30980 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. �OVHO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-ME:CHANICAL
BUILDING PROJECTIDKNTIFICA'1'ION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL HATE
OWNHI;'$NAMB: Q Al I'HON:: CONTRACTOR'S NAME: LICNO: Aw y9
l/JI z 60) l: NIC CONTROLp
RCHITECDENGINHER: LIC NO: ADDkRSS: ❑
CONTACT. PHONE: Ar./pl ,
//fl�J BUILDING PERMIT INFO
Ci l ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT - PLUMB MECH
❑ ❑ ❑
LICENSED CONTRA DR'S DECIARATION QTY. ELECTRIC PERMIT E
1 hereby uftirm that 1 um licensed unlet provlsim.-f Chapter 9(commencing JOB DESCRIPTION
a2with Section 70E)nf Diskinn3afthe Bnnincxsand
pOj� DnPFficsnann Caleoadm Heatseis
\
RESIDENTIAL
full COand eBed. � '7 PERMIT ISSUANCE
Uf- Lcsem Lic.p I ❑SFDWL
C1 KITCHEN REMODEL
FCoraonr APPLIANCES-RESIDEN''IAL [:]ADDITION ❑PLUMBING RE-PIPE.
ARCHITECT'S DECLARATION- PANELS
F,prn MULThUNIT ❑STRUCTURAL
Z O Y1 a 1 understood my plans shell he used as public records A � MODIFICATION
OZ D / UP IG 21X1 AMPS 1 ❑INTERIOR CCHIMNEY REPAIR
Licensed Professional 201-I(NN1AMPS IMPROVEMENT
�Sd that I -IfUILDER front
dieC DECLARATION OVER I W'1 AMPS ❑BATH REMODEUREPAIR 0 DEMOLFUON
% I hereby affirm that 1 am cxetnpt from the Conuanor's License Lew for the
,3O L U following reason.(Sation 703 1.5,Business and Potassium,Gale:Any city or county SIGNS ELECTRICAL ❑OTHER
1E F which requires a permit to construct,Am
ter,improve,demolish,or repair any s ricrc
y prior'.its issuance,els-noconasthe appli
(NXcant for such permino fiknsignW statement SPECIALSPECIALCIRCUIT/MISC.
p- that he is licensed pnnuunt to the provisions of the Contractor's License Law(Chapter 9
ILI.+00 (commencing wit Section 7000)of Division 3 of the 13 usiness and Professions Cade)or TEMP.METER OR POLE INST. COMMERCIAL:
E k n' that he is exempt therefrom and the busis for the alleged exemp'i.n.Any Admion of ❑NEW BLDG/ADDITION ❑DEMOLITION
null W Sectinn7031.5 by any applicant for a permit subjects to applicant to a civil penalty of POWER DEVICES ❑TESANT ❑FOOD SERVICE
sy not more than five hundred dollars($500).
6 01.as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
t.0 will do the w.,k..ad thesuicmre is not fnmadedmolTced forsale(Sec.?044,Business ❑OTHER
and Professions Code:The Commit License law does not apply t.as owner of OUTLETS-SWITCHES-FIXTURES
It ^ property who builds or impmves thereon,and who does such work himself or trough
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR
sale.IL however the building or impmvemcm is sold within one year efcomplc'ion.the SQ Irl..FLOOR AREA $/SQ.IT,
wmr-(milder will have the burden of proving that he did not build or improve for put- P LAY
pose of ole.).
❑1,as owner-f the property,am exclusively contracting with licensed contractors to 3
.mtmct the unjact(See,]Wy Business ad["Residents Coe:)The Convactots Li. FEB �vo
Mae
cense Law does not apply to an owner of pmpedy who but Ids or improves thereon.und Q Y. PLUMBING PERMIT rr
who convects for such projects with a cnntmcloos)licensed pursuant to the Commalor's
License law. - PERMIT ISSUANCE
CITY OF cUNEHTINO
C] Imo exempt under Sec. ,B&PCfm this rtamn
Owner Data ALTER-DRAIN @ VENT-WATIER(EA) VALUATION
WORKER'S COMPENSATION ofpajobe
PACK FLOW PRO'TECf.DEVICE
1 hereby will mai under Certificate
enxlty.f perjury one of the following duher's Co
❑(have and ided forbyntain eio37 of ComcmmCodeasurefor Worker'sce if the DRAINS-FL(]OR,RDOP,Aft[?A,COND. STORIES TYPE CONSTRUCTION
action,as provided for mi Section 3]00 of the Labor Code,for the Performance if the
work for which this permit is issued. FIXTURES-PER TRAP
❑ I basoft and will maintain Worker's ante of rise
work
hi m mmermmal by Section
My othes Co for the and
work number am:
permit is issued. GAS-FA.SYSTEM(INC.40UI'LCTS PCC GROUP APN
Ca e.rkete Compensation Insurance carrieroticPolicy numberare:
Caniee Policy No.: GAS-EA.SYSTEMOVER 4(PA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEJINIIUSTRI.WASTE INTERCEPTOR BUILDING DIVISION PEES
(This section need not be completed if he pcmrit is for.hundred do][.($1 W)
orless.) GkTASE TRAP PLANCHECK PEE
I anifyt tOffce. ew.rkfor whit thispemtitisissueJ,lshall SEWCR-SANITARY-ST(IRM P.A.200 FT
nm employe a.t becomesub elI Wn s' ompaa ENERGY FEE
� ATran I' 7!//-�// / WATERHEATERW/VENT/EITCIR
Pp GRADING FEE
NOTICE T A Linking tis Cenif3cate of Exemption,you should WATER SYSTF.MITIFtVDNG
became w t.tpcnsmian praskions of the LuMsr Code,you Imus' SOILS FILE
{kI
forthwith ply wit such provisiomorthis permit shall be deamed revoked. WATER SERVICE
a Q
CONSTRUCTION Ltion leading agency
NEW RESIDENTIAL PCMB. SQ,IT. PAID
UO I for
rwhich this Permits isuam(Sce.3n lending agencyfor the performance of Data Recciptp
4.0 17" La work for which this permit is issued(Sec.109],Civ.C.)
O U Lendcts Name TOTAL:
W bendcls Address TOTAL:
I cart ify that 1 have read thin application and state that the strove information is BUILDING FEE
Ln comet.I agreem comply with all city.adc.omy crchanses and team law.xreloml On QTY. MECHANICALPERMIT FEE -
U Z building convection,and hcrcby authorize representatives ofthis city to enter np.n the SEISMIC FEE
F-t above-mentioned proper for inspection purposes.
(We)agree to save,indcarray and keep hamdess the City of Cupenino against PERMI'TISSUANCE ELECTRIC PER
liabilities,judgments,costs and expenses which may in any way tactile against said City ALTER OR ADD TO MECH.
in consequence of the gmming of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('f0 10.000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 1400)CFM) CONSTRUCTION TAX
Signatum of AppllcanNTAX
UCommct.r Data EXHAUST HOOD HOUSINOMITNFBE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant start nrhanlle hazardous material HEATING UNIT(TO I010,(E00Tll)
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? TREATING UNIT(OVER 100,000 BTU)
❑Yea E3 NoI 151.
VENTILATION FANS INGLE RES ID) PAID
Will the applicant or future building occupant use equipment or devices which Data Receips 0
emit hazardous air comendiwms as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
District! TOTAL:
C]yes ❑N. BOILER-COMP(OVER 100,000 BTU)
I trove r<ad the hanWous matadals rt uirements War Cba ter 6.95 of the Cali AIR CONDITIONER
9 P ISSUANCE DATE
Tatou Health&Safety Code Sections out,0.1i 15533 nod 25534.1 umkrsmnd tinif the NEW kESIDENTIAI.MICH. SQ.PT.
building dinsnotc which havet mnanrtat.ism,ce of.nCartiytonotifythe,noty. '
.f to requirements which must Fc met prior m issuanre of a CrniMnm of[Xcupmmy.
Owner or authorized agent Dam TOTAL:
ISSUED BY:
OFFICE