30083 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO_
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 30083
I BUILDING PROJECP IDENTIFICATION
BUILDING ADDRESS
SANITARY NO' APP ATION SUBMITTAL DATE
O µ�`&,
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v�ylEq S NAME PI10 CONTRACTOR'S NAME LIC NO NIC CONTROL x
t Is S 6i l6P 1 5C0 t ro£ fl
RCHITECfIENGINEE LIC NO. ADDRESS ,
CONTACT, PHONE I H�ILDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT P<LU MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE I ❑ ❑
M=Z 1 hereby when that I am licensed under previsions of Chapter 9(commencing ///��� ` 7 B DESCIj�PTION
iN=� mfpufottie and effect the BUSfnwsend Prolessums Code,and myhcevsc is I t PERMIT ISSUANCE �SFDWLNTTA4 El KITCHEN REMODEL
V Leam c Class L¢.°
<, U I APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F ts1 Date Carman-
y P' ARCHITECTS DECLARATION El MULTI-UNIT ❑STRUCTURAL
ZOy Z� Iandententlm lam obeli be used de bbc records PANELS pp MODIFICATION
oz- P Vu I l UPT02W AMPS SVq �� ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Panic atare] 201-1000AMPS IMPROVEMENT
6^� OWNER-BUILDER DECLARATION OVER IfNN1AMP5 C1 BATH REMODEL AIR El DEMOLITION
V 1 greasy affirm that 1 1. exempt tram the Centimeter's Profession, lacense Law for the I ❑OTHER
{iL5 d
following reason(Section 7031.5,Business and Proiesntons Cnde:'Any oty or county SIGNS ELECTRICAL 12 f
su 3 as pl"j which recoups a permit w conswm,alien improve, howlelh or repot,any strucwre _..
go pnorio ismanco,albore'ups the"hetm fm sed+permnm file asigned'rmement SPECIAL CIRCUIT/MISC
,7s thmhe i,is,,censed pursvam I theprov.vmnof the Contoeroes License Law(Chapter 9
(commencing with Section 7000)of Division 3 at the Business and Professions Code)or TEMR METER OR POLE INST. COMMERCIAL;
d p�a that he is exempt merchant and the basis for me alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 70315 by any il,imim for a perm applicant it wd,,drs the applicano a crvd penaltyo! POWER DEVICES I (]TENANT [I FOOD SERVICE
zN ao no than five hundred dollars($500) I IMPROVEMENT
owner of thepmpeny,or my employees with wages as that,sole range nsamen, SWIMMING POOL ELECTRIC OTHER
_
G
Had the work,and tha ocandurets not fa upended or offered patinae(Sao 9044,Busmess '
W and Pndesstons Cape The Cormacmrs License Law does not apply to an owner of L OUTLETS-SWITCHES-FIXTURES
properly who builds or Improves thereon and who does'.do work himself or through '
his own employees,provided that such improvements are not Intended or offered for NEW RESIDENTIAL ELECTS SQ FT
sale.If,however,the budding or tinprovemeni is sold within one year ofcampkinas the SQ PT.FLOOR AREA S/SQ.FT
owner-budder will have the burden of proving that he did not build or improve fotpur-
paaeofadp.), - PA p D
1,as owner of the Napery,am exclusively contracting wish 1¢ensed eomracma to �'i P St,✓
consumer the project(Sec NM,Business end Pmlessmne Coiled Tho Coniracler'e Li-
c Law does not apply to an owner of property who builds m improves d, QTY.
(QTY PLUMBING PERMIT FEE If/III
wh contracts Antioch protects with a commetnr(s)licensed pursuant or the Catharines I JUN 19
Learad Law PERMIT ISSUANCE
I am exempt under Se. .B&P C fnnhis reason I V t
`•.eY- ALTER-DRAIN&VE lER(EA) t vt VALUATION I(Y j' 1
Jw r � uaic 1
COMPENSATION DECLARATION BACK FLOW PROTPQT.Dj1
thereby a[fr 'r penalty o(perjury one of the follnwiog declereuovs:
�[)Ihaveand will montain aCerttftvate of Cansem to self-insure for Workers Compen- i
DRAINS-FLUOR,ROU��9 C� i STORIES TYPE CONSTRUCTION l
cation,vs provided for by Section 3]1X1 of the Labor Code,fonhe performance of Ili_ /
walk for which this permit ssu
is issued FIXTURES-PER TRAP
i have and will maintain Warkees Compensation Insurance,as confined by Section
3200orthe Lab nto
or Code,for the performance al'the work far which this pa ,.issued. GAS-EA SYSTEM-I INC.4 OUTLETS OCC GROUP APN
My Worker's Compensation Insurance c.,at and Policy number arc.
Career ' Policy N-
CERTIFICATE SYSTEM-OVER 4(EA)
CERTIFICATE OP EXEMPTION FROM WORKERS' GRF.AS[IINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(this secaan—door at completed lithe permit is far one hundred dollar,0000) i
or less) GREASE TRAP I pLANCNECK FEE
I certify that in the performance ofthe work for which this permit is issued.I shall SEWER-SANITARY-STORM EA 203 FT.
not employ any person m any manner sees lo become imbileI to the Worker-Compen- I FNERGY FEE
O X. stains Laws of California Dot- WATER HEATER WNENTMLECFR
Q GRADING PFEE Applie^i
uj NOTICE TO APPLICANT.If,afar making this Certificate of Exemption,you should I WATER SYSTIPACREATING SOILS FEE
become subject to the Workers Compensation provisions of the Labor Code,yon must
forthwith comply with such provisions or this permit shall be deemed revoked I WATER SERVICE 1 -
Q
CONSTRUCTION LENDING AGENCY NEW ftESIDENTIALPLMB. SQ FT PAID Dam keceiptx
I hereby affirm that there is a constructors lending agency for aM1e per[onnance c: I
W O the work for which this mach Is Issued(See 3099.Civ C)
Lenders Nam=
Len der's I I TOTAL'
Adler, TOTAL,
y 1 certify that 1 have read this application and male that the above information Is BUILDING FEE
FV�jj correct.I agree m comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT PHE (SEISMIC FEE
G G hwlding consuucuon,and hereby authorize representatives afthis city to enter upon the xs
ahovemantioned properly far inspection purposes. PERMIT ISSUANCE
(Wt,)agree to save,Indemnify and keep harmless the Coy of Copmtino against I I ELECTRIC FEE ,
debihhes,ptdgments,costs and expenses which may in any way accrue against said City I ALTER OR ADD TO MECH. - (PLUMBING FEE I
In consequence of the granting of this Ismail.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) I MECHANICAL FEE I
SOURCE REGULATIONS
I AIR HANDLING UNIT(OVER 10,1100 CPM) (CONSTRUCTION TAX
Signature of A,ficendCmiract Data EXHAUST HOOD(WIDUCT) I HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will lheapphcaatm future building uccupaan'low or handle hazardous material HEATING UNIT(TO 100.000 BTU) -
s defined by me Capenmo Municipal Code,Chapter 9 12,and the Health and Safety I i
Code.Section 25532(m) HEATING UNIT(OVER 100,000 BTU)
Yes []No VENTILATION FAN INGLE RESID) (PAID
N
Otte Receiptx
Will the applicant or future hiuldmg occupant use equipment or devices which BOILER-COMP(1HP OR I(q,tgO BTU) I
�t hazardous air contaminants as defined by the Bay Area At,Quality Management TOTAL
tncYi I BOILER-COMP(OVER 100,000 BTU) I III
E3 Yes L]No
I have mad the hazardous materials requtremenas under Chapter 695 of the Cah- AIR CONDITIONER ISSUANCE DATE
torn,.Health&Safety Cade,Sections 25505,25533 and 25534 1 underpand shut tf the NEW RESIDENTIAL MECH SQ FT 1
building does not currently have a tenant,that it s my mildre ihilay to notify the occupant
of the requirements which must ap met prior to issuance of a Certificate of Occupancy,
Owner r authorized agent Data _TOTAL I ISSUED BY _ ,
OFFICE