30736 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO DUE LDING-ELECTRICA I. PERMIT NO. 3 0 J^6
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. J 13
BUILDING PROJECT IDRNTIFIUA'i'[ON
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
to 3 a c 101(A Sw P-0,CELA ,
OW A T7 0APHONE: NTRACTOR'S NAMC:,1 LICN
AC FrN/C CONTROLM
M 'Don
A TECT/E.NGINEF.R: LIC NO: ADDRESS: - ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE Ar
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
HOZ with Section]I%p)ofDivisionJofthe Buxineo and Rvfcs orla� an license is RESIDENTIAL,
F fyF in full(arena d Teo. 1 \. (e.( PERMIT ISSUANCE CSFDWL ❑KITCHEN REMODEL
�U Li cense Clavvi.ic.s - ""- C CJ APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
zW Ilam Contractor
'p. - RCUrECT'S DECL A ls PANELS El MULTI-UNIT DSTRUCTURAL
z 7 1 nderstm my Plans shall he uacdespublie records � � MODIFICATION
;:on UP T02W AMPS [I INTERIOR 0CHIMNEY REPAIR
C^jp; Licensed Pmfessianal 20LIOf10AMPS IMPROVEMENT
�{ OWNG&exempt Ifr DECLARATIONeContrcto OVER 10110 AMPS D BATH RF.MODEL/REPAIR [1 DEMOLITION
X36Uas 6 i hereby affirm on 70 em exempt from the Gamna Cas License Low for the
followingair,.pgtratto 0JL&Busine imp Professions Cash: ati city or county SIGNS CLIiCfRICAL ❑OTHER
Ya11 t� which requires a permit to conswcl,ehcr,impmve,demolish, fi repair any structure
that hoitscensecparmentto the lhovisions ot for ofthesuchractor Licensle.e Law
SPECIAL CIRCUIT/MISC.
QE
that he is licensed pulsuam to the provisions of the Contractors License Law(Chupter9
❑GO (commencing with Section 7000)or Division 3 ofthe Business and Professions Code)or TEMP.ME I'ER OR POLE INST COMMERCIAL
c y that he is exempt therefrom and Ihe,hmis for the alleged exemption.Any violation of D NEW BLDG/ADDITION C1DEMOLITION
rn
tL
Section 7031.5 by nay applicant fon pend ii subjects the applicanlm a ci vi l penally of POWER DEVICES
m ' CP ❑FOOD SERVICE
p, n none than five hhundreddollars(55(IIB' IMPROVEMENT EMENT
Q ❑Lo the work,and
pmpeny,remycmntended wiNfemd for
rlaleirsdecnmpenoness SWIMMING POOL ELECTRIC
will duthework,endthe swetereisnot s Livens Lawdoforsale(Sec.1. a Raciness OTHER
and Professions Code:She Cnntroemr'x License law does not apply m if owner of OUTLPTS-SWITCHES-FI%'NRES
properly who builds or improves thereon,and who dos such work himself or through k'e
his own employees.provided that such mens is sold
are not intended
yew ofeti nfferM for NEW RESIDI3NTIAL ELECfR SQ FT Ir
owner-bower will have
buror den
of prvintisat he
non build
or improve for
- SQ.Ff.FLOORAREA LSQ.FT.
owner-builder will have the buNen of proving that he did not build or impmve for par-
pose of sow �
co -usow roftheproperly,am,Business
and contracting with licensed commcmm to . TOTAL: rp
enns9mcl the project(Sec.]U44,Buslncss and Professions Code.)no Commcmr's Lt. �I
came Law does not apply to on owner of propeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE elry Vh L
who contracts for such projects wish o contract (a)liceaaecl pursuant to the Cmaracoo, LUr`%f IL,�
License law. PERMIT ISSUANCE
E)1 am exempt under Sec. .B&P C far Nis ma.wn
Owner
ALTER-DRAIN&VENT-WATER(HA) VALUATION
Dale
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
•xu I hereby hfirm under Penalty of pc Jury one of the fallowing deelaotions:
have and will maintain a Cerificate ofCamem to self-insure for Workers ComD.pcn- DRAINS-FLOOR,ROOF,AREA,CON
nnas provided for by Section J]W of the Labor Code,for the performance of the STORIES TYPE
woCONSTRUCTION
ow which this permit is isocd FIXTURES-PER TRAP
1 have and will maintain Worker's Compeovation Insurance,in required by Section
ofthe Labor Code,for the performance oflhe work for which this permit ix'oc GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Workk�er'sfffP�J vatin and Policy u
Cumes � Polley No.: GAS-CA.SYSTCM OVER (EA)
✓✓ 'a,,��,, R IFlCA'C OPI?%I?MYI'ION IROM ORKERS'
COMPENSATION INSURANCE GREAS191NDUSTRL WASTE INTERCCPfON 1)UILDING DIVISION FEES
('Ihi...irm mad ret becompletcd ifthe pcmut is far one hundred dollals(S I WE GRCASCTRAP
or leo.- PLANCI3ECK FEE
I renify that is the performance of lbe w k rwhi t is iasud,Ishall SEWER-SANITARY-STORM EA.200 P.
y
not employ any person in any manntt o as top v 1 N Workcn'Compere ENERGY FEE
/y x811t1n Ilfamle.D
O ��� WATER HEATER WNF.MI'/ELECIR
C) z ApPli'nt GRADING FEE
q y NOTICE.T LLCAN :If. rvnuki thi tea :walµyg{,you should WATER SYS'THM/fREATING
aM1ecome xnb to the W. .Cont emu s of the Labor Cade,you must SOILS FEE
fnnhwilh comply wish such pmvixinnv nr this permit shell he deemed revoked, WATERSHVIC17
Q
CONS'rROCT'ION LENDING AGENCY NEW R ESI DHWI AL PLME. SQ.Fr. PAID
UO
I hereby affirm Nanhere is ncnmwaion lending agency far the performance of Date Receipts
the work for which this permit is issued(Sec.3097,Civ,C.)
Q Leaders Name TOTAL:
WLenders Address TOTAL:
Fy I certify that 1 have read this application and state that the above information is BUILDING FEE
W wren.l agree to comply with all city and county ordinances and state laws mining to QTY. MECHANICAL PERMIT FEE
G building construction,and hereby authorise representatives of this city meaner upon the SEISMICFEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE(We)agree m save,indemnify and keep hmmless the City of Cuper inn against ELECTRIC IEE
Iiahiliticv,judgments,wstsand expenses which may in any way accmcagoiomisuid City ALTI7R OR ADD TO MECIL
in asequence of the gmnling of this Permit. PLUMBING PEE
'APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT(TO 10,1100 CFM)
SOURCE REGULATIONS. MCCHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signmurt of ApplicanUConuacwr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATCRIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I(XI,"BTU)
as defined by the Cupcnino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532bol HEATING UNIT(OVER 100,000 BTU)
❑Yea El No VENTILATION VAN(SINGLE RESID) PAID
Will the applicant m future building occupant use c'miniem Or daviecs which Dale Receipts
ren bmardova air coatrommats as defined by the Bay Area Air Quality Management BOILER-COMP(JHP OR 100.05T BTU) "
)IilllCtq
Yes CNn BOILER—COMP(OVER 100,(100 BTU)
❑
I have and the hmardwc materials AIR CONDITIONER ISSUANCE DATE /
rt,2533 an under Chapter h.95 of the Carie
fomiajEd.OHealth&Safny Cade,Sabana]5505,SSJJand255X.1undeifyil Nutifthe NEW RESIDENTIAL MECH. SQ.FT. r
building dos nm is which
y have a mm1rp that o ninny ec of a Certifi to e o fy the pray.nt
of the requirements which must Ire ren prior m iouance of a Certificate of(kcupancy. \I V
Owneroruuthanzed agent Date _ ISSUED BY:
OFFICE..