S 3890 AYYLIQAN I w rRL IN INrORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �+ ^ /A O
BUILDING PROJECT IDENTIFICATION - J 3 `VI
r BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
10-298 iiiA.V C'aurr �� 9g
OWNER' PHONECONTRACTOR'S NAMEC- �� 7�� LIC NO:
CONTROL#
CHITF.CT/ENGINEER: LIC NO: ADDRESS: Oa�JA/N S�• LZOQ� ❑
CONTACT: PHONE: 4i BUILDING PERMIT INFO
❑ Consultant Fees Paid By Applicant(Initial) BLDG ELECT PLU B MECH
❑ ❑ ❑
LICENSED CONTRACTOR'SDECLARATION QTY. ELECTRIC PERMIT E
I hereby o m' that I am licensed under nd Probns of Chapter 9(commencing JOB DESCRIPTION
�1with Sermon]defecDivision3of the Business and Professions Code,anJ my license is
F1_ ih full force and effect
/�_ PP.RMIT ISSUANCE
�U License Cla. ` Linco 3 - SFOWL ❑KITCHEN REMODEL
rFDE Date CO.DELL APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
A CHITECT'e DECLAR T PANELS DMULTI-UNIT []STRUCTURAL
O Z y Z 1 understand my plans shall be used as public records MODIFICATION
UP T0200 AMPS - El INTERIOR 11 CHIMNEY REPAIR
F4�Lt Lsensed Rofessmnal 201-1"AMFN IMPROVEMENT
aye W< OWNER-BUILDER m Ce Conte ON ❑DEMOLSWIMMITION POOLS
y W Q 1 hereby a(irm on 1 am exempt from the Contracmr's License Law bribe OVER IIXIU AMPS L1 BATH REMODEVREPAIR 0 DEMOLITION
W C 4 U following tensor.(genion]U31.5.Business and Professions Code:Any city or count /(7
W 3 W F y SIGNS ELECTRICAL r`OTHER
y which requires issuance,permit to cunswm,aper,nt forsu demolish,ri repair any swment
F.�yQ thatheor slts ensepursuarequiresihovisiosof for Compach ctor's Licensle ae ned aw(Chapt ani SPECIAL CIRCUii/MIS
G that min licensed functionmthe of Division
of the the Business
Cicero Law(Chapter r so thammes exempg w t therefrom
and ofbasisonlofiM1eeged exempton.AnynnsCode)or TEMP.METER OR LEINST. COMM .R IA
that he is exempt therefrom and the basis for the alleged exemption.Any it penalty of - ❑NEW BLDG/ADDITION ❑DEMOLITION
noSlatmore than by hundrelicentrs($50 emit subjects the applicant toacivil penalty of POWHR DEVIC DTENANT ❑FOODSERVICE
F Y rot more than five bonded dollars($500).
qDl,as owner nfthe property,or my employees wird wages as their sole compensation, SWIMMIN COL.ELECTRIC IMPROVEMENT
will do the work,and the strammob taunt intended interfered forsale(Sec.9044,Business C OTHER
3 and Profession Code:The Corrosives License Law does not apply to an owner of OUTLE -SWITCHES-FIXTURES
property who builds mangroves Hereon,and who does such work himself or through
his own emplayees,provided that such improvements arc not intended or offered for HE ESIDENTIAL ELECTR SQ PT
sale.If,however the building or improvement is sold victim one year ofcompletion,the SQ.FT.FLOOR AREA $/SQ.ET.
nechuilder will have the burden of proving that he did not build or improve for par.
pose of sole.).
D 1,as owner of the property,am exclusively contracting wit'
m licensed O uctore to AL
M
construct the project(Seo.74.Business and Professions Codc)The Gmrscror's Li- a
ense Law does not apply m an owner of property who hurch,or improves thereon,and QTY PLUMBING PERM FEE
who contracts for such projects with a connacmr(s)licensed pursuant to the Conrnemi s
License Use
❑ I am exempt under Sec. ,B&P C for this reason PERMIT ISSUANCE
OwnerDate ALTER-DRAIN&VENT-WATER E Of
VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE .CaD a{a
I henebyeilinm under penult,.fpelery one of 0e following declarations: aJ V e
I have and will maintain.Cenificam of Camentto self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND.
,scion,as provided far by Section 37M of the Labor Cork,for the performance of tan STORIES TYPE CONSTRUCTION
work for which this permit is Issued. FIXTURES-PER TRAP
la 1 have and will maintain Worker's Compensation Insurance,as required by Section
I] oflhe Labor Code.forme penarmance afthe work for which this Permitisissued. GAS-EA.SYSTEM-)INC.4 OUTLETS OCC.GROUP pPN
C rzWorker's Cam�tnn u Y%!A//h+nm cY Nn Y n/,I4+76V
er
GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANOUSTBE WASTE INTERCEPTOR
(This section need not be completed if the permit is for one hundred dollars($1WE BUILDING DIVISION FEES
or In,,.) GREASE TRAP PLANCHECK FEE
Ioy any that in tin Ieran,armance of the work for which thispermit Workers
ed,I shallCantata-
SEWER-SANITARY-STORM EA.2M FT.
tat employ any person in any manner so ayMJ�ry9 y{�y�no the Workere'Compen-
z scion Laws of California (G/LYY�'17 ENERGY FEE
� WATER HEATER WNENT/F.LECfR GRADING FEE
Applicant
% NOTICE TO APPLICANT:If.afte,Making this Certificate of Exemption,you should WATER SYSTEM/I'REATING
become subject m the Workers Compensation previsions of the Labor Cade,you must SOILS FEE
{ Q forthwith comply with such firsts....or this permit shall he deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY
D ,Z NEW RESIDENTIAL PCMB. SQ.FT. PAID Date Receipt#
I hereby efBrm that there Is s cnnwcdon lending agency for the cen'orm.nw of
� � Ih.work far which mix permit is issued(See.309],Civ.CJ '
Lender's Name
WLeodeis Address _ TOTAL TOTAL
F
fL 1 certify that I have read this application and state that the above information is BUILDING FEE
tinr-i Z buusawst ilding close on comply hereby
youth arta wuntyntatives ofandcity to enter
QTY. MECHANICAL PERMIT FEE
V above-mentioned
droert herebysurhonprposes.matives.(thiscitymemerupon the SEISMIC FEE
above-mentioned properly for inspection purposes.
(We) ce g PERMIT ISSUANCE
( gree to save,indemnify and keep harmless the City o a nano i against ELECTRIC FEE
inconsequnce of ts,the coming expensesermit.hmay in any way.crneagainst said City ALTER OR ADD TO MECH. m
consequenceofUNDERSTANDS
thiscermit. PLUMBING FEE
APPLICANTULATIOTANDS'AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO IU,BpO CFM)
SOURCE REGULATIONS, q �,, MECHANICAL FEE
/ f0 (,� y�q AIR HANDLINGUNIT(OVER10, CFM) CONSTRUCTION TAX
Signature ofApplminic tmemr Drug EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant stores handle hazardous material HEATING UNIT(TO-IN, BTU)
as derated by the CLpecom Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? / HEATING UNIT(OV 10g011p BTU)
D Yes X.
III"'
VENTILATION P (SINGLE RESID) P Will the applicant or future building occupant use equipment or devices which
it hazardous air communists as defined by the Bay Area Air Quality Management BOILER-C P(3HP OR 100,000 BTU) c
strict? T J V
El Yes No BOILER ONE(OVER I Wood BTL
I have read the hazardous materials requirements under Chapter 6.95 of the Cal,- AIR NDITIONER $ A T
feria Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the RESIDENTIAL SUCH. SQ.FT. '
building area oat cunenUy have.retain,that it is my responsibility m notify rhe nceupani
.fine
f there u ra which tan i t issuance a fa CenlficeI If/Jccupa.cy, .
UwmI m smhortzed sp ntIs
t TOTAL:
OFFICE