30592 APPLICANTTO FILL IN'INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY !
CITY OF CUPERTINOrI I
,_ BUILDING.ELECTRICAL. PERMIT NO; rS0
JVL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION Jl
BUILDING ADDRESS: I _ - SANI'I'ARYN(l. APPLICATION SUBMIT UAL DATE
q6.OWNERSNAME, P11( CONTRACTOR'S NAME: LIC NO; r'
/'l/ NIC CONTROL g '
r a- n Cli 6{' ail✓� n EJ4RCIIITF.GF GINNER: _ ,LIC NO:
CONTACT/': - - PHONE: -0BUILDING PERMIT IN
A.' ❑ Consultant Fees Paid by Applicant(Initial) LDG ELEcr PLUMB MECH -
- LICENSE[)CONTRACTORS DECIARAITON QTY ELECTRIC PERMIT IsEE
1 hereby of lrm that I 'li - d t] pro,'.' I Chapter 9( n' g JOB DESCRIPTION'
1�1yyXZ with Saturn 7")ofD n3 of the Businessand lkafession.Cade, dray Leen u
FSO itfullforee nn If ''''`` �j n - PERMIT ISSUANCE RESIDENTIAL:
�F.UzU License Cl ash LiaN ' •
TJ ,�ln 2 ❑SFDWL ❑KITCHEN RIiMOUEI.
Date�Gortac !ON 0 APPLIANCES-RESIDENTIAL J ❑ADDITION - ❑PLUMBING RE-PIPE
ARCHITECTSDECLARA'I'ION PANELS ❑MULTI-UNIT [:]STRUCTURAL
Z OryrZIunJc.mnd no,plans shae u
ll hsed es public rcwNs, MODIFICA'fiON
OZ UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
�¢+4E' Ucen: IP I . ' it - 201-1000AMPS - PROVEMI • :d
yX �l _ OWNINBUILDER DECLARATION
-,W, 1 hereby firm Ih a 1 OVER IWII AMPS I{RF.MODEURIiPAIR ❑DEMOLITION
y pt f m 0 lt oms. License 1 for the OTHER
W f rhich req permit nt construct.a alter,
improve,
P IJ rvali,l or repair I y structure SIGNS ELECI'REAL
❑ .] priurl tensed I ante also requiresthef such parnitt File a.g dstatement SPECIAL CIRCUIT/MISC.
{ !(y Ihm Leis l pursuantto thepnmvision,c IF the Contractor's License Low fChaptar)
�C (commencing with Section 7f10(UefDivi.sion3 of the Business and Professions Code)or TEMP.METER ON POLE INST. f COMMERCIAL: '
6 p, eG that he is exempt Nercfmm and the han,Soothe alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iLLCI Win
Section 7031.5 by any applicum for.permit subjects the applicum ton civil pcnaltyol POWER DEVICES ❑TENANT t ❑FOOD SERVICE
qMm mare In..five hundred dalliers(5500).
(] I,as owner nl'Ihc pmpeny,rir my employees with wages os their sole compcnsmian, SWIMMING POOL ELECTRIC OTHER IMPROVEMENT,
will do the work;anJ the stricture is not intended modered forsale(Sec.7044,13minesr ❑ THIiR
d3� and Professions CNe:The Contractors License Law doss not apply an an uwner of OUTLETS-SWITCHES-FIXTURES
pmpeny who builds or improvm thereon,ant]who does such work himself or through
his own employees,provided that such improvements are ani intended ser offered for NEW RESIDENTIAL ELECfR SQ F1'.
sale.If,however.Ne building or improvement is sold within one year ofeampletion,rhe /' SO.FT.FLOOR AREA VSQ.FT.
r-builder will hove the buNen of proving that he did nam build or lmprovo forpar- w
you of sated. "
❑ 1,as owner of the property,am exclusively contracting with licensed ceramic.n, TOTAL: L
oosouet the project(Sec.7(94,Business and Profes.vlum CmIa:)The Canlrannr's Lt. Y t
cense law Josz not apPlYmnn ownerofpropcny who builds urimproves mercrin.and QTY. PLUMBING PERMIT PEE
whocormicts fnrsueh projects with ocon mineO licensed pursuant o the Cantmcmr's
License Law. PERMIT ISSUANCE E-
-
I am exempt under Sm. ,B&P C Tennis reason /
❑ 2'3 ^
Owner DI t ALIER_DRAIN&VENT WATIR(EA) LI/) VALUATION
WORKERS COMPENSATION DECLARATION BACK PLOW PROTEiCP DEVICE - ser Ly
I harchylE-nuderpc lly ofpj Y one of11 following dl I ll
I have and willi tan a Cenificatic ofCon,cal toIf' marefir-Worker's pen+ DRAINS -FLOOR.I OORANEA GOND. " STORMSTYPE CONSTRUCTION'
cion provided f by Section 3700 of Inc Latin Code.f theperformance of rhe
work I..windo windthi,por it is twomeir - FIXTURES-PER TRAP I _ ,
1�PP[ett 1 have and will maintain Workers Compensation Insurance as Import by Section
'3700 efahe Labor We.for rhe performance ofthe work for which this Permit is issues: GAS-G.SYSTEM-I INC.4 OUTLETS. • (FCC.GROUP, M'N
My Wnrlief yvptiut .lyra gasfier and Poliay.aysrjcr eget f'.� ^
Cartier. C lJ J./ Policy No. (Qlt GAS-EA.SYSTEM OVER 4(EA) '
I CERTIFICATE OF EXEMPTION FROM WORKERS' GRIiASFJINUUSTItL WAST It 1M IiI10El'TOR
' COMPENSATION INSURANCE
This section need not he complels
ed ifthe ma,is future hundred dollims. BUILDING DIVISION II?ESSIgO) GRIiASETRAP
s ser lcvsJ - PLANCHECK FEE
' Iccnify that in the PeB'nmrantt of the work fur which this penmil is issucal,Ishod- SEWER LA.21X1 PI'. -
not employ any Persian in any manner sa as m become subject m the Worker'Crimper. ENERGY FEE'
O ,'7. stolon laws arechornat Dam - WIG 13R ITIlITR WIVENTIELI?CTIt
z 0 Applicant GRADING FEE
p{' NOTICE TO APPLICANT:IL after making this Conu ficam of Exemption,jou should WATER SYSTEM?HEATING
became supjat m the Worker's Com,....ran It..vision of the Leon,Code,you cowl 5OILS FEE
ar. forthwith comply with such previsions or this permit shall be deemed mvoked. WATER SERVICE. ,
r L7 ,z CONti'1'RUC'I'16N LENDING AGENCY NEW RESIDENTIAL PI.1,1I1. SQ.F1', PAID
U 0 thereby affirm that them is a construction lending agency for performance of Data Receipt is
H
the work for which this permit Is Issued(Sec.3197,Civ.C.)
O (ti fender's Name , T TOTAL:
U Landers Address
I cenifythin I have rad this.pplicmion and state Ihnl the above information is - 'TOTAL: BUILDING FEE
h correct l agree to comply wish all city and county ordinances and state laws relating m' QTY. MECHANICAL PERMIT FEE
UZ building consuuctima and hereby amhmim represenamives of nastily no enter upon the SEISMIC PEE
ubovc-nmmimteq property for inspearian parpnsm. I •1, I ..I . P17RMIT ISSUANCE
(We)agree to save,indemnify and keep harness the City of Cupertino agaist 51.1iLTR1 r'.
liabilities,judgments,costs and expenses which may in any way acemeu aims said City ALTER OR ADD TO NIECE.in conte pairse Of the grand as of this actual. PLUMBI
APPLICANT UN1ERSTANDS AND WILL COMPLY FI'LIAL1 .ON.PFH T AIR HANDLING UNIT DO 10.000 CPLD
SOU RCE REGULATIONS. MECHANICAL Fr: '
AIR HANDLING UNIT(OVER I(),000 CIM) CONSTRIICTIO. TAX
'ignoureof pp restn/Commeror , `, pates•// EXHAUST HOOD(W/DUCT) - HOUSING MIT rAT1ON FEE '
HAZARDOUS MATERIALS DISCLOSURE
oil]the applicator future building nccupamsnsre orhandle hazardous material HEATING UNIT(TO 100,00q BTU)
ns defined by the Cupenion Munlclanl Codc.Chapati 9.12,:mel the thadh and Safety,
n C.Ie,Section 25532(a)7 ' ' HP.AI'ING UNIT(OVER 1(0,010 BTU) '
❑Yes _r ❑No VENTICATION FAN(SINGLE RESID) PAID
Will the applicant or future holding occupant use equipment or devices which I _ rite ceipl M , s.
mit hovNous air contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(3HP OR 100.000BTU).
TOTAL:
�pfrdcfl BOILER-COMP(OVER 1(O.OD fU'U) -
❑Yes ❑No
Ihave read the hazardous mulerials reyuircmentsander Chopter fi.95 of the Culi. Atli CONDITIONER - ISSUANCRD E
fomia Efeahn&Safety Core.Section.25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECIi. SQ.FC -
butlJingdm: sc nt1yB calwtanL Nm t y po sibiliryl rfy rh cecupum
of l c astu remenr.which m .therm priors"issuan r f a CCE'( t f 0 panty. ,
Ow m r sed again Da tc 'IOTAL ISSUED BY.
Gd�.fi1`
OFFICE
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= Y.�••.�,._n`.x ^^max. �*i