S 0872 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PF TT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING'MECHANICAL J0872
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPLICAmT1ION SUBMITTAL DATE;
-� .a
OWNER'S NAME: PHONE: CONTRACT'OR'S MF.: I.IC NO:
12 C CONTRDLX
OAR i N41 ADDRESS:
k: LIC NO: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Appllcanl(Initial) BLDG ELECT PLUMB MECH
wA=k� fez ' a -L,Rza ❑ ❑ ❑
LICENSED CONTRACTOR'S DF.CLARA'1'[ON QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(colmnencing JOB DFSCRIPTION
Poo ZO with Section 7")of Division 3 oflhe Business and lhofewinns Code,and my license is RESIDENTIAL'
I1-- nfullforccandefl / PERMIT ISSUANCO
F-VU License an—s— 1.11 ,�- L ❑SPDWL ❑KITCHEPLUMBINREMODEL
N<G Date Commcmr APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
g.pm A CHITECTSDF.CLA A I N PANELS ❑MULTIUNIT ❑STRUCTURAL
Z O 2 I understand lshall nmy pans sahe used as public records v� MODIFICATION
OZ-- UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Pror sial n°I 201.1"AMPS IMPROVEMENT [I SWIMMING POOLS
CY 3 OWNER-BUILDERDECLARATIONCLARATION OVER IIXg)AMPS ❑BATH REMODEUREPAIR El DEMOLITION
Wypg C Q I hereby off nn on 1 am exempt from the Cocoons Car License Law for the
W a Ii UE. following mason.(Section 7tD 1.5,bosinwx vnd Prnfassi,nn Coda Any city or aunty SIGNS ELECTRICAL OTHER
IFC LL O so¢ which requires a permit to construct,alma,improve dcomf.sh,or repair any structure
prior to its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL Cl RCUIT/MISC.
r{{�yyisY that he is licensed Purmem,,the provisions of the Connector's License Law(Chapter 9
W6�'QQ (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or TEMP.MITER ON POLE INST. COMMERCIAL:
ti c that he is exempt therefrom and the basis for the alleged exemption,Any violation of
NSection 7031.5 by any applicant for v permit subjects the applicant 1n a civil ❑NEW BLDG/MDITION. ❑DfiMOLITION
nm more than five hundred dollars(f5 W). VP Penalty nr POWER DEVICES l ❑TENANT ❑FOODSERVICE
Las owner ofthe IMPROVEMENT
"O ❑ papery. remye,antended orofle df or their sole compensation, SWIMMING POOL ELECfRIC C1 OTHER
will drthework,and the nmerure isnots Livens Ledo listotapply ]oan,Business
4�1 amt Pmfwhob Costs:noContractorsthereo License Lawdoesnotapplyalstnrfromof OVIt,ETS-SWITCHES-PoXTURES
his o ny who builds or improves thereon,aper veto Ares such work intended
or or through
his own employees,provided that such improvements are not imended or altered lin ISH W NESID[NTIAI.ELECTR SQ FT.
sale.ILhowevee the building or improvement is sold withinome year ofcompletion,the PSO.T TUR AREA $/SQ.Fr.
mer builder will have the foort m orpnwing That he did not hulld or improve for par- A {v/
pose ofsale.).
EI 1.as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
Consumer the project(Sec.7044.Business and Professions Coale:)The Connector's J. (1A®�/ 6�C �[/1E�11
Cense law tlass not apply m an owner of property who builds or improves thareon.ad QTY. PLUMBING PERMIT FEE (� rJ 25 R[V{/
who coarcts for such p rdecw with a combo orris)licensed tomorrow the Contractor's /�
License Law. PERMIT ISSUANCE CI Ut l,Ut-thI�NU
❑ m laexempt under Sec. ,B&PCfar this reason
ALTER-DRAIN&VENT-WR'I'ER(EA)Owner Dem VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT DEVICE //��yp��
1 hereby will
mai under Certify of penury ent of the following W d er's C s:
wr
i] Ihave and willmaintainstion 37ac of the LabrCode.for the
Workersce of the
DRAINS-Iy.00R.ROOF,AREA.COND. STORIES TYPECONSTRUCf10N
solar, r provided for mi Section 3]IX)of the tabor Cde,for the perfonnance of the
work for which this permit is issued, FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,which his Perm by Section
My of then Conawar Code,fonhsurance turnenfthework froodrare permit is issued GAS-FA.SYSTEM-I INGYOUTLETS OCC.GROUP APN
Cmrilm. 'n Compensaion Insurance wrierand y NICY nunnher un:
Caries PION No.: GAS-FA.SYSTEMOVER 4LEA)
CERTIFICATE OF COMPENSATION
INN FROM WORKERS'
COMPENSATION INSURANCIi GRCASFIINDUS'1'HL WASTE.IMI'IiNClil'TOR
(This section need nm be Completed!if the permit is for one hundred dollars(5[00) BUILDING DIVISION FEES
to Iwo.) GREASE TRAP PLANCf1F:CK IgiE
I Certify Not lathc,crtormanceofthe work forwhich thispermit is issued,l shall SEWER-SANITARY-STORM FA.200 Fr.
not employ any person in any, tR object the Workers'Cmml'cn- ENERGY FEE
O Z alma U (Cal ym Da � � u WATER HEATER W/VENT/ELECTR
.� O APPIicq/�l'� GRADING FEE
ti NOTICE T APPLICANT:IL a0er along this Certificate of Exemption,you should WATER SYSTENUT'REATING
abecome subject to the Workers Compmortion provisions of the Lahr Code.you must SOILS FEF.
ibl forthwith comply with such provisions or this permit.shall he deemed revoked.
WATER SERVICE
z CONS'rRUCRON LENDING AG17NCY NEW RESIDENTIALPLMB. SQ.Fr. PAID
V 0 I lumbyabfrmlhaWmmisacomwctionleading agencyfrnhe performance of Dane sip p
f" the uml,far whichthis permit is issued(See3097,Ci,C.)
C) Lenders Name T(yfAl.:
} Landers Address T(II'Ah:
I� I clad ry that 1 have read this application and state that the above iannotation is BUILDING FEE
L 1AA c,neCl.I agree at.,,all,with.11 city and eoanty naval...csandxtwelawxrelmirglo QTY. MECHANICAL PERMIT FEE
VZ building Conswaion,and herebyauhoritt representatives ofthis city to enter upurthe SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCIi
(We)agree m save,indemnify and keep harmless the City of Coruna.against IiLECTRIC FEE
liahilitieajudgmam,coons and expenses which may in any way a mw against said City
in ALTER OR ADD TO M[CH' PLUMBING FEE
comequence of the gaming of this permit.
APPLICANT UN STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 10."CFM)
URCE OGULr T ONS. \ MECHANICAL FEE
I\^1 P��� AIN HANDLING UNIT(OVER IU.fMp CPM) CONSTRUCTION TAX
lig• F.l
Signature of ApplicanVContrvcmr Date EXHAUST HOOD PMDUCD HOUSING MITIGATIONI>EE
HAZARDOUS MAT12RIALS DISCLOSURE
Will the applicant in future building uecupam store or handle haurdous material BEATING UNIT(TO 100.0)0 BTU)
as retired by the Collection Municipal Crile,Chapter 9.12,and the health and Safety
Can,Section 25532pd? HEALING UNIT(OVER IOB W B'I'U)
O Yes ❑Nn PAID
VENTILATION FAN(SINGLE RCSID) Date Receipt p
Will the applicantinor future building occupantassl.Air unt ordManaementes which BOILER-COMP OHP OR 100,000 BTU)
emit hazardous air contaminants m defined by the Be,Area Air Quality Management TOTAL:
Dinner?
❑Yes E]No BOILER-COMP(OVER IW,0011 BTU)
I have read the bamable,materials reyuiremerts under Chapter 6.95 afire Cali- AIR CONDITIONER ISSUANCE DATE
burns Heath&Safety Code,Sections 25505.25533 and 255)4.1 undersarvl that if the NEW RESIDENTIAL MECH. SQ.FT.
building class not currently have a tenant,that it is my responsibility an notify the occupant
or the quirmmems which must be mel prior to issuance of a Cerilicam of Occupancy.
Owner or milhumzsxl agent Dal. TOTAL: VJ 0
ISSDED Ii V:
OFFICE