28535 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL n Q 5 3 Ck
BUILDING PROJECT IDEN'I'1FICATION G lJ v
BUILDING AUDRfSS:' SANITARYNO. APPLICATION SUBMITTAL DATF
5 -84P 'oq
O NER'S NAME: PHONE: CONTRACTOR'S N 1 E: LIC NO:
1p7 Z NIC CONTROL
ARC /ENGINEER: LIC NO: ADDRESS: ❑
CONTACT, - PHONE: .. - BUILDING PERMIT INFO
UUSA& 10P 7,T7-94& ❑ Consultant Fees Paid by Applicant(Initial) > P.LECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTORS mile, DIi ion,of hap QTY. ELECTRIC PERMIT NP.P.
1 nereny afnrm that 1 a3 licensed unser provishom of Chapter 9l m,liceneme JOB DESCRIPTION -
a'Z with Sedinn]UIgB oC Division3 nl'Ihr Bnsinese and Professions Code,and my license is RESIDENTIAL: .
DO I'BRMIT I590ANCIi El KITCHEN REMODEL
�., infmlfma and erteal. ❑SFDWL
Ucenae Class Courtrai
ourt APPLIANCES—RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
NQonDole—T'S DE or
❑rn ARCHITECT'S DECLARATION PANELS ❑MULTI-UNR, ❑STRUCTURAL
�'1 understand my plans shell be uxd as public records � MODIFICATION
op,z—(� UPTO200AMPS. a -1 INTERIOR El CHIMNEY REPAIR
rr'3�ty Lieensed Profcaaional 1 � 2111-1000AMPS IMPROVEMENT
6❑ OWNER-BUILDER DECLARATION OVERo"AMPS ❑BATH REMO RPPA ❑ ION
C 1 hereby affirm Nm 1 am exempt from the Contractor's License Law fiat the Icy IL■
3 a U following mown(Section 7031.5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL. ❑OTHER
0J a[a- which requires is pemet to mmtruct aIle,improve,Jemolisb,or repair any stromata
Eq•� priorn its ixmance,also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUITIMISC. `
0gyy0yy }
that he is licensed Immoral to the provisions ofthe Contractor's License Low Chapter!) _
see 00 00 0
(aommeacingwilh Seclion7fKK))of DivLsiori3 ofohcOmincsa mJ Prnfenrinna Code)ar TEMP.METER OR POLE INST. , - COMMERCIAL,
a
that he is exempt therefrom and the basis for the alleged exemption Any violation of ❑NEW BLDG/ADDITION [I DEMOLITIONiq5
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
❑TENANT ❑FOOD SERVICE
t mare than five hundred dollars($500).
F C ❑1,as owner of the progeny,or my employes with wages as heirsole compenaaion. SWIMMING POOL ELECTRIC IMPROVEMENT
will do the walk,and tine structure is not intended or offered for sale(Sec.JW4,Business - - - ❑OTHER
ad and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
A' property who builds or improves thereon,and who dna such work himnclC nr throogn
his own employees,provided that such Improvemema arc not intended or"hared for' NEW RESIDENT ELEC'I'll SQ FT.
sale,If,hovase,the building or improvement issold within mm'arofcnmPRdan.the SQ.FT.FLOOR ARTA S/SQ.FT.
owner builder will have the burden of proving that he did not build or improve for put-
pose of tole.). S4 1
❑.1,as owner of the property,am exclusively cmatmeti.,with licensed cammcmrs to TOTAL:
consumer the project(Sec 7014,Business and Professions Coder)The Comntetor's Li
-
riseLawdoesnotapplytoanowner of property who builds or improves menon,ane QTY. PLUMB( ,PERMIT FI•:E
who corimacts for such projects with a mmmmoge)Iicanmd Immoral o the Contractors
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C for this reason
Owner Dam-
ALTER—DRAIN&VEST—WATER VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one mine following doclomtions:
❑I have and will maintain a Cerliftcite of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,CON2 STORIES TYPE CONSTRUCTION
ounce,as provided for by Section 3700 of the Lvlasr Code,for the performance of the
work for which this permit is issued. FIXTURES—PER TRAP
❑1 have and will maintain Workers Compensation Insurance,az require)by Section -
3700o1fthe bettor Carlo,fvrthe performance ofine work for which this permit is issued. GAS—EA.SYSTEM.I INC.40ITTLLTS
My Worker's Compensation Insurance carrierre
and Policy number a : OCC.GROUP APN
Carrie: Polley Nn,; GAS—EA.SYS'fHM-OVER4(BA) '
' CERTIFICATE OP EXEMPTION FROM WORKERS'
CDIgT
MPL"NsAriON INSURANCE GRBASEIINDUS'IRLWASTE INTERCEPTOR BUILDING HVISIUN
(This section need not W complcted if permit is for one hundred dollars($100) OR BASE TRAP
or less.) - PLANCHECK FE
Loy any matin the perfonnner o as
work for which permit is issued,lshall
on- SEWER—SANITARY—STORM fA.2fX1 FT.
not employ any person in any manner m az m become subject m the Workers'Compen- ENERGY FEE
O 7.
.he.Laws of California.Date WATER HEATER WIVI?NT/ELECFR
Z Applicant GRADING FE
to NOTICE TO APPLICANT If,vfmr making this Certilicam of Exemption,you should WATER SYSTENUTREA'1'ING
abecome subject to the Worker's Compensation provisions mine Labor Code,you must SOILS ITE
forthwith comply with such provisi an or his permit shall be deemed revoked. WATERSERVICE
CONSTRUCTION LENDING AG17NCY NEW RESIDENTIAL.PLMB. SQ,FT. PAID
U O 1herehynffrm thatthe.iso construction lendingogcm,Tom e,ri-formanceof D te Receipt#,
w !^ the work to,which his permit ls'asued(See.300.Civ.C.) -
O FU Landers Name TOTAL:
Landers Address TOTAL:
1 certify that 1 have read this application and stale that the above information is BUILDING I
rn correct.1 agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
— 495
U building construction,and hereby authome,representatives of his city to enter upon me SEISMICFE
aMwe-mentioned property for inspection implies. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hannleas the City of Cuperlion against ELECTRIC FEE
liabilities,judgmem.s,costs and expenses which may in any way accrue against said City AUER OR AUDIO SUCH. PLUMBING FEB
in consequence of the gianting mhis germs.
APPLI 1NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOUR EGULATIONS. T MECHANICAL FEE
AIR HANDLING UNIT(OVER IUp(0 CPM) CONSTRUCTION TAX
Si more I lcrnUContra for Dade EXHAUST HOOD(WIDUCT)
HAZARDOUS TE IALS DISCLOSURE HOUSING MITIGATION 1z1t
Will Ina up,icam or f rime building occupant sere or handle haandous material ((EATING UNIT(TO 100,0011 BTU)
as refused h,the Capone.Municipal Cade,Chapter 9.12,end me Health and Safety
Code.Smile.25532(.)^ - HEATING UNIT(OVER 100,090 BTU) A
[I Yes []No ' - PAIp❑
VENTILATION FAN(SINGLE.000 Br -(l ,pate r� wBeceipt#
�)
Will the air amatm m furore building occupant use equipment or devices which �41T e Y
emit hazalloua air consaminama ns defined by the Bay Ana Air Quality Management
BOILER—COMP(3HPORI00,(100 H'fU)
TOTAL:
BOILER—COMP(OVER 100.000 BTU)
es ❑Nue real the hmallous mammals is under Cha ter 695 of the Cali- AIR CONDITIONERre.25533n p 1, IS ANCE DATE
&Sufny Code,Sectinnv 25505,25533 nnJ 255:W.I unJemwnA ranoif me NIiW RESIDENTIAL.MIiCH. SQ FT. 'ain currently have.oawm,data is my respmulhil it,to nail fy(be avupunt mems which mull be met blot to issuance of a Certificate mOccupancy.henced agent Date TOTAL ISSUEDBY:
OFFICE