30364 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL.POINT PEN ONLY '
CITY OF CUPERTINO - BUILDING ELECTRICAL MRMITNO3
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BUILDING DIVISION APPLICATIONWERMIT PLUNIBIYG"MECHANICAL s 3 YV� (�,
BU1I�LDIN;PROJECT IDENTIFICATION
_ NUIL'ING ADUgI'SS: / G C� l/J-1IND I, SANITARY NO. APPLICATION SUBMITTALDATE
OWNER'SNAMQ/EE /.. �fHONPI, '7 C(NTRACC#)R'SN 1?:
G. W V •I 13 V I Y� O NIC TROL,�_
T.CHI /'NGINF
CONTACT: I/1J{�/J'II�/IL1�yr1 Pf/HO E:Z
- - BUILDING PERMIT INFO
"V'"' 1 ^✓I S X/ ❑,Commitamt Fees Paid by Applicant(Initial) D ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONes, QTY ELECTRIC PERMIT FEE ,
I Kereby afRem that 1 em licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�OZ ith Smtlon J((If))of Divisim3oflhe Bus,*as. WProfessionICale dmylicenuis RESIDENTIAL:
F O n fulIfuree end effect. PERMIT ISSUANCE :5E �50
p;W 0 ❑ DWL . ❑KITCHEN REMODEL
ayU Li nu Class Cie.p ppPLIANCES-k1iSIDENTIAI, (TION ❑PLUMNING RE-PIPE'
ydL le TSDFno.tm
y A kI1TEC1'S Di,uhh,ATION MUI;f6UNIT ❑STRUCTURAL
FP •' ". PANIiLS• s� .
Z O .I undentmd my plans shall be used us pnhlic records p c - ^ MODIFICATION
02 UI'7Y)200 AMNS'
O ❑INTERIOR : ❑CHIMNEY REPAIR
1-�I. Licensed Professional 2f1L1000AMP5 - IMPROVEMENT '
y�Y OWNER-BUILDERm DECLARATION OVER IBBBAMPS - ❑BATH REMODF,UREPAIR ❑DEMOLITION
K I hereby affirm that I am exempt from the Cors Liam.Law forms,
p(36U following mason.verckt J031.5,Buainnaand Professions r.drndbaor Any city or county SIGNS ELECTRICAL ❑OTHER - -�A A r►'
fsl 0. when q a permu t c wn alter.improve demollsn p r t cwre ,
priori t e dl. ray re th appycunt tar such perms fl g J t gement SPECIALCIRCUROMISC'
y thasl Ic nselp n n Ih p ns of the ConvamorsL 1 ICh pter9
AO (commencing withSection 1000 ofDivision 3 mfmc Business and Prfc.:t Code)or 'TEmp..METER OR POLE INST. CO
0. n 1 Nm he is exempt therefrom and Ne basis farrmthe alleged exemption.Any violation of ❑ VrB
z' LDG/ADDITION1 WIlv10LITION
M Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of I'OWF,R DEVICES ❑ Aj�7�r/'•• ❑FOODSERVICE
nmore than five hundred dollars(S500). C<dVrt�I O ❑ot L as ownerofthe property.army employees with wages as Meir sale compensation. SWIMMING POOL ELECTRIC IMPROVEMI j0U
will do the work,and the xwcture is not intended or offered for sale(Sec.71,14,Business OTHER
0. and Professions Code:The Conmctols License Law does not apply to an owner of OUTLETS IES-FIXTURES
property who builds ar improves thereon,and satin does such work himself or through v
his own cmpinycce,provide that such improvements cone,not intended nr offered for NEW RESIDENTIAL III=11 SQ IIT.
sale.If.however,the building or improvement is sold within one year of completion the SQ.Iq'.FLOOR AREA S/SQ.FT.
owneribuilder will have the bathes of proving that he did not builJmintpmve for par- , ^0M �gISO _re,
parroc
❑ 1,as owner of the property.am exclusively contracting with licensed comincu s m L, _ u�
onstmct the project(Sec.7004,Business and Professions Code:)7Le Commnor's Li-
cameLawdoesnotapplytoanownerofpmpertywhobuildsorimproverthereon.and QTY, PLUMBING PERMIT FEE '
who contracts for such prnlccta with a cummctoroo licensed punsoanno the Contractor's .
Llc.nsa Law. - PERMIT ISSUANCE
❑Iamexemm nder See. .R&1'C far this rtasnn
Owner DataALTER-DRAIN&VENT-WATER(EA) Q^yVALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE —1 2 �—
,+ I hereby affirm under penalty of Krlory one of the following dulumtions: - ` `V�`
I have and will maintain a Certificate of Comentto self-insure for Worker's Canyon- DRAINS-FLOOR,RODE AREA,COND.
action,as provided for by Section 37x0 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
c. work for which this Pei nor is issued. FIXTURES-MRTRAP
❑ I have and will maintain Wnrkels Campenralum Insn...at.�es myuired by Section
3700afthe Labor Cade,fnrmeperfarmvnce ufine work frrwhich this permit is issued. GAS-IIA.SYSTEM-I INC.4 OUTLETS `OCC.GROUT' APN
My Worker's Compemation Insurance carrier and Policy number arc:
Cartier. Policy No.: GAS-EA.SYSTEM-OVER O(GA) ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPIINUU$TRI.WASTE INTERCEPTOR
(This action Iced urn rte completiJ if the permit is Torose hunJmldnitats($IIX0 BUILDING DIVISION FEESr
or less.) , , . r GREASE TRAP ,
PIANCHECK PEC
I.ertify that in tbi perl'ormmcc ofthe work for which this permit is issued,I shall 7 S -
HWERSANITARY-STORM EA:20()R1'.I
nut employ any person In any manner eo ate m he u Sano the Worker'Cnmpen- - ENERGY FEE
O ,Z siorm Lawsbf Califs ate / WATER HEADER W/VENT/ELECIR -
Z O Applicant ' C i U GRADING FEE.
% NOTICE TO APPLICANT.If,after making this Certificate of Exemption.you should NATER SYSTEM MATING
a; become subject 1.the Worker's Compensation pmvisions of the Labor Cod,you most SOILS FEE
F31 forthwith comply wiminich provisions or this permiuhall be deemed revoked WATERSERVICE
7. CONST RUCTION LENDING AGENCY. NEW RESIDENTIAL.PIM
B.PI B. SQ,RC PAID ,
,L)Q l hereby affirm than hem is a comoracoon lending agency lot the perfurmmce of ID' cia"4
w the work far which this permit is issued(Site3(r97.Civ.C.) _
O U LendersName - TOTAL:ilik
Lendels Address 1' ,:I
I ready bar l have readmis application.ad stem that the.have information is BUILD
to correct.I agree to comply with all city and county ordinances and state laws relating in QTy. MECHANICAL PERMIT FEE
building construction,and hereby amhnim rsprerenmtives ofthiscity m cfacrupon the SEISM( EE
above-mentioned property for Inspection purpua., PERMIT ISSUANCE
(We)agree set sure,indemnify and keep barna...the City of Culsonino against IihECI'RIC F "
litilablicKjudgmams,crisis and expenses which may in any way sccmati,mmt said City ALTER OR ADD TO MECH.
in cunsequcnce of the Remain,ufthis permit. PLUMBIN EE
APPLICANT UNDERSTANDS AND 91117—COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO 10.0010 CFM)
URCE REGULATIONS, J Q MECHANtALFEE 079
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRU AX ,• Ir
Signamreof Applicant/Co/Contr✓ucmi` Dam {{{ EXHAUST HOOD(W/DUCf) HOUSING MITIGATI FF.E
i , I IA7ARDOUSMAIHRIALS DISCLOSURE
Will the coppliamt or future building occupmBstoreor handle naruNnusmaterial HEATING UNIT(TO 100.000 BTU)
us defined by the Cupenino Municipal Cale,Chapter 9,12,and the Health and Safety
Cock.Section 25532(.)7 1 HEATING UNIT(OVER 10),000 BTU) ,
❑Yes ON. I VENTILATION FAN(SINGLE RFSID),, PAID -
Doc Rcect tN
Will the applicant it future building by the B sex equipment orMiufdevices which BOILER=COMP(3111'OR 100,1700 BTU)
It hazardous air contaminants as def sed by the Boy Area Air Quality Mnmgement - OTAL:
itrictO ON.
I BOILER-COMP(OVEIt I(Nl.(N)II BTU) r•
Yes
I have read lbehvurdour andrials requirements under Chapter 6.95 of the Cali- • AIRCONDITIONER ISSUANCE DATE
forma Health&Safety Cade,Sections 25505.25533 and 25530:1 understanul that if the NEW RESIDENTIAL MECH. SQ.FT.
building ams nor currently have a rearm,that it is my responsibility m notifr the factional
of the requirements which must be met prior to issuance of a Cenidaleof Occupancy.
• Da , T(IOwnernauthorized agcm ISSUEDBY.Y:
OFFICE