29972 wrruk.Hry 1 Fu raL IN INFUMMATIUN WI[MIN HED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING
MECHAF.LEcrRICACAl.) PERMIT No. ^ n
BUILDING DIVISION APPLICATIONIPERMIT PING PROJECT IDENTIFIC L L
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: / SANITARY NO. APPLICATION SUBMITTAI,DATF,
V W G-lam
OW rR' A ' ry `^I OL41i: CONTRACPOR:S NAME: LIC NO:
L J a L N CONTROL p
\R /ENGI ITER: LIC NO: ADDRESS: - El
9.. co24540 V/
CONTACT. PHONE:. BUILDING PERMIT INFO
FAUY Fu u A 408)2827321
Consultant Fees Paid by Applicant(Initial) BLD( ELECT PLO B MOH
LICENSED CONTRACTOR DECLARATION QTY ELECTRIC PERMIT FF.F.
I hereby affirm that I am licensed under provisions of,Code. 9(commencing AL, DESCRIPTION
Qat with Swtion](Nhp ofDivinion3nfthe Business unJ Professions Code,and mylicense is RESIDENTIAL,
00 in full force and effect. / PERMIT ISSUANCE
oe W b ❑SFDWL [I KITCHEN REMODEL
.CUU License Cl Lic.M �^ APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
I-D on Date _ TS DECLARATION
/ '
g.Qh ARCHITECTSDECLARATION vpsakn fifa gY PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z Ov2 Z� 1 undersand my plans shall o used n resorts ros MODIFICATION
Oy:4 UI'T0200AMPS Cl INTERIOR [I CHIMNEY REPAIR
Licensed Professions]
OWNER-BUILDER DECLARATION 201.1000AMPS IMPROVEMENT
S Y a OVER IOW AMPS ❑BATH REMODF.UREPAIR [I DEMOLITION
L 0.' botchy ofErm that 1 um exempt from the Contractor's License Law for the
O U 'which ng yeas a roue oto comm Business,h . mpr Profdemoli h,or m music
coy or county SIGNS ELECTRICAL [I OTHER
which requires a permit to construct,dor,improve,demolish, fi repair ony sttucmre
1pp. patheisscnmdpursooreyuim pre inion ofthe Contractors
fiiea Low(Chapted es) SPECIAL CIRCUIT/MISC.
2„!I per.
thatheit purstan7000)povisionsof the Conuaztors License Law(C Code)
that he
(commencing Section Tadd the hvisionr of the Business and
ption d, kCode)or TEMP.METER OR POLE INST.
0.ps aG That he is exempt therefrom and the basis fm the idleged ascription Any vialmion of -NEW BLDWAUUITION ❑DEMOLITION
it 4th. Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
YJ not mote than Eve hundred dollars(S5W1. TENANT ❑FOODSERVICE.
Zs„i IMPROVEMENT
S,d Q [1 I,as owner of the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
g. wdl do the work,and the structure is not intended or offered for We(See.J(kW.Business THER �Y
6 3 and Professions Cade:The Convenor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or imprvea the m r.and who does etch work himself o though
his own employers,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.ILhoweventhe tamidingerimprvemmt is sold withinone yam M'cempledon,the SQ.FE FLOOR AREA QSQ.FT.
owner-builder will have the burden mf proving that he did not build or improve for pur.
pose of We.).
FI I,as owner of the property,am exclusivelycomrmmg will licensed convectors to TOTAL ;%--
constmct the I rject(Sec.]044,Business and Pofcaaion Cede:)Thu Ctmlromor's Li- �� - A). �^^
cense Law does not apply to an owner of popedy who builds or improves thereon,and QTY. PLUMBING PERMIT FEE SEP ]nnc
who contracu for such pmved jcets with a contraGods)licensed pursuant to the Contractors IJJV
License Law., PERMIT ISSUANCE s�l�
El Iamesemptunder Ses. ,B&PCfmdusrdum
Owner Dole ALTER-DRAIN&NEW-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICEQa�Q sk.!
1 hereby eando under penalty of perjury are of the following deramtier s:
j I have and will estimation CedilicmeofConscm tosdf-insare for Worker's Compen- DRAINS-FLOOR,ROOF.AREA,GOND, STORIES TY PE CONSTRUCTION
tion,n provided for by Section 37W of the Lror Code,for the pedmrnnce of the I
work for which this permit is issued. FIXTURES-PER TRAP
4jM have and will maintain Workers Compensation Insurance,as required by Section
37W of the Lehr Code,far the performance of the week for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCG GROUP APN
M Worker�f'�;� ppnsmd Insum�armncrand Pda, tyyt!hr oro: �t
Carter: �x17A.L2 -(I,�Policy No.Y-7r l�S((��Ir I GAS_EA.SYSTEM�OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERSq(pp1.231 GREASF/INDUSTRf.WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDIN 1 ISIO FEES
(This section road not be completed time permit is formic hundred dollars 0IW) GNBASEI'RAP
or less.) PLANCHECK FEE .
Foy any lhaso the perfonnance of the work far which this permitisisoeA.Ishall S17WER-SANITARY-STORM F.A.2W FT.
not employ any person In any manneearymbemryrr�suM1jecno the Workeri Cmmpcn- � ENERGY FEC
Z action laws of,Gelifunds Dat "C��"r Fi_ WATER HEATER WNENTIELECTR
Q Applicant (rrL.4w $ GRADING FFP.
NOTICE TO APPLICANT:If.after making this Cemmlicam of Eacmption,you should WAIERSYSTENUTREATING
F+ become abject to the Workers Compensation povisions of Be Labor Code,yon must SOILS FEE
(a � forthwith comply with such provisions or this lumbo shall he deenel revoked. WATER SERVICE
aQ
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLIR. SQ.FT. PAID
U 'Z Thereby of cat that iso construction lending agency for the perforence of Dam eco
V the work for which this permit is issued(Sec.3097,Civ.C.)
F" lenders Name TAC:
GLender's AfflictsTOTAL:
I dimity That 1 have read this ap,fciam tend state that the move information is BUILDING ME
f�7/J correct agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC .E
V G building construction,and hereby nomadic representatives of this city to enter upon the
above mentioned property for inspection purposes. PERMIT ISSUANCE ELECT IC FEE
(We)agree m save,itulemnify and keep hamdess the City of Cupertino against
liabilities,judgments,conn and expenes which ony in any way attre again.a said City ALTERORADDTOMECIL
in consequence of the grunting M this perndt. PLUM LNG FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0011 CFM)
SOUR RFgN :GULATIONS.fi MECHANICAL FE
(�_. � - -r6 AIR HANDLING UNIT(OVER IB,00D CFM) CONSTRUCTION TAX
Signature o plicanVCo rector Date EXHAUST IIOOD(W/DUCry HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Neapplicant or Boom building occupant nom or handle hasallous material HEATING UNIT(TO I00,000 BTU)
as defined by the Caledonia Municipal Cale,Chapter 9.12.and the Health end Safety
Cade,Section 2553260? HEATING UNIT(OVER Bud."B'HID
Ycs Fl No
VENTILATION FAN(SINGhP.RESID) PAID
Dole Receipt M
Will the applicant or future building occupant use equipment or devices which
it haiardous air comamiaams ns defined by the Bay Area Air Quality Management BOILER-COMP QHP OR 100,000 BTU)
TO
tricot BOILER-COMP(OVER 1W,OW BTU)
❑Yes EINo
I have real the lactation materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 8534.1 understand Nat if the NEW RESIDENTIAL.MECH. SQ.FE
oilding does not currently have a mount,that it is my responsibility to ratify the eccupam
of N�}y"moment'
which uahe mepnim to issuance ofa Cadtfiane idoccnponcy.
/y♦twa 7-S SLIc
O tern thorixeda em Ilene TOTAL: ISSUED BY:
OFFICE