S 2030 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEtrr No, 2030 O30
BUILDING DIVISION APPLICATION/1'ERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
SANITARY NO. APPLICATION SUBMITTAL DATE
BUILDING ADDRESS:
0338
OWNER'S NAMf'. PH9A1ONE: RACfOR'S NAME: LIC NU:
9� �p^ ,yI D�C NIC CONTROL#
CHITF:CTIENGINEER; LIC NO. ADDRESS: //14uLK // ❑
CONTACT: �• /� PHONEILDING PERMIT INFO
: BU
��"Lo (-/rfLQ� 3`"_, a ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
`4 ❑ ❑ ❑
LICENSED CON'TRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I and licensed under prow sinus of Chapter 9(commencing - JOB DESCRIPTION
GCZ with Section 9000)of Division 3 orthe B,mc,.and Profenal...C.da,andmy license is RESIDENTIAL:
VJ O O PGRMI'r ISSUANCE
Fly,. in full Low and elle ❑SFDWL ❑KITCHEN REMODEL
�UU License Lia# -51; APPLIANCES-RESIDENTIAL. ❑ADDITION [I PLUMBING RE-PIPE
PziZ Dato- Conlmclnr _
ARCHITI DECLARATIO El MUCH-UNIT []STRUCTURAL
Z OC) z I understand my plans shall be uaedoapablic records �� PANELS MODIFICATION
OZO UPTO 200AMPS ❑INTERIOR CHIMNEY REPAIR
F,y„1C-'Iy Licensed Professional 201-1000AMP$ MPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER II1g1AMP5 Cl BATH REMODEVREPAIR El DEMOLITION
C M d 1 bereby o[O,m Nat 1 ran axempt from the Contravene,Liceme Law for he
r'p5,O y V following rea cca.(Section 90315,Business and Professions Code:Any city or countySIGNS ELECTRICAL
❑OTHER
w W WO pFj which regnime o permit to wnswet,alter,improve,Demolish,or repair any stmcmre
6� pri t t,tcaurrove,al q ' Ile applicant fhpetcnO Ile ad,nodarre nen SPECIAL CIRCULYMISC.
that he is licensed pan amt the provision.,If he Contractor's License Law(Chapter 9
d'
(resonating with Sect 7")orDivir 3 or the Business andProfessions Code)nr TEMP METER OR POLE INST. COMMERCIAL
d y e C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
YXI tvy
Section 711311 by any applicantfar a permit subjects the applicant In o civil penalty or POWER DEVICES
nm mare than five hundred dollars($500). ❑TENANT [-I FOOD SERVICE
F'Z��' IMPROVEMENT
yyd DLae awner.f rte pmpedy,or my empinywe with wages nsihairsole nom,Briviinn. SWIMMING POOL ELECTRIC
FO 01
wdlelodowndL.and the armcmm is not intended.,offered for sale(See9044,Business ❑OTHER
6'3 m
and Professions Code:The Conttactor's License Law does car apply t.an owcar of OU'1'LF.TS-SWITCHES-FDGURLS
prapedy who builds or improve,thereon,and who does such work himself e,freight
his own employecs,provided,hot such improvements are not intended or offered for NEW RESIDENTIAL ELP,GTR SQ FT.
role.lf,however,the building nr lmpmvement is said within oueywr of wmpletinn,the SQ.PT.FLOOR AREA 8/SQ.FT.
Ewcnet-bulkier will have the burden of proving that he did not build ar improve for put-
eofealeJ.
❑ I,,I owner of the property,nm excluti vely c.nnnning with licensed conimnnrs m TOTAL:
consract the project(Sec.704,Busines,and Professions Code.)'Ifie Contmanrs Li- C
use Law does not apply to an owner or property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts Cor such projects with a cantractood licensed pursuant to the Contractors le /
License Law. PERMIT ISSUANCE
I oro exempt..our Sec. ,B&P C for this.,,at
Owner Dote ALTER-DRAIN&VENT-WATER(EA) ���IIIVALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
m n (S oo
1 hereby affirunder paty of perjury one of he following declarations: (�
I have and will maintain a Certificate of Consent to self-Insure for Worker's Coupon- DRAINS-PLOOR,ROOF AREA,GOND. STOR S 'TYPE CONSTRUCTION
sation,as provided for by Section Told of the Labor Code,for the performance of the /
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compens ttion Insurance,as required by Section
3700.fihI Labor Code,for the performanceoftha work for which this pend,is Issued. GAS-EA.SYSTEM-I INC 406TLETS OCC.GROUP � APN
My Worker's Con ycion Iosyre a orderand Polley n u s / q l(
Cartlee4 GJrP I;i-g oPolicy Nb,, / '�"w����Z OAS-EA.SVSTEM-OVER4(P.A) CD r
�ICATE OF EXEMPTION FROM WORKERS'
GItF,ASL/INWST_RL
COMPENSATION INSURANCE BUILDING DIVISION FF.E.S
(This section need mlhe completed ifthepmmit is for one hundred doilam($100) GREASEIR
or less.) Ir- PLANCHLCK PEE
I cenifythm in the performers the work for which this permit is issued,(shill SEWER-SA Y-STORM GA.200 Fr.
not employ any pen in rsoany manner sa as to became subject to the Workers'Comped- ENERGY FEE
O Z xolio.laws of Coliform..Dare WATER IIEA9 /V C GRADING FEE
O Applicant
y NOTICE TO APPLICANT:IL are,making his Certificate of Exemption,you should WATER SYS'i' ?RGATING
(~ '•^ become subject m the Workers Compensation provisions of the Labor Code,you must SOILS FEF.
forthwithcomply r1lb-ch provision.or this permit shall he deemed revoked, WATER SERVI E
Q
z CONSTRUCTION LENDING AGENCY NEW RESIDE FT PAID
late Revel r#
1 hereby afirin that is o construction lending agency for the performance of p
the work I.,which this pe,mit is issued(Ser.Yr17,Civ.C.)
Lender's Name A TOTAL:
O W Lender's Address TOTAL:
Ty i codify that I have read this application and stale that the above urdso olon is BUILDI E
y cn,rea,Iagree to comply with all city tode.unty nrdinanee,and amre mwaraladng rot QTY. MECHANICAL.PERMIT FEE
(,) building construction,and hereby authorivc representatives of this ehy to toleration theSP,ISMI
above-mentioned property for inspection purposes PERMIT ISSUANCE
(We)agree,,suce,indemnify and keep henries,the City of Cupwtino against ELECTRIC-
Iiebilibes,pingments.costs and eapenxs which may in any way norm.against said Cry ALTER OR AILD TO MECH.
_ in wnsequence of the granting of this pencil. PLUME GFF.E
APPLICANT UNDERS9'ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Biagi CPM)
SOURCE.REGl1L O MF.CHA CAL FEF.
4111i Z—/Z^yr/ AIR HANDLING UNIT(OVLRPlant CFM) CONSTRU'TIONTAX
Signature.fA onVC.mracurz Dare EXHAUST HOOD(W/DUCT) HOUSING MITIGA'I]ON PEE
HAZARDOUS MATERIALS DISCLOSURE
Will Neapplicanrorfmnre building oecupent suneorhamdlehmaN.n....da d HEATINGUNIT(TO 100,000BTU)
as defined by the Coped!..Municipal Cale.Chopin,9.12,and the Health and Safely -
Cale,Section 25532(0)? HEATING UNIT(OVER 100,000 BTU)
❑Yea No VENTILATION FAN(SI NGLE RESID) PAID
Date Receipt#
Will the apphanot ur future building occupant use equipment or devices which Bf11LBR-COMP(3HP OR I W.0flf1 BTU)
mit hartrdaus air cantaminants as defined by the Bay Area Air Quality Management OT O
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes No
I have rain Interior,materials requirements lender Chapter 6r5 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Ede,Sections 25505,25533 and 25534.1 understand that ICI NEW RESIDENTIAL.MECH. SQ.Er. _ Q
building crustal earood,haveatecan0thatirisnry responsihm ilaynotify tconvention C /
of the t hick mus t prior to issuance of a Carilieare of Onvpeanncccyy.
TOTAL:Z%L ISSUED BY: —_
Owner or authorized agent Date
OFFICE