30767 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO • BUILDING-ELECTRICAL PERMIT NO, 30767 O .1/a a.a
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL '3
BUILDING PROJECT IIIF.NI'IFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
/ IvIt7tvIVS07y hV6 �'l
OW .R'SNAME: PHONI3: �7 11 RX'(ORS NAME: J LCNO:�
r NIC CONTROLX
ARCHITECT/ENGINEER: - LIC NO, gpIlBC55„ �� �� ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ C9ngultant Fees Paid by Applicant(Initial) ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONIlicensed a&,'SUEoons AI[ONof Chap QTY ELECTRIC PERMIT FEE
1 hereby a)of and 1amlicensed undernd Prooreo(Chode. 9 my license is JOB DESCRIPTION
OWZ withSfincon0010of Division3ofthetlminess and Professinnx Code,and mylicenueis RESIDENTIAL,
00 PERMIT ISSIJANCF?
�F in full force and offs �� �S72J/9' ❑SFDWI. [I KITCHEN REMODP.L
4F�..VV License class Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
rn 6 d De Cartel N
AItCHIT13CTS DF,CLARAI ION - ❑MULTI-UNIT []STRUCTURALF❑m PANELS
7:04 1 understand my plans shall be used as public records MODIFICATION
OZ M UPT0200AMPS ❑INTERIOR El CHIMNEY REPAIR
F.yE'� Llcomed Prefiasinnal 201d000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 10(0 AMPS El BATH REMODEIBEPAIR ❑DEMOLITION
K W Q 1 hereby often that 1 1. exempt from the Contractor's o License Law for the
igqi5$04 V following reason.(Section R13L5,Business m rProfcsuinm Cole:Any cityor county SIGNS Ehli[TRICAI. []OTHER
t++LL C y
w1fichorcubili..a permit re cmawcL alien improve,demolish,n repair any swment L
PITF' htTmin censece.alaantto the thovisiosofthecom for such pwan's icensTiese ned aw(Chmmcnt SPECIAL CIRCUIT/NISI. 6
} Ilial he ircing licensedpursuant7E )of
Diviormof the Gmmnss License loons Code)or
�rX
that he
(commencing therefrom 7(1007 of Uivision3 d(the Business and Professions GrJe)nr TEMP'.METER OR F'OhE INST. COMMERCIAL:
d 6x p that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
WMto Section 7031 S by en,.p,lie.t fora permits.bjectsthe applicant an.civil penalty of POWERDEVICFS
ZZZ d more than five imndooddollars($500). ❑TENANT q, FOOD SERVICE
� C ❑ I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECT IMPROVEMEM'p
will do the work,and theswaure is not intended or offered for sale(Sol.7044,Business ❑OTHER 4
gste Porlesinns CnJe:The Commnnrs License Law Anes nn apply m un owner of OUTLE'T'S-SWIi'Ct1115-F fUliES
property who M1uildx nr improves therein,and who alas such work himself or through
his awn employees,provided that such improvements are not intended or offered lot NEW RESIDENTIAL ELECTR SQ n19 ell
sale.If,however,the huilding or improvement is slid wiihinoneyeurnfcnmislclinn lbs az y50i P1'.FLOOR Alte,y„ S/SQ.FT
w .
oner-builder will have the burden of proving r that he did not build or impose for pat L (//
pose of sale.). (,z J/A'
1,as property,of the propy,am exclusively contracting with licensed contractors m A Q
construct the project(See.7144.Business and Podfic,inns Cwlc:)'I'he Contractors Lal.
use law does not apply to an owner of property who builds or interests thereon,and Q'FY. PLUMBING PERMIT tEE
who commons for such projects with a conlmctot(s)licensed pursuant to the Commcmrs
I.seense Low. PERMIT ISSUANCE
Iamesemptundcr See. ,B&PCfor this reason
Owner Date X�w
ALLER-DRAIN&V13NT-WATER(EA) V LUATION
� —
WORKER'SCOMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE y , y�
1 hereby afRml under Penalty of perjury one of the following declarations: ��(/
,❑ I haanad will moinmin uCerificv¢of Cnnuenl losel Girimme fnr Worker's Cnnpm- DRAINS-FLOOR,ROOF,AREA.CONTI. STORIES TYPE CONSTRUCTION
union,as provided for by Section 3700 of the labor Code,for the perfornwnce of the
work for which this permit is issued. FIXTURES-PER TRAP
❑I have end will maintain Worker's Compensation hi,amaram as required by Section
37M of the Labor Code,for the Performance of the work for which this pemtit is issued GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
))) My Work Ins Ins cee Cartier and Policyn pp��
Carrier. �/(fr(Jd1L[J Policy No,: Y t /-f'-n GAS-EA.SYSTEM-OVER 4IEA)
/ CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE INTERCEPTOR
('Ddu section nerd not her completed ifthe pemb is Intone hundred dollars I$Him BUILDING DIVISION FRES
or less.) GRHASI:TRAP PLANCHECK FEE
Icenifythvr inthe perfartmncm(the work(or which thispermirisissued,l shall SEWHR-SANITARY-STORM EA.200IT.
not employ my person in any manner un as m become subject to the Workcn'Compel- ENERGY FEE
O z action Lawn of California.Dote WATER HEATER W/VRNT/ELECTR
Z Applicant GRADING ME..
.N. NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMO`RHATING a SOILS FEE.Mcome,0jecl to the W..ke,Cm,rnsminn prnviiions n(the Labor Code yea muss
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
WJ
CONS TRUCTION LENDING AGENCY NEW RESIDENTIAL PL.MB. SQ.FI', PAID
L)O Thereby affirm that hem is a construction lending agency for the Performance of Dam ReeeiprX
Fthe work for which this permit is i....d(Sec.3097,Civ.CJ
U de
Lenders Name - TO
U Lenr's Address I for
TOTAL:
UJ Lender's,
cmify that 1 have orad this application and state that the shove information is BUILDING FEE
f/] comet.I agree to comply with all city and county ordinances and stale laws«latingto QTY. MECHANICAL PERMIT FIRM
building construction,and hereby authorize representatives ofthis city teener upon the SEISMIC FEE
aMve-mentioned propeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hartnless the City M TRIC F
Cupertino against ELECTRIC
li.laidin.pollmere,.costs and exper,ex whid,acry in any wnyacvote again,tadd City ALTER OR ADD TO MECH,
in consequence of the granting of this pcmir. PLUMBING FEE
APPLICANT U' ERST DS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0X0 CFM)
MECHANICAL PER
SOURCE tE ftAO t
4�1 AIR HANDLING UNIT(OVER 10,000 CFM) CONST RUCTION TAX
ignuoure lfrApplicart/ConfloyforIne
EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
• IIAZARIIOUS MATERIAI S .DISCLOSUR
Will the applicant orto(=building occupant store nrhandle hazardous material HEATING UNIT CTO 110,000 BT U)
' as defined by the Cupertino Municipal Code,Charter 9.12,and the Health and Safety
Cade Section 255321.)" HEA'L'ING UNIT(OVER 100,000 IITU)
❑Ycs ❑No PAID
VENTILATION PAN(SINOLI3RESID) Vale ReeeiptX
Will the applicant or furore building occupant use equipment m devices wMch
emit hazardous air comaminume as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,1100 BTU)
Dome' TOTAL:
C]Yes FNo BOILER-COM P(OVER I W,000 BTU)
I have read the harardes mal requirements under Cbapmr695 of the Cali AIR CONDITIONER ISSUANCE DATE.
(omnia Health&Safety Gale,Sections 25505,25533 and 2,5534,1 undeNtnd that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not cumntly have a tenl that it is my re,midbiliry m notify the ocmpmt
of the requirements which must he met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE