30153 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO'_ BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 30153.
BUILDING,PROJECI'IDENTIPICATION
IBUILDING ADDRESS - SANI'TARYNG APPLICATION SUBMITTAL DA'I'11
,. i o l i a ADELH�i D GT c-�rT-- �7 q q 6
iOWNERS NAME. ��� ,���`Ory ��� Cnjv"���S NA LECrOC, • "' ^ NIC - CONTROL# ,
�ARCHITECLENGINIT.R:, LIC NO: ADDRESS: LL IlV_ ❑
n-o. '3ox- 174,3 cA-Mnl�u- .
CONTACT': PHONE. ,, t BUILDING PERMIT INFO
• ❑ Consullanl Fees Paid by,Applicant(initial) I ' BLDG ELECT PLUMB MECH
❑ 6� ❑ „ ❑
ucENSBUCDMxd dmR's DECLARATION QTY EhIiCTRIC PERMIT FEE �-\
1 heresy 0)of mat Iran obe Rd undermd lind.....homer 9(Lammemms I JOB DESCRIPTION
M. 0 with]]( ", 1111(B of Division BUSine:vand lhafeesions Caiaand my bccnurs r� RESIDENTIAI�
f-UP Lermarcdand off t. I �O�A /N / PERMIT ISSUANCE _� ,C1SFDWL , ❑KITCHEN REMODEL
U U Lreenu Class Lm# Laee e1 IL
yGL Date 'Conteenor_q� API'LIANCFS-RESIDPNI'IAI. ❑ADDITION ❑PLUh181NG R1>I'IPE
ARCHITECTS DECLARADON ❑MULTLUNIT C]STRUCTURAL
F.D to PANIiLS
Z Op2 Z 1 understand my plans,hall bs tau l s pis rccnrds -- MODIFICATION
UP TO 2111 AMPS
O,Z gJO T ❑INTERIOR ❑CIIIMNEY REPAIR
F`=G Licensed Prof,,imal 201-IOWAn1Ps
OWNERr se,amE om he Canino IMPROV EMEN'T"
Q i herehy:dorm 11tm I am erempt Iron thd Comro.mr',Lmen,c Law Ira ilia OVER IIXq AMIlS ❑BATH kEMODEI%REPAIR 0 DEMOLITION
fit'06 V following reason.(Section]ol L9.Rosiness and Professions Cate.Any city or county SIGNS ELECTRICAL El o eR .�4!!at— f—�-
W 34 in which requires a permit to et namet,alter,iopmao,demoldh,or repair tiny unlmre
prior tons issuance.also regaires the applicant for such Permit to file a signed stmcment ` SPACIAL CIRCUIT/MISC. ?� ~—
C a that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9
W 1commenci ng with Seal ion]01q(of Division 3 of the East ness and Foul c,sions Coder 'I'EM P METER OR POLHINS'I'. s COMMERCIAL:
L a e�, that he is exempt thercfiom and the basis for the alleged exemption Any vmlmom of ❑NEW BLDG/ADDITION . ❑DEMOLITION
,y w Section loll 5 by any applicant fm a permit subjects the applicant e u civil penalty of POWER DEVICES. �TIiNANT Q FOOD SIiRVICP.
F•ZY n marathon five hundred dollars 15500) IMPROVEMENT
MEN'T '
Q ❑ Las owner of the property,or my employees with wages as their sole cmmpt®ation, SWIMMING POOL ELECTRIC '
$$ will do me work,and ilia structure is not intended or offered lot said(SeL.7044.Business ❑OTHER
Wigs and Professions Cale:The Contractors License Law drs not apply to an owner of OUTLETS-SWITCHES-FIXTURES ^ '
pmpeny who hoolds or 9mproves thereon,and who does such work hlm,elf or through,
his awn employees,Invented!shat such tmpowemcnts ere not intended or uttered for NEW RESIDENTIAL ELECI'R SQ FT
sale.If,haweve,the building or improvement is sold within one ycarof completion 'he - SQ FEFLOORARFA 5/SQ.Pr
owner builder will have the burden of proving that he did not build or improve lot par- r
pose o ' P' /y
[_1 I,as"am owner of the pmpeny,am Isal usrvely cnnoaniug with licensed comr:mtors er_
convwa the pto)ect,Sec.]I}W,Bu,inev,and Podessmm Code)The Contnctnr's Lo - — .• -
c seI dos not apply man ownerof pmpeny who bmldv or improves thereon,and ,QTY PLUMBING P17RNIIT FEE. I UC o9
who contracts tin,uch pra)ects with a contractors)licensed pursuant me Contiadtar, '9 ,
[.,come Law, PERMIT ISSUANCE tl7/Y 96
❑
I am exempt under See, ,13&P C for this Fallon
ALTER-DRAIN&VENT-W RTA)
Owner [ Un,. _ — Cr}Iuyv TION .l.
• WORKER'S COMPENSATION DECLARATION BACK PLOW PROTE CE e
I batch,uprm under penalty of permit,one of ou following declarations `
Ilidse and will maintain a Ciodicate of Comenno selbinsure for Worker's Gnopen- DItA1NS-FLUOR,R .AR OND STORIES TYPE CONSTRUCTION
sound,as provided for by Staten 37W of the Labor Cale,for the performance of the
wok fur shwh iho,cra n is i,wed. ILL\'1'UR[S-PER TRAP., `��
❑1 have and will oainmm Worker's Compensation Imurane,.as required by Section /i� o A I ,
37W of the Labor Code,for the performance of me work for which airs perms iv issued. GAS-EA.SYSTEM-I INs.fO TI.. <l OCC,GROUP APN
My Worker's Compen,utiun Insurance darner and Policy nnam i re /l �a
Comer. Policy N^ I GAS-HA SYSTEM Ov1 (L'1�1��/
.CERTIIICATF,OF EXEMPTION FROM WORKERS' GREASEANDUSTRI.WASTE INTERCE �/
COMPENSATION INSURANCE - I BUILDING DIV151ON FEES
(This seution need net be completed if the permit is for one hundreddollary ISlnp
nr laud .. GREASE TRAP ,, PLANCHECK PEii
Icemfy ilia mateperGmnance nfthe wad far which this pennarsissued.l shall -
iuncmplayanypers�n inony invnnerso uv mM1edoniewhjccun ilia WmkerV Cumpen- ,SEWER-SANITARY-STORM FA 200 IT. ,ENERGY FT:F. '
O Z Ation s of Culdomm La Dam - ,WATER HEATER W/VENTIELEMR GRADING FEE
y NOTICE TO APPLICANT,It,after making this Certdcate of lixemptinn,you.hould + WATER SYSTEAI/TREATING a
F ^ bccomesublecuo the Worker's Compensation proton.,of the labor Cade,you must isoils FEE
WIva+ nnhwah comply with such rtwivun,math proton shall be deemedmeoked. WATER SERVICES -
Q
CONSTRUCT ION LENDING AGENCY I NEWRESIDSNTIALPLMB SQ.IT. (PAID
U O IM1ercby afford that there isa construction lending agency for mepermadarreol , Date ,Receipt#
be work for which his perms.aas,ued See. 09].Co,C) V/
ULender's Nenr- ', TOTAL.
W :.,ad,,, - TOTAI.
Fly 1 easily that I have rcnJ ran application and vote That the above irbnmntion is BUILDIV.E 0 emrem.l agree to comply with all ciiy and county ordmmces and sere laws relating In QTY MECHANICAL PERMIT FEE buildingconswetion,andherebyauthorizerepresentativ esofthiscityto enteruponthe SEISMI
above oundmird properly f or inspcamn purposes PERMIT ISSUANCE
(We)agree m cove,m le uafy and keep hmmless the City of Ctipenmu eSama ELE IC FEE/ 14C�7!�
mhihtms,)udginents,costs and cxpdmses which any in tiny way occmeagaost said City ALTER ORADD'IOMECIL PLUh 1 E
in consequence of the granting of this perms'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT G O 10,M)CFMI hIF,CIIAN AL FF.F.
SOURCE REGULATIONS.. .,,q//
/9 _ Q- 7Vl a�Q 7-- 9-1q6 I AIR HANDLING UN TIOVER 10,0(6)CFM) I CONSTACTfON TAX
I Signorine of Appheam/Commcmr Dam I (EXHAUST HOODDYIDUCT) - HOUSrl'G MITIGATION FBE
I IAZARUOUS MATERIALS DISCLOSURE
WJlthespplicemor more hmldeg,rcopomsem or handle hazmlm,material HEATING ON['T(TO W.000 BTU)
as defined by he Cupcnmo Mrmieipal Cale,Chapter 9.12.and the Heald and Safety
Cade.Q -5532(sT! , HEATING UNIT(OVER 100!x)0 BTU)
Yes 0 N I,
VENTILATION PAN(SINGLE RESID) ,PAID Da Reutpt#
Will the applicant or(tiutrc building occupant me egmpin ar or'dev icev which BOILER-COMP 13HP OR 108.000 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quuhty ManagementO
Uistncf0 Yes ❑No x •I (BOILER-COMP t OVER IO.WB BTU)
.,a AIR CON DD'IONER /
I have mad the hazaNam materiels mgoircnrnty under Chapter b 95 of the Col, I IS ANCE DATE
foram Health&Safety Cale.Section,25505,25533 and 25534 1 understand mat it he NEW RESIDENTIAL MECH. SO EL _
building does not currently have a mrant,thin a is my resp nomility n,notify the'acupaid
of the requirements which must be met poor to issuance of a Catharine of Occupancy.
Owner or authorized agent ,- ,Date I TOTAL ,ISSUED BY:
OFFICE