30260APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
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PERMIT N(1 30260 O
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
V
BUILDING PROJECT IDENTIFICA'T'ION
BUIL//DI^^NGnnADDR�SS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
CONI'RACTOkS NAME: LIC NO
Ek:S NAG:
N2M
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NTN(
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KVI-S
4RCHITECTENGINEENLTC NIT pDDkSS:
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG P E PLUMB MECH
EJ
LICENSED CONTRACTOR DECLARATION QTY ELECTRIC PERMIT FEE
JOU DESCRIPTION
nuclei of slag
1 hereby affirm mat 1 am licensed under pd of C 9 (my
Pmons
�d'Z with SectionIBM1of Dlvision3nf me Business and Rufes>ionsCec. and mylicenae is
oda. c lim
RESIDENTIAL
FOO ntfall form .tied effa-t PERMIT ISSUANCE ty
❑ WL ❑KITCHEN REMODEL
�UF License Class Lk.is
Q V APPLIANCES
DDITION ❑ PLUMBING R&PIPE
Fab Dart Contractor
h ,TI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION
FDrn PANELS
ZOrt%sz' I understand my plans shalt be used as public broccoli,
MODIFICATION
OZ—C UP'10100 AMPS
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
^QvsFW Licensed Pmfessiunal 201-1000AMPS
DWNF.kNI111,DER DECLARATION OVI7R IOOAMPS
❑ BATH RF.MODEUREPAIR ❑DEMOLITION
C C Q I hereby affirm that I am exempt from me Contractor's License law for the
o. V
❑ OTHER
K0 following reason. (Section 7031.5, Business and Professions Cale: Any city or cnumy SIGNS ELECTRICAL
which r,.imv a to construct, noun. impmae, demolish, or repair any vwemrc
_ O permit
prior,. its issuame.aIs.mquires the applicant for such prmTiuo file a signal smarrlent SPECIAL CIRCUIDMISC.
Eby thnthealecrampursumnmthcpr..vrann.cofthu Connomens License Luw(Chapter9
SectionTIME)ofDivi.sion 3 of The Business and Professions Gyle )or TEMP. METER OR POLE IN51'.
COMMERCIAL:
+I CO (commencing with
SM ea -but he is exempt therefrom and the basis for the alleged caemp rmc Any violation of
Section]UJLS by fora the of 1'OW[R DEVICES
C3 NEW BLDG/ADDITION ❑ DEMOLITION
X,^JN any applicant permit subjects upplicannoacivil penalty
❑TENANT El FOOD
Y not mom than five hundred dollars (8500).
IMPROVEMENT
^ �Q ❑Lo the pmryny,onnyemplees SWIMMING POOL ELECTRIC
W C
❑ OTHF
a, offered for
F The work, is not intended or for a,
will do-he work, ander strhe
License Law dues not apply ss an owner of OfTREfS-SNITCHES-FlXTURES sale
Com Livens Law do of apply to weer of
W 3 m and Professions Cale: The Gm
berays and who dose such tinte himself offeredfthrough
who builds or h Therch
sidedimpmt
his own employees, provided the such improvements art not intended or offered for NEW RESIDENTIAL Ii1.GCTR SQ FT.
his own i
w',
1S rT. FLUOR AREA
LSQ. FT.
hnwever,-he building nr intpntvemenT is sold within one year nfcnngtlerion -hoc
-builder will have the burden of proving that he did now build or improve for put-
swsr
7
of the tan excluively rontmcons Cita d crrino
ions or The
Sm. 704 mW :) TITh Li
i-arcuLa -he
jea (Sec.
t) an wneBusr oa
k. i
soriotpmvasmereon,ond QTY. PLUMBING PERMI1' FEE
es oyProwh es he on,
appty,.unownerofpmpmy wceb
oawdownm
d
mnuans fmsuchpJettswimacommnor(s)licenud pursuant tomeComrac-ors
e law PERMIT ISSUANCE
exam u d Sce. B & P for ThisrcuonAI
:sation,
JUL 2 3 199n
.
TER - DRAIN & VENT- WATER (FA)
VALUATION
"
III I. r(g.1yIhamhya
O ER'SC fYENSATUN DECLARATION BACK FLOW PROTEGE DEVICE
- .-y of perjury one of the fuowingdeclandinn
IC/kr `►
ave and will maintain a Certificate of Consentto wIf.m rm forWorker's Compen- DRAINS- FLOOR. ROOF. ARBA, CONE'
STORIES
TYPE. CONSTRUCTION
as provided for by Section 37001 of -hoc Labor Cee. far the performance of me
work for which this permit is issue. FIXTURES - PER TRAP
❑ I have and will maintain Worker. Compensation Insurance, as required by Section
OCUGROUP
APES
PRO of the ].shot Code, lir the puhumuncedthe work for which This permit es issued. GAS -EA. SYSTEM-1 INC. 4 OUTLETS
My Workers Compensation Insurance canter and Policy number are:
Currier: Policy No.: GAS -EA. SYSTEM -OVER 4 EA)
CERTIFICATE OP EXEMPT [ON FROM WORKERS'
GRIiA5El1YDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
COMPENSATION INSURANCE
('Thiswonern need not@; completed if lhcpenulrn former haral dollurs(SIM) GKEASE'TRAP
or leas.)
PLANCHECK FEC
(cenif}-hot in the per(ntmance ofthe work for which Ibis member in issued, l shall SEWER-SANITARY- STORM EA. 200 FI'.
not employ any person in any nmnnerso as to become to me Workers' Cooper.
ENERGY FEE O
,Z union laws of California. Date WATER HEATER WNENT/ELECfR
O ApplicanT
GRADING FEE
ill
'Z h
NOTICE TO APPLICANT: If. after making This Certificate of Exemption. youshou)d WATER SYSTEAcTREATING
F�
become subject us the Worker'v Compensation provisions of the Labor Calc, you must
SOUS FEE
5
hansom comply wins such pmvisions or this permit shall b< decme revoked WATER SERVICE
A
as
CONS'1'RUC1'ION LENDING NEW RES IDE PCMB, SQ. FT.
PAID
Uate ReceipTN
U 0
Thereby affirm that them is aconstrucrion[ending agency for me performance of
TOTAL:
the work for which this pcmrit is issued (See 3097, 3097, Civ. C.)
ULender'.
Name _
Lender's Address TOTAL:
BUILDING FEE '
LLT
a.
I^
1 cenif, that 1 have read this application and state (bar the above iafnnnmmn is
U1
correct. l agree to comply with all city and county ordinances andstam laws relating,. QTY. MECHANICAL PERMIT FEE
U
building construction, and herebyuutbon7a representatives ofthis city Torturer upon the
SEISMIC FEE
ELECTRIC F
abosn-mentionrd prepeny for inspection purposes. , PERMIT ISSUANCE
(We) agree no save, indemnify and keep hmmless the City of Cupetdms against
.E
PLUMBING IEE
liabilities.judgmeria, costs and expenses which may in anyway accrue ugairou"aid CITY ALIERORADUTOMECH.
in consequence of me gooming of this permit
MECHANI(:AL FEE
APPLICANT UNDERSTAN US AND WILL COMPLY WIT If ALL NON-POINT AIR HANDLING UNIT (TO II1,M0 CFM)
SOURCE REGULATIONS,
CONSTRU TA%
AIR HANDLING UNIT (OVER IBM) CFM)
Signature of Applicam/Comrac,.r Dam EXHAUST HOOD iW/DUCT)
HOUSING MITIGATI .' E
HAZARDOUS MATERIALS DISCLOSURE
Win Thespplierm., furore buildi.,ocenpantsomob handle hosaolous ma-enal HEATING UNIT (TO 10.00X) BTU)
as defined by the Cupertino Municipal Cee, Chapter 9.12, and the Health and Safety
Code. Section 25532(od? HEATING UNIT' (OVER 10,lm) BTU)
C] Yon, C:1 No VENTILATION PAN (SINGLE. BUSED)
PAID
Da¢ Receipt
Will mea applicant or future building compliant um - or devices which
pp g pa e.
TOT L
Airneo tlOILER-COMP(3HPOR IO.t]OfI BTU)
emit hueardnnsurir contaminnna us Aellned by the tluy Area Air Quoli-y Management
T
District:' BOILER- COMP (OVER 10,0011 BTU)
11.
❑Yes ❑Nn
1 have card the hmardws mmcriat is under Chapter 6.95 of me Cali- AIR CONDITIONER
ISSUANCE DATE
forrtyuiremen
ficin,us, A, Safely Calc,
ovi 255115, 25531 and 25530. I u1.nderstand d ma- if the NEW RESIDENTIAI. MECH. SQ. 17.
e a is 01
Wilda currently have
meng
W mettmmit
ua ce ofaihim Campaniaof
of The rcyuimmcntx which mus be tact prior ht issuance of a CeniBcme of Occuparmy.
of ulmorn
ISSUED BY:KIIP'.
Ownerorau-honmd agent Dam mL
OFFICE