30639 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES--'USE BALL POINT PEN ONLY 'f
CITY OF CUPERTINO BUILDING-ELECTRICAL _ PERMIT NO. O
BUILDING DIVISION - APPLICATION/PERMIT PLUMBING-MECHANICAL ,
BUILDING PROJECT IDENTIFICATION
` B ILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
ST��v��s GiL�EIc BC.VA ' (Q-L-QA
NE N/pME: r' P,rHypN(E NTRACTOR'S NAME: LIC NO:
l7 'Iv A �J�J Gtj zg,8 J UZ- S^r LEc-TEO .N/C - CONTROL#
AN 4RCHIHACIIENGINEER: LIC NO: .gDDRE S: - ❑
/11 l'S PO JI9.4i N C 7�✓ O+ aA-A SOAL-
NTACr: ., pp `aPHONE. , BUILDING PERMIT INFO
,�1• J 'v L 17,-. [� ❑ Consultant Fees Paid by Applicant(Initial), BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
C 1 hereby affirm that I m licensed under p v'.' r of Chapter (commencing JOB DESCRIPTION
with Seda.7IPRE iimmkio.J fth llmi l Prafel,trusCade,marrylcenseis PERMIT ISSUANCE RESIDENTIAL, -
Wr in full force and effect ❑SFDWL Q KITCHEN REMODEL
�ULicense Class - LicN APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
on W a, nate - Contract.,
ARCHITECT'S DECLARATION [IMULTI-UNIT ` ElSTRUCTURAL.
z 0'"K I understand my plans shall be used as public records MODIFICATION
MODIFICATION
oz— UPT021NIAMPS ❑INTERIOR CHIMNEY REPAIR
[�.r/„{FC"W Licensed Professional 201-IOMAMPS - IMPROVEMENT '
+y'2 OWNER-BUILDER DECLARATION ❑
C L'a I hereby affirm that I am exempt form the Cnmractnrs License Law far the
OVER 1000 AMPS BATH REMODF.UREPAIR DEMOLITION
O U following museum.(Section 9031,5,Business dad Professions Cale:Any city or eeunty SIGNS ELECTRICAL ❑OTHER
W I-' which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIUSAISC. -
ys thatheisliefrsedpursuem t0 the provlsiona of the Cmnmmt0r'e Licuw Law(Chap.r9
00 (commencing with Sec,,..700m Of Division 3 ofthe Business and Professions Cade)or TEMP.METER OR POLE INST.
6y m C that he is exempt therefrom and the basis for the alleged exemption.Any violation of - - NEW BLDG/ADDITION El DEMOLITION
iC k. lection]OJLS byvny appllcotn In,a pormilabjece,the 1caut1,aeivll penalty or POWER DEVICES ...���ccc��_������
W"y ANq' ❑FOOD SERVICE
t more mnm five hundred d0nda(tore)' PROVEMENT
❑'Las owner of the he arecome myemptaudewitheedfastheirsce.c0mperemlon, SWIMMING POOL ELECTRIC
will dothewalk,and he snot.rcisnm"License Use,
actl TTI,7044,Business ❑OTHER
Wh and professions Cotler:The Gmvvetor's License Law dopa not dpp1Y to xn owner of )UTLETS-SWITCHES-FIXTURES
propeny who bulls,or improve,thereon,and who does such work himself or through
his nun employees,e provided that such improvements are not intended or offered for NEWRESIDENTIALELECTR SQ FT.
ownef,howeventhevetire bur iniprovnnent issold wiid ntbild or
improve for
SQ.PT.FLOOR AREA $ISQ.FT.,
err-huilJer will have the burden of proving Nolo did not build or improve fnr Pur- _ _
pose of bathe). _
❑1,es ow r of the popery,ran exclusively cantmcting�with licensed armmdors to
omswd the project(Sec.](w4,Business and Professions Codc)The Contractor's U- y
temp Law does not apply to an owner of properly who builds or improves mnreon,and QTY. 'PLUMBINGPERMIT OCT'
who contracts for such projects with a commcwr(s)licensed pursumr to rho Cmnmcmr's License Law. - PERMIT ISSUANCE72; I 199
.101 I am exerepturder Su. ;B&P C for thlsub."m J�J(�
Owner r Data I ALTER-DRAIN&VENT-WATER(EA) I- LVALUATION
WO KER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ��FEri
s 1 hereb ffinn ander penalty f cru -
yr p yat p J ryoneoftheinsre for dorket'imss:
❑(have Rodillmainbycene.fate ofConsent to Lab,Code I far the Wmker'e Compete. DRAINS-FLOOR.ROOF,AREA,COND.
i cation,os provided far by Sactlom 3]INI of the LeM1or Cnde,far the performance of tha STORI -TYPE CONSTRUCTION
work Par which this permit is issued FIXTURES-PER TRAP
Uri
1 have and will mainmin WOrker'r Cablawmetime In umnce,as required by Sectioo - - -
3700 fi the LaM1m Cnde,fortheperformarecofthe work for which this permit is issued GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP - APN
- My Worker's Compensation Insurance carrierand Policy number aro: -
Carrier: - Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION I7ROM WORKERS'
COMPENSATION INSURANCE GREASGINDUSTRLWASTE INTERCEPTOR "f)UILDIN (VISION PEES
- (This section need not be completed ifthe permit is for one hundreddelta.($100) GREASETRAP
or los) - PLANCHP.CK E
I certify that in the performance ofthe work fortifier this permit is issued,I shall SEWER-SANITARY-STORM FA.21x1 FT.
not mnploy any person in any manner so as m became subject.theWmkers'Compen- PNERGY NE
0ZRation Laws of California.Dale WATER If EATER WNENVELECTR
z 0 Applicant - GRADING P[
NOTICE TO APPLICANT.If,aRor making thio Certificate of Exemption,you should WATER SYSTESUTREATING
F become subject to the Worker's Compensation provisions of the Labor Code,you most SOILS F
forthwith comply with such provisions(it this permit shall he deemed revoked. WATERSERVICE -
94
QqW
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM. SQ.FI'. PAI
1 hereby affirm that is a construction lending agency for the performance of Receipt a
W F the work for which this permit is issued(See 309],Cot C)
0 V Lender's Nome TOTAL:
lenders Address TO AI
• 1�1��s a I cehify that 1 have mud this application and orate met mevbove informedon is BUILDING .E
Fa 0 correct.l agmeto comply with all city and county eminences and state btws relming to QTY. MECHANICAL PERMIT FIE
V ,7. building ametruction,hod hereby authorize represemrdves of this citymen.r upon the SEIEMICF E
above-mentioned property for inspection purpascs.' PERMIT ISSUANCE
(Wa)agree w save,indemnify nnJ keep burse,the City of Cm�nin0 against ELECTRIC -
liabilities,judgments,costs and expenses which may In any waysecrne miumstmitl City L'fBR OR ADD TO MECH. PLUMBING FET.
in consequence of the granting of this permit. `
APPLICANT UNDERSTANDS AND.WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 1(1,000 CFM) MECHANICAL PEE
'0(RCB REGULATIONS.
AIR HANDLING UNIT(OVER I0dxN1CFM) CONSTRUCTION TAX r
61.tLO fi7+ H
Signature fApplicnor md� EXHAUST HOOD
HAZARDHOUSING MITIGATION IOf.
HAZARDOUS MATERIALS DISCLOSURE '
Will the a Cipatn or future building e,Cham.912,handle Health
omet Safety HEATING UNIT(T0100,000 BTU) ,
C dentedio thecupertinu Municipal Cade,Chepmr 9J2,,ad the Health and Safety
Cale,Section 2.5532(a)" - HEATING UNIT(OVER I00,000 BI U) -
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Dow Receipt
Will the applicant memsfuture
a,building byreappear use e.AirQuality M...selces ch BOILER-COMP(3HPOR IOO,000BTU)
emit hmamnus air comvminam,vs define)by the Bny Ama Air Quality Management- '
District,
`�El Ye, nNo BOILER-COMP(OVER IW,fNq BTU)
I have read the hazardous materisls remnemub under Chrpler6.95 of the Cali- `AIRCONDITIONER _ ISSUANCE DATE
main Hu1th&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ:Pp. -
building does not currently have a format,that it is my responsibility to notify the accepant '
of me requiremem,which ome,Be metprior to issuance of a Certifier.of Oc,.,amcy. - -
s
Owner or authorized agent' - Date \ ISSUED BY:
OFFICE