30569 • APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING.-ELECTRICAL. PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
Itl11LDIN6 PRO,IRCI'IUENTIFICA'1'ION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DAT(
21545 2tiS35 K-,v,i ,d- C,4-- ef -'1' 7-U
OWNIi 'S,NAME: //'•• LL �(�Ip PHONE: CONT'RACfOR'SNAME: - LIC NO:
jtn 1.�1, 1-FV, ` 4A.1%-IlwzO NAC CONTROL at ,
4RC. ECT/ENGINMR: - LIC NO: ADDRESS: ❑
A S LLO,:2b 322.
CONTACT.I PHONE: . -r I BUILDING PERMIT INFO '
.PAUL Ro��k K•I PRESS Nog_IG, ❑ ConsWlanlFecgPaid ByApplicant(InlHal) DG ELEC PLUMB MECHe
1 r\Cr 8'Z`bD � ❑ ❑ ❑
I' LICENSED CONTRACTOR'S D17CIARNFION "
I herebyfirm that 1 am licensed under visions of Chapter 9(commencing QTY ELECTRIC PERMIT FEE
DOZ a Pro p g JOB DESCRIPTION
F�.UZO L(idle force
and clfect)ivixion3ofmhaBdsinczsaod Pnstessinns Coee,and my liaenreh - RESIDENTIAL,
_ PERMIT ISSUANCE.
CWF n ass Li ❑SFDWL ❑KITCHEN RF.h10DEl.
N6u Dat v core APPLIANCES—RESIDENTIAL ❑ADDITION, m '�PLUMBINGRE-PIPE
g,Don `[' RCHITF 'S .0 1 PANELS ❑MULTI-UNIT ❑$TRUCTIIRAI.
E O N Z 1 undemvnJ m) a shall he taco - - ODIRCATION
O y..0, - UIs T0200 AMPS El INTERIOR CHIMNEY REPAIR
Q4..fA n. Professional - 20140WAMPS Ih1PROVEMENT
S4E•,.l WNER.BUILDER DECLARATION OVER IIXXIAMPS
PE ad 6 hereby uffmm t in 1 am exempt from the Contmm n',License Law for the ❑BATH REMODEUREPAIR ❑DEMOLITION ,
til 3 cs U faun 11:g reason.ISectinn Ind(5.Business and Pmfexsions Cale:Any city or County SIGNS ELECTRICAL ❑OTHER
Oa which requires a Permit to construct,alter,improve,demolish,or repair ny strumum
.i
prior its issuance.also requires the applicant for such pemtil to file a signed stat em an SPECIALCIRCUIT'/MISC.
�pNr
that he ii licensed pursuant the provisions of the Contractor's License Low(Chapter 9
p,'QD (commencing with Section 7000)of Division 7 of the Business and Professions Code)or TEMP.METER OR POLE INST COMMERCIAL:
6 e e' that he is exempt therefrom nd the basis for the ullegcd exnnplism.Any violation of ❑NEW BLDG/ADDITION D DEMOLITION '
mm'Section 70715 by any applicant for a pdrant subjects the applicant to n civil penalty of POWER DEVICES ❑TIiNANT ❑FOODSERVICE
not more than five bundrW dollars(SSW). IMPROVEMENT
❑ bus owner of the propcny,or my employees with xvges os Neir ole compensation, SWIMMING POOL ELECTRIC ,
will do the work,and the structure Is not intended or nim ed for sale(Bea.7044.Business []OTHER
G and Pmfexsions Cule:The Contractors License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
property who builds or impmves thereon,and who does such work himself or through
his con employecx,presided thin such improvement,are no(intended m offend for NEW RESIDENTIAL ELECTR SQ IT.
sale.If,however,the building or improvement is sold within one year of completion,the - SQ:FT.FLOOR AREA ESQ.IT,
,wnerbolder will have the burden of proving that he did not build or improve for put- - -
,, of rade.).
asowner ofthe fampety.am exclusively contracting with licensed convenors to TOTAL:
o wm the project(Sec.7044,Business Doti Ps(essinns Calep The Cnnvannrs Li- lI�— d• �fl��
cense Law does not apply loam owner of proper who holds at impmves m hereat,and QTY, PLUMBIN IT FEE `1r 1 9
who confined,for such pntjeias with a tmcmr(s)licensed pursuant to the Contractors �)
License law. c PERMITISSUANCIi
❑I sec exemp> S �7 ,11&P C for(his intron .v
Own . — — w ALTER—DRAIN&VENT—WATE 1 VALUATION
WORKER'S COMPENSAi'ION DE LARATION RACK Iq.OW PR(I'1'ECT.])]!VICE _
1 hereby milmm under penalty of perjury one of the following declaration.:
•ElIhaveand will maintain Cetificvte of ConsenunsclLinsumfor Wntkets Compact- DRAINS—FLOOR,ROOR AREA,COND. STORIGS. TYPIi CONSTRUCTION
moor,as providcd for by Section 37M of the Labor Code,for the perforin n e of se
h
work fur which this permit is issued. FIXTURES—PER TRAP
C]1 have and will maintain Worker's Compensation Insurance,m required by Section
77M of the Labor Code,for the performance of(he work for which this permit is issued. GAS—HA,SYSTEM-]INC,4 OUTLETS OCC.GROUP
My Worker's Compensation Bnummm artier and Policy nvmMr are:
Carrier: Policy No.: GAS—FA,SYSTEM-OVER 4(EA)
_ f CERTIFICATE.OF HXEMIeI'[ON PROM WORKERS'
COMPENSATION INSURANCE - GRFASIJINDUSIRLWASI'R INTERCEPTOR
(This section recd nm he completed ifthe permit is(Drone hundred Jollan(SI W) BUILDING DIVISION FESS
others.) I GREASE TRAP PLANCUECK PER
Icctify thmin(he anrlimnance of stohrk for which this the Wrkeruee.l,,en- SEWER—SANITARY—STORM EA.200 lel'.
na employ any penin in any manner sn as m become subject m the Wmtrn'Compcn- - ENERGY FEE
sation Lows of California.Dore
Applicant WA'I'IiR HEATER WNENT/IiLECfIt GRADING FEE
El— vI NOTICE TO APPLICANT:If,after making this Cetifctim of Exemption,you should WATER SYSTE-MOVEATING
heeome,subject to the Workers Compensation provisions of the labor Cale,you must SOILS FEE: is Zy
Lakl Q
forthwith comply with such provisions or this permit shall be deemed revoked.. WATER SERVICC -
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FE PAID
s,V Q Thereby nfftm that there is o construction lendlogagenuy modusianonammeof Dam t../)l
Reoeip(N
I.L. p•m the work for which this permit is lowest(Sec.3197,CD,C.) ,
„ Q U Lcndce,Name TOTAL:
Lender's Address TOTAL:
y 1 cenify that I have read this application and state that the above lamination is BUILDING PEE
IA correct,I agree to comply with all city and county anthances and nate lows relating to QTY, MECHANICAL PERMIT FEE
L> 7- building consimeiien,and hereby authorize repm,canmim,ofthis citym cnmrtryon the SEISMIC FEE •
ahuve-mcmloned propsty,for inspection purposes. PERMIT ISSUANCE -
(We)agree m save,indemnify and keep harmless the City of Cupertino vg.inst ELECTRIC FEE
liabilities,Iudgmitax.costs and expenses which may in any way acme against said City g1.TEROR ADD'I'O MEGH.
in cnnsequi nce of the granting of this Pesti(. PLUMB INC FEC:
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,(X10 CFM)
SOURCE REGULATIONSME
AIR HANDLING UNI'1'(OVER U%0oo CFM) CONSTRUCTION TAX
Signatureo(ApplicaroContmetor Date EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE,
Will the applicant or future building occupant store unbundle hamNous material HEWING UNIT(TO 10o"BTU)
as defined by the Cu semao MunicipalCode.Chapter 9.12,and the Health and Safety
Cwle;Section 25532m)'f 'ms HEATING UNIT(OVER 100,0(X)IT'Of _
❑Yes F1 No VENTILATION FAN(SINGLE RESID) PAID
Will she applicant ca,false,faulting occupant use equipment m edevices which'
emit locations air renomination,as defined by the Bay Area Air Quality Management BOILER—COMPTIRPDate Retcipt N
OR 1X,11011 BTU)
Now? TOTAL:
s ❑Yes ONo DOVER—COMP(OVER 100,000 B'IOf
. I have mad the hatatdous damrmisrtuirements under Chronic,6.95 of the Cali- AIR CONDITIONER
qP _ ISSUANCE DATE
foods gduasn Safety Cahn have
naso 25505,2553?and 2.5594. understand that If the NEW R8SI01?Mf1A1.MECH. SQ.PT.
building pars not m which
have a anent,Nat it is my responsibility ct eoufy the occupant
of the mquirtments which must be met pnorm issunce oft Cetificem of Occupancy. :
Owner or command agent Date TOTAL: ISSUED BY:
OFFICE