30658 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION - APPLICATIONIPERMIT PLUMBING-MECHANICAL ,
BUILDING PROJECf IDF,NTIFICA'rION
BUILDING ADDRESS: ,aL v� SANITARY NO. APPLICATION SUBMITTAL DATI
AWS' AE !K
OW NJfie S NAME: PHONE'. CONTRAC'TOR'S NAMI!: LIC NO.
Sala NfT• fidC/ATE ,V7,; 77,lrr '�D/2 "lc coNTaoLa .
'�ARCryy'EC//ENGINEER:� LIC NO: A
W,61
16�
7—
CONTACT: PHONE: BUILDING PERMIT INFO
'7���QD ❑ Consultant Fees Paid by Applicant(Initial) BLDG EL� PLUMB ,C
ENSEI)CON'MOTORS )ECLARM ION QTY. ELECTRIC PERMIT FEE ❑
1 hereby atom,that 1.,A licensed ander pro r,am,ar Charlie,9 mammeucing JOB DESCRIPTION
Dalt with Section]IXNB of Uivision3ofthe Business and Rnfessinre Cade.antro license is
�00 y PERMIT ISSUANCE _ RESIDENTIAL•
in fall force And eB
�F Z ❑SIDWL ❑KRCHliN RF.MODEI.
FU U License C ass Lia.a
T-Zw Date Connecter APPLIANCES—RESIUfiNT1AL ❑ADDITION ❑PLUMBING RE-PIPE
p.pn ARCHITECFSDECLARATION - ❑MUL 11' OSTRUCTURAL
1 odersmndm lens shall he used as blit arrant, PANIH,ti
,LO� YP Pu MODIFICATION
O Z UP TO 2W AMPS
F C4 t W Licensed Professional 1 ❑CHIMNEY REPAIR
201-IINNI MPS �+
_ OWNER-BUILDER r m the Com ION OVIiR 1Tw MPS BATH REMODEVREPAIR �DEMOLI'1'ION
IL Q I hereby affirm that I ran exempt from the Contfac Co a:A.,a law for the
iq5 06 V following reason.(Section]O3 L5,Nosiness anA Professions Coda:Any city or county SIGNS til.? CAh ❑OTHER
F 4 y which requM,s a pemtit w construe,Aller,improve,demolish,or repair any arucsure
p�tr prior to its issuance,also requires the Applicant branch permit to file a signed.nmement SPECIAL. Ik ]M
W.
A 6 , that he licensed pursuant illthe provisions oftha Contractor's License Law(Chapter 9
YCIG�O (rommcncing with Sceian]O(Np ol'Divinlon3 of the Businux und Pmfessinnx Cotle)ar TEME MfifHR ORJAL
a n m That he is exemm therefrom and the basic for the tllegW exemption.Any violation of DITION ❑DEMOLITION
�y Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER UE ES ❑FOODSERVICE
t mom than five hundred dollars($500). fAN'T
ROEMRNT
C Q I,As owner of the propen,,army employees with wages as their sole compensation, SWIMMING POOL ' IiCTRIC
aYA will do the wmk,and the stmetme is nor unloaded nraffrred for,ale(See 7044.Ilusiness .� ❑OTHER
6 3 and Professions Code:The ContractorsET
License law does not apply to an owner of / OUTLS—SWITCHES— TUkES D
propcny who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements are nm intended or aRcred for NEW RESIDENTIAL ELECTR SQ IT.
nide.IL however,the building or naloovement is salt withinone yam of compllion.be SQ.FE FLOOR AREA - $/SQ.FT.
owner builder will have the burden of proving that he did not build or improve far por-
pose of role).
❑T.as owner of the property,am culusively contracting with licensed contractors to TOTAL:
consumer the project(Sec.7044,Business and Professions C,d-7 The Conmamr's Li- w 9
cense law does not apply to an owner or property who builds or improves thereon,und QTY. PLUM B ING PERMIT FEE
who contracts for such projects wihh a contractor(,)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑I amexempt under Scc. ,B&PCfor Nisrtaon
ALTER—DRAIN&VENT—WATER(EA)
Owner Dwa VALUA'T'ION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTE rr.DEVICE /7 DO6
• Iherebyaflrm under peAIDty oftepury ane of the following dedamtiom:
❑ I have and will maintain a Cenificme of Consent to self-insure for Workers Compen-
sation,as provided for by Section J]W of the Labor Cade,for the pertromance of the - STORIES 'TYPE.CONSTRUCTION
work far which this permit is issued. FIXTURES—PERTRAP - -
❑1 have and will nmarmin Walker',Compensation insunmee,as required by Section
37Wafthe Labor Code,for the perfumiaMe.f the work for which this permit isissued. GAS—HA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Werke,Com ti InsumnC m und Policy nu
Cwthea, �`e Cron Pdicy Nlr:, GAS—IiA.SYSTEM OVER 4(EAT '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRI,WASJE IN'1'EIRCEPI'OR
B DN IVISION FEE$
(this action need not be completed ifthe lcnnit is foron<hundred J(illars l5l W) GRF.ASIi TRAP
or less.) PLANCHECK FBI. ! �
Icenify prohatanoa. in pertommnceofra work for whicM1thin pliThe W kaMC..d.l shall SEWlilt—SANITARY—STORM F.A.2110 FT.
Am enrLaw any per,on in any manncr'so ram hecnmu suM1Joct ro ll=Worker,'Crnnpen- ENIiN
,anon Laws of Cnlifirmia.Hare
O 2 Applicant WATER HEATER WNENT/ELF.CTit G
tZ)2 NOTICE bj APPLICANT.If,after making n pr Certificate of Exemption,you should WATER SYSTEMlfREATING
a 0 become subject to the Worker's Curer air this
provisions hot of the Labor Cade,you must SOILS TEE
61 forthwith comply aid,such provininnr or thio permih shall heJremul revnkul. Wpq'lik 9L'RVICE
Owl
0
:DZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID
U 0Thereby affirm on
that there is a construction lending agency far the peHbrmance of Date Receipts
W r. the work for which this permit is is.iurd(Sec.JW],Ci¢C.) -
C U Lender'a Name _ TOTAL:
Lender's Address - TOTAL:
Fy I cenify that 1 have read this application uad state that the above information is BUILDING FEE 7.
IA carted l agree to comply with all city and county ordinances and state taws relating to QTy, MECHANICAL PERMIT FEE
G
U building conslmction,und hereby Authorize representatives of this city to,emer upon Ne SEISMIC FEE 3a --
abovnmcnthime d no,a ty for Impaction putpaeas. PERMIT ISSUANCE
-(We)agree to rove,indemnify and keep harmless the City of Cu,mrmo against ELECTRIC FEE Q
liabilitiesjudgments,costs and expenses which may in any way ac=me against said City
in consequence of the Storting of permit. ALTER ORADDTOMIiCH. ZaZ PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Iq(NIB CPM)
SOURCE REGULATIONS. MECHANICAL FEE a
AIR HANDLING UNIT I'(OVER TO."CFM) CONS'IAUCTIONTAX
Signature ofgpplicamsConuanor Dam EXHAUST HOOD(W/DUCE) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the Applicant ormwre huilding occupant store orhanlle haaArdoux material HEATING UNIT(TO ItN),000 BTU)
a defined by Ne Cupertino Municipal Code.Chapter 9.12,and the Health and Safety -
Cade,Section 255J2M)? HEATING UNIT(OVHR 100,000 BTU) //
❑Yes No VENTILATION FAN(SINGLE REST[)) PATIY—
Dam Receiph#
Will the applicant future huilding occupant ase equipment or devices which BOILER—COMP•JHP OR I W,qN)NTH)
Til h.cankas air contaminants As defined by the Bay Area Air Quality Management
District9 k/ TOTAL:
❑Yes BOILER—COMP(OVER 100,003 B TO)y�Nn
I have the humNo nu ialsreluementsunJer Chapler6.95of the Culi- AIR CONDITIONER ISSUANCE DATE
form SafetCtale err ns 25505,2$533 wd 25574.1 understand that if the NEW RESIDENTIAL MECH. SQ.ter.
;;0#11, act tyrant, tit is my responsibility mnatify the occupant M
s me orb iauaM.•e ofa Cenjflg-reaf�Ocw _,/YYY✓/a
nuutho rs.eJa 'LL ��t6,Dae V TOTAL: IS �s
OFFICE