30869 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES•USE BALL POINT PEN ONLY '
CITY OF CUPERTINO Ir BUILDING-ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MI?CHAN]CAL 30869
BUILDING PROJECT IDENTIFICATION
BUIIDINGADDRESS: / � �/ •�� �W SANn ARYNO. APP LICATIONSUBMITTALDATI
Sf 2 2 U sT�- 'LTL i�
OWNERSNAME F'f10NE: COMI'RACfOR'S NAME: LIC NO'.
N Z n .� I IM ZL.�Nees..st I N/C CO TROL#
�gRCHITECT/ENGINEER: I5 L- LIC NOW: s-JTl ADDRL•SS: j2�O " Sr4—SIVA O
:E. JIL5 to m
CONTACT: ��� P ONE: BUILDING PERMIT INFO
.S�ACillsAw`� pig QWp„11(OJ 4e;g� '❑ Can sultant Fecs Paid by Applicant(Initial) BLDG 1310 PLUMB ME�C(y
�. M Q I K LI
I.ICENSF.I C)NTRACTOR'9 DECL QTY ELECTRIC PERMIT FEE
1 hereby elrrso Nat 1 am licensed under provin rs ter 9(co coping JOB DESCRIPTION
aw�z with5ection011W)ofDivision3ofthe Monasterial C c,and icenseis
Fx�� in full force en� Z PERMIT ISSUANCE. DWI ,• ❑KITCHEN REMODEL
Rub Wecnm Class Gap
�6i Doc Contractor APPLIANCES-RESIDENT'IAI- A (TION El PLUMBING RE-PIPC
��on ARCHITECTS DECLA > ❑MULTI-UNIT ❑STRUCTURAL.
PANEL
z rn z I malmu nd my plans%hull I used us pub' R rob MODIFICATION
oz—, - UPT0200 AMPS ❑INTERIOR 1 �, ❑CIIIMNEY REPAIR
�+�{�j.� LicensW Profession"I 201d100WAMPS IMPROV,- E
a0.'Sd 2,,Jj
OWNER-BUILDE DI3CL N OVER I"AMPS ❑BATH RP.MODEUREPAIR E)DEMOLITION
X OC Q I hereby affirm that[am exempt firTrasxjomftaptor's License Law for the _
fS O w V following reason.(Section 7031.5,Business and Professions Core:Any cit,ar countySIGNS ELECTRICAL ❑OTHER
W'3 W F which"him,u permit to ruminant,alcor,Improve,demolish,or repair airy structure MAIMU U
12 E2,20
prior to its isvuonce,ulsu requires he applicant fte such per ritit)file it signed statement SPECIAL CIRCUI'i'/MISC.
;vW!gy�p. Nat he is licensed pursuanno the provisionsofthe Contractors License Law Choprcr9 �J s]
L
CaO (anon arvingwith Section9XNB.f nsio.s.3of Ne BusinessanJ Pr.fexsinns Cak)or TEMP.METER OR POLE INST {x
fY o C that he is exempt therefrom and the basis fur the alleged exemption.Any violation of ❑N -D_AUDITION El DEMOLITION
m Section?OJ LS by any applicnm Inc v pemrh suM1Jems the applicant to v civil penally of POWER DEVICES /� TENANT El 1700D SERVICE
CQnot more than Ove hundred dollurs(&500). PROVEMENT
❑ Las owner ofthe progeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC 001
22G will do the work.and the structure,is not intended orofered for sale(Sm.7044,Business HER
m and Professions Core:The Comlut9.rs Licemc Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves deriver,and who does such work himself or through
his ownemployees,provided that such improvement are not intended or offered for NEW RESIDENT IAL ELECT'R SQ Fr.
sale.If,however,the building or improvement is sold within one year of completion.theS .FLOORAREA $/SQ.Cr.
w
oneobailder will have the burden of proving that he did not build or improve for put.
pose of sale.). J`A(
1,as owner of the property,sen exalusivuly coutmeting with licensed contractors to r2
consumer pmject(Sec.]044.Business and Professions Code:)The Contractors Li. �(/
cense Law does not apply loan owner of progeny who builds.,improves amicus,and QTY. PLUMBING PERMIT FEE
whoro I-mv. or such Pmjeas wiNvcontmcurds)licensed pursuant to C.mmcmr's �]� ���.
License Lew. PCRMI'I'ISSUANCE J l.l-f/
I um exempt under,Sec. ,H&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dam - /YA
WORKERS COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE ���{{{"'
I hereby al trnrunder penallyle ofCayonoofthefallowing orkerians:
❑ ILove andpro will for
tard by
eCion 37¢ofthe wal Labor
self-immrefor WnornprComf the DRAINS-FLOON,ROOF,AREA,COND. STOR[ S TYPE CONSTRUCTION
sou s, provided fur Emend
Section d. of the Lubu Coda for the perfnnnanir of the
for which Nis permit is I.aoN. FIXTURES-PER TRAP
have and will maintain Wosefte Compensation Insurance, required Satins
37IX1 nfihe Labor Cnde,fonhe lmrfnrmanec nl the work for whichh this permit
is issued. GAS-EA.SYS'1T3M-I INCA OUTLETS ACC.GROUP AIN
My Wnr mrcnsatio�ura�qI artie Policy
No..4i lrp�
Cottee s A1C N� rand No_Y I 'R GAS-EA.SYSTtiF1-OVER4(IA)
CERTIFICATE 01:EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRIIASVINDUSTRL WASTE 1NTT3RCEITOR
'Obis cation need not be completed if the permit is lir one hundreA ED ILD]NO DIVISION PEES dollurs($IIXIL GREASE TRAP
or less.) PLANCHECK PEE
Iccnfythraothe any nrnanceofshe work
inam m,todue Wosissueditpveo Ishall SEWER-SANITARY-STORM P.A.2W FT.'
oat employ any peruse in any manner,so as to hecume subject m the Worken'Compen- ENERGYFIX
-O z satins rom '`Cnlifnrnia.Dam - WATER IINTER W/VENT/13LECTR
O NOTICE
OT(um _ GRADING PEE.
Ncame subject
APPLICANT.theWorker's
Compensatier anciallong on Provisions
Certificate ofC aboras .youmyou ulst WATER SYS'1'EM/fREATING
(~
Becameeh comply
to the Worker's.War,or thisprovisions of the
med Labor Cash.you must SOILS F7iC
W ti forthwith romply with such provisions or this permit shall he deemed revoked WHIRR SERVICE
Q -
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.FT. PAID
L) O (hereby affirm that there is a construction lending agency for performance of Date Receipt#
U. (.. the work for which this Permit issued(Se 3097,Civ.C.)
O U Le � 1 �
{iI Lender's Addms nder's Name TOTAL;
-�" _ - 'TOTAL:
ps , I certify that I have read ave this lication and state that the information
is BUILDING FEE
Ncorrect.i agree to comply with try d county ordinances and sure laws relating to QTY MECHANICAL PERMIT FEE
U z bullJingconsruci ndheyouth 'ze mpmunmtivca of Nis cirymcnmr upon the SEISMICFEE
abov-pwnho ,inspect' npurpnses. PERMIT ISSUANCE
-
(We c ejadennaland keep harmless the City of Culmnino against ELECTRIC FEE.
liabilitiesEar ostande cosec which may in any way accrue against said Ciry
in once
pared. Nis permit. ALTER ORADD'1'0 MECH. PLUMBING FEE
APPI ABRST DS AND WILL COMPLY WITH ALL NON-POINT
SOLATI S. AIR HANDLING UNIT(TO 10.0100 CFM) MECHANICAL FEE
I ( P ' '�
S F1,Ar% AIR HANDLING UNIT(OVER 10,M)CFM) CONSTRUCTIONTAX
SrVCommnor Wrap EXHAUST HOOD(W/DULT) HOUSING MITIGATION ECF.
a
'ITC MATERIALS DISCLOSURE
r Willlhpapp'um nr future huilding.ccupunr nom nr handle hu'roll mmeri:l HEATING UNIT(rpDIW.O(XIII'1'U) -as def sed by upenino Municipal Cole.Chapter 9.12,and the Health and Safety
on 25532(x)? HEATING UNIT(OVER 100,0(10 BTU)
❑Yes �No VENT ILATION]AN(SINGLE RESID) PAID
Date Receipt#
Will rhe it pmlmicaut or:cacao building by the B use Area
Air eur.t Management
which ement
1--hit hazmdous air cnnmmrnant. lined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR IIXI,q)0 BTU)
TOTAL.:
District? BOILER-COMP(OVER I IXW.IXXW BTU)
❑Yes �Nn r.
I emodoms ateliuls rcyulrenxnt under Chapter 6.95 of Ne Cali- AIRCONDHIONER - - - ISSUANCE DATE
fomia f r a1N S Cale, tions 25505,25533 cad 25534.1..&e ,.nd th.tif the NEW RESIDENTIAL MECH. SQ.F1'.
'a ddingto
I tte
rendy ea nathat nt, it is my nesponsibili u.partly the occupant
of the i ms must be met prior to issuance of a Cenifcem of Occu ones.
A rJ 1
ori¢lagenl Da' '1'O'fAL: ISSUED BY:
OFFICE — 4