdMPION FROM WORKERS' IAV
COMPENSATION INSURANCE GREASFYINDUSTRL WASTE INTERCEPTOR
(This auction need not he completed ifthe crout is formic hundred dollars($100) BUII ING DIVISION FEES
of less.) GREASHTRAP PLA
��
Ioy any mesat on in perany mnnanceofine won toylfor ichmis perthe it Wrlaesued.I shalls,Comen- SEWER-SANITARY-STORM HA.2W FF.
�
not employ any Pe any manner s9p bjm a the Workers'Compen- F
,Z satiun Laws of Cul�(pptm.❑tete sys"Ippecoyltt
�O A hemol ///�'�/Dr 4 CCS i// WATER HEATER W/VENTRi1.liCTR
y - PP G ING IE
G y NOTICE TO�PPLIGANT:11;ef¢r making this Ccni0cute of F.xcmption,you should WSJ UR SYSTEM?RELATING
become subject to the Worker's Compensation Provisions of the Labor Code,you most 6ZIM IT.
Q forthwith comply with such provisions drifts peemidsh.11 rte deemed revoked WATER SERVICE ,
7 z CONSTRUCTION LENDING AGENCY NEW RVS1DEN'I'IAI.PLMB. SQ.IT. PAID
UO 1berehyoffirmthauhe.isaconawctimn lendingugency fart he performance of ,Date . Receipt#
L$s r- the work for which this Permit is issued(See.3(199,Cie C)
O U lsnder's Name "TOTAL:
W Lender's Address 'TOTAL
Lyt, Lit 1 certify that I have fend this application and stale that the above infomiation is B LDING IEE
i-. V) correct.I agree to comply with all city and county ordinances and state laws miming to QTY. MECHANICAL PERMIT FEE
U building construction,and herehyaumoriae representatives ofthis city menterupon the S ISMIC FEE
.hove-mentioned properly for importmo purposes, PBRMI'I'ISSUANCE(We)agree to save,indemnify and keep harmless the City of Cuna,mnn against H ECTRIC FEE
Iinhilides,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO M[CH.
in asequence of me granting of this permit PL ING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Iii CFM)
SOURCE REGULATIONS,
MECHAN AL FEE
/
V-2- s1p 7 AIR HANDLING UNIT(OVER IgfN10CPM) CONS]R1/CT NTAX
Signa re of Applicam/Contmcer Data EXHAUST HOOI)(W/DUC) HOUSING MIT- 'ION FEE
HAZARDOUS MATERIALS DISCLOSURE g
Will the applicant or furore building rocupant sere nr handle hnmNous maleriel HEATING UNIT(T0 00,000 BTU)
as defined by the CLpenin t himutiled Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100.000 BTU)
❑Ycs 7N VENTILATION PAN(SINGLE RESID) PAID
Date R elpt4
Wrdiumll the air commtmcant of future building by the nt[lay Area
Air Qualitiscra or y
vinagemint BOILER-C0MPOHP 0R IOROODBTU)
nit hazardous air contamiwnn as d<final by the[lay Arca Air Quality Management TOTAL:
District?
❑Ycx F7 No BOILER-COMP(OVER 100,000 BTU)
I have reed be hazardous mcounds is under Cha ter 6.95 of the Cali- AIR CONDITIONER re,25533n p ISSUANCE DATE
from small,Healdoes&Safety try e.ha Sections 23505,is to, vnd 25531.1 u derstandnmif,th that if the NEW RESIDENTIAI.MECH, BQ,FT.
oeadoes ce currently bust utenets,ranto ismycee of a ertifmnotifythepancy.
of me requimnents which must be teed prior m issuance of a Certificate of Occupancy.
Owner or continued agent Date TOTAL: ISSUED BY:
OFFICE