30944 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO BUILDING-ELECTRICAL PERMIT NO. susO9 sg /1
BUILDINGDIVIS10N APPLICATION/PERMIT PLUMRING-MECHANICAL s V14[�
BUILDING PROJECT nyrbrTIFICAT[ON
� BUILDING DDRESS: � SANITARY NO. APPLICATION SUBMITTAL DATE
X223 Ctc�painKo �
OWNER'S NAME: PHONE. - NTRACTORS NAME: - LIC NO:
6 u� U C C�ffgg ,L lk16 NIC CON//RyyOLN
ARCHITECT/EIJGINF..R: 4C.1-1NO: REO. `rT De,' J�
CONTACT: PHONE: BUILDIN('GC�PEJ+RM✓IT`IN�FO
r�• s(�� ❑ Consultant Feev Paid by Applicant(Initial) BLD ,EL PL MECH
09
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affum that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
y�y�00 with Section 70(1 of Division 3 ofthe Business and Professions Code,and my license is - RESIDENTIAL
F+�� in full force and effect. PERMITISSUANCE
I�W ❑a�SFDWL ❑KITCHEN REMODEL
z5 License Clazs LIC.IF APPLIANCES-RESIDENTIAL Q DDITION ❑PLUMBING RE-PIPE
Ina o, Dam TSConDEvn
y ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
'Q P�x 1 understand my plans shell be used er publ'm rceords MODIFICATION
Z UPT0200AMPS -
�474F'C mud Professional ❑INTERIOR ❑CHIMNEY REPAIR
g 201-HI(.Y)AMPS IMPROVEMENT
;Ejy
OWNER-BUILDER DECLARATION OVER IINY)AMPS ❑BATH REMODEL/REPAIR 0DEMOLITION
pp�� Q 1 hereby affirm that 1 tan exempt from the Cssions o License Law(or the
W 0 U following reason.(Seaton 703IS, t,itheas and Professions Cade:Any city or county - SIGNS ELECTRICAL OTHER
a which requires a permit to construct,niton improve,demolish,or repair any structure
�m prior to its issuance,al so requires the soft icantfirsuch peatit to File asigncdsmmment SPECIAL CIRCUIT/MISC.
that he is licensed pursuant the provisions of the ConuaaOrs License Law(Chapter 9
(commencing with Smuom](KKgof Divisbm3of Ne Bminesaand Pmfesmm Cale)or TEMP.METER OR POLE INST,
EE e a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Permit
N
Section 7031.5 by any applicant for a subjects the applicant to a civil Penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
ZY not more thin five hundred dollars($500). IMPROVEMENT \
pa El,as 0wn<r0(Ne propeny,Grmy employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
G will do Newark,ands: he Contractors
License Law
of opecA0an owner
ox [:1 OTHER
u1,3 and arty whio links
Code:The Conmacmr's License law sties not apply to an owner of OUTLf7S-SWITCHES-FIXTURES
CC properly who builds ser improves thand who soca such work himself or through
his own employees,provided Nsuch tat such improvements an,not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA f/SQ.FT.
own of sou.).will have the harden of proving that he did not build or improve for pury
pore of talc.). TOT ,
1,as owner of the properly,am exclusively com acting with licensed contractions to t
construct the project Sac.7044,Business rend Profmd.rc,CWea The Contractors Li- Q
cense Low does mtapply mamowner oflurwity who builds or improves thereon,and TY. PLUMBING PERMIT 1 E (�(r•
.mmnraarBnsueh projects withacomarma0licumed pursuant w fie Cantracmts �T Q
License Law.
C I am exempt under Sec. ,B&P C for this reason PERMIT ISSUANCE 2,.y y Is.
Owner - Data — ALTER-DRAIN&VENT-WATER(BA) UA ONN
offWORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE / 1��6 /3q—�'
Iherebyrmundat er penalty Gfpsed.,oof the following declarations: ^` — l
.❑l have and will maintain a Certificate ofConsentto self-insure for Workers Cornice- DRAINS-FLOOR,ROOK AREA,COND. STORIES TYPE CONSTRUCTION
nation,as provided for by Section 3700 of the labor Cede,for Ne performance of the
work for which his permit it issued. XT E. - TARP
C 1 have and will maintain Workers Compensation Insurance,as required by Sectio yy
37W of the Labor Code,for Chep nrmance of Ne work for which this permit is isnurAl. - .SYRTEM-I INC. OUTLET9� g� OCG GROUP APN
My War cc curie,and Polic ' J.o
j Comer: n 'et I'n1icY Nn.i'M _v` GAS-EA.SYSTEM OVBR4( n tea' 3 /� old
ERTIFICATEO EXEMPTIONFRO tK /` (•J �
" COMPENSATION INSURANCE GRPAgI/INDUSTRLWASTGImulnuo
BU G DI .ION FRES
or lesr("is section neednnt be completed ifthe permit is foronehunind do][.($100) GREASETRAP CO
a PLANCNE
I candy that in the performance ofthe work forwhich this Pettit is issued,l shall SEWER-SANITARY-STORM EA.200 FL /NoJ
Ne Workers'Compen- ENERGY
not employ any Person in any manner so as to become subject to
Z section Laws of California.Data WATER HEATER WNF.NT/ELECTR
Applicant GRADING FEE
N NOTICETOAPPLICANT:Ifaftm making this Ccnificate of Exemption,you shouldWATER SYSTEMII'REATING
I" become subject m the Wmkees Compensation provisionsof Ne Labor Cale,you must SOILS FEE
Wforthwith comply withxuch provisions or this Permit shall be deemed revoked. WATER SERVICE
UO CONSTRUCTION LENDINGAGENCY NEW RCSIDE?NTIAI.PCMB. SQ.Fi PAID Da¢ ReceiptN
1herebyich tat thatmere iss issued
.30 lending agency I'or the performance of
the work for which mit permit Is issued lgtt.3119],Cib,C.)
U Lenders Name D 'OTAL:
Isnders Address
FC 1 ccnify that 1 base .it this application end state that the atwve information is BUILDING*ss- �...
Vy) contact.I agree to comply with all city and county ordinances and stat lawsolaing ro QTY, MECHANICAL PERMIT FEE
U F7 building commotion.and hereby amhonu represemativex ofthis city to enter upon Ne SEISM[ E
above-mentiated property for inspection purposes. PERMIT ISSUANCE
(We)agree to save.indemnify and keep hamdess the City of Cupenio.,.'s nit F.LECTRI E
liabilities,judgments,costs and expenses which may in any way acerae against said City ALTER OR ADD TO MECH. PLUMBING FEE
inconsequence Nthe RSTAN Of this permit. \
APP RCEREUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO BLOW CFM) MECHANICAL ME
5 URCE RF.G4L NS.
- AIR HANDLING UNIT(OVER K."CFM) CONSTRUCf10Nt
SignawmniiApplicenVCommetor Data 1 1 EXHAUST HOOD(W/DUCD HOUSING MITIGA ON ME 1
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hwoundous material - HEATING UNIT(TO 100,1100 BTU)
as defined by the Cul enino Municipal Code,Chapter 9.)2.and the Health and Safety - \
Cede,Section 25572(x)? 1[EATING UNIT(OVER 100.000 BTU)
r-1 Yak ON. PAID
VENTILATION FAN(SINGLE RESID) Dam - Receipt
Will the applicant or future building Occupant use equipment ordevices which - BOILCR-COMP(3HP OR IW,fNN)BTU7
emit Indications air cnmvninants az defined by the Be,Area Air Quality Management TOTAL:
District?
❑Yes []No BOILER-COMP(OVER 100,000 BTU)
I have real the hicardoms matenals¢quirement under Chapter 6.95of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code.Sections 25505,M533 and 25534.1 understood that V the NEW RESIDENTIAL MECH, SQ.ET.
building does not currently have a tempt,that it is my responsihillty to notify the occupant
of the requirements which must he met prior to io.moc or.Certificate of Occupancy.
Owner or aumonted agent Data O ISSUED BY: V ✓' ��
OFFICE ' /