99100136 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ELECTRICAL PEROWN
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: Y NO. APPLICA N SUIIMUMAL DATE
i 0-?-73e wk well _��P
OWN NAME: PHONE: CONTRACTOR'S NAME: LIC ND:
L (5b� 2A 1321 AL NICD NIC co Nm.a
RCHLTECfIIINGINEBR: LICNO: ADDRESj ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) 'BrLDDCF� ELECT PLUMB MECH
"CJ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affna that I am licensed under prvisions of Chapter 9(commencing JOB DESCRIPTION
�aZ�� with Section 700X)of Division 3 of the Business and ProfesxionsCNe.and my license is @ENIDENTIAL:
in full lane and cB t. PERMIT ISSUANCE
W -�4161. ❑siDWI. ❑KITCHEN REMODEL
�p.UU) Licenx Class Lic.a pPI'LIANC[S-RESIDENTIAL
N[.<i Dom Contra �j �L� []ADDITION ❑PLUMBING RE-PIPE
ZO=ys ARCHITCCTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
�� Iunderstand my plans shall Leased ns public reamrds n )bIO�FICATION
OZ -0 /�t3LoU2 U11102WAMP5 �,
I=,4LM Licensed Professional ❑IN'I'ERION IMNIiY REPAIR
OWNER-BUILDER DECLARATION 20LIOW AMPS PROVIiMENT SWIMMING POOLS
9 g Q hereby eRn that I am exempt from the Comre<mrs License Luw for the OVER Los)AMPS LATH RF,MODEUREPA IN ❑DEMOLITION
xS�(
uJ 3LQ following reason.(Scotian]031.5.Business and professions Cade:Any city or county SIGNS ELECTRICAL HER
W I" which rcyoires a Permit In construct,alma improve,demolish,or mpm,any structure
Laden.it nimance.also requires theapplasum torment permitto file a signed stammeat SPECIAL CIRCUITIMISC.
that he is licensed pursuant to the provisions of the Contractor's License law(Chapmr 9
a� (commencing with Section 7000)of Dlvldnn3of the Business and Proftssi, Cadc), TEMP.MET ER OR POLE INST.
6 a e W that he is exempt thcmfrom and the basis for the alleged exemption.Any violation of B )G/AODIT ❑DEMOLITION
'+� mSection 7031.5 by any applicant for a permit subject the applicant to a civil penalty of POWER DEVICESDWEN L1 FOOD SERVICE
C a y not mom than five hundred doll...(550). IM 0 E 4
=Q Cl Lssowner of the pmPerty,mmy employers with wages as their sole compensation. SWIMMING POOL ELECTRIC f�
f,c.0 will do the work.and theswaum i.notimedddalaoffertd for sale(See.] A.1humess ❑OTHEN
IW
3 and Professions Gale:The Comracors License Law does cont apply to un owner of OUTLETS-SWITCHES-FIXTURES
property who hi ilds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements am not immtdal or offered for NEW RESIDENTIAL ELECM SQ PT
ass.ff.however,the building or improvement is sold within one year of completion.the SQ14.FLOOR AREA E/SQ.1-L
owner-builder will have the burden of proving that he did not build or improve for put-
pose of salcj.
I,as owner of the pmpeny,am exclusively contracting with licensed contractor.to TOTAL:
comment the project(Sec.904,1,Business and Professions Cade:)The Contractor's Li-
cenx Low does not apply to an owner of property who builds or improves thereon.and QTy, PLUMBING PERMIT FEE
who contracts for such projeets with a contractor(s)licwsed promant t.the Contmctnr's
Lie.Law. PERMIT ISSUANCE
Fj I am exempt under Sec. ,B&P C for this mason
Owner Dme ALI ER-DRAIN&VEIN r-WAi ER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION peBACK FLOW PROTECT.DEVICE
1 hereby affirm under Knotty of perjury one of the following deeli mmus:
❑lb.v "willma.W..Cenif.ta ofConsemoxlf-insunlor Workers Compcn- DRAINS-FLOOR.ROOK AREA,COND. STU TYPE CONSTRUCTION
sari..,as provided fm of by Section 370 the Labor Cole,for the performance of the
work for which this permit is issued. FIXTURI?S-PER'TRAP
1 have and will maintain Workers Compensation Insurance,us required by Section
39W of the Labur Cods,f.rths,pciltmonnceof the work far which this permit is issued. GAS-G.SYSTEM-1 INC.q OUTLETS OCC.GROUP APN;/
My Workers Compensation Insurance carrier and Policy muddier are
Carrier. Policy No.: GAS-EA.SYSTEM-OVER S(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRBASUINDUSI RL WASTE INTERCEPTOR
BUILDING UI VISION PEES
(This section neat not becampleted iRo permit is fortune hundred dollars(SIM) GREASETRAP
or IeasJ LANCHLCK
Loy any lPersnthein prounany
as he work
which this'he W.kers ed.Ishii][Cradacd- SEWER-SANITARY-STORM FA.2W Isf.
not employ any person in avy comae.s.m m biome suM1ject t.the Works.'Compcn- GY Id"Bf-tLl it
Z .tion Lawsaf Calif rya.p m� WATER HEATER W/VENTMLECI'R
Q APPli—ind'�t 1 ass l(//vt(�( ING FEE
A
fn NOTICE T15 o me Work If,.formaking this previsions
of Labor iodyoushould WATER SYSTLM/IRFATING ILS
h ; become subject t.the Workers Comas or this pmvisinns ons the meed Cole,you must
forthwith comply with such previsions or this permit shall hJeemed rcvnkeJ. WATER SERVICE
y A
.�T. Z CONSTRUCTION LENDING AGENCY NEW NESIDIiNTIAL PLMB. SQ.FI'. Pte• Date Ncccipte
V Thereby affirm that there is u constraclion lending agency for the Performance of �+�
the work for which this permit is issued(Sec.309].Ci,C.)
Lender's Name TOTAL:
W Lender's Address TOTAL:
1 certify,that I have dud this application and state that the move information is BUILDING FEE
correct.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
L) Z building construction.and herehy authorize representatives of this city to enter upon the SEISM IC FEE
aovo-menti.ned property far inspection purposes. PERMIT ISSUANCE
(We).gree to save,indemnify and keep harmless the City of Cuperino against ELGCI'RIC IEE
liabilities,judgments.costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITGO 10,000CFMI
SOURCE REGULATIONS./1 MECHANICAL FEE
{,rs�XG_ul- _j/iJ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
LLL atare.fApplicanVComanctur Dam FXHAUS'TLOODtW/DUC'1) HOUSING MITIGAILON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harardi material HEATING UNIT TO IOOdAq BTU)
as de0radd by the Caliendo Municipal Code.Chapter 9.12,and the Health and Safety
Cale,Section 85321.)' HEATING UNIT(OVER IIMLWO BTU)
❑Yen FIN. VIiNTItA'I'ION PAN(SINGLE RIiSIU7 PAID Dam Recciptp
Will the air contaminanan,or ts a Wilding ac the al Bay
xea Air Qualitt or y
Managees ment.
BOILER-COMP(3HPORIW,9"M)
mit hazardous sir contaminants as ddined by the Bay Area Air Quality Management.
TOTAL:
District? BOILER-COMP(OVER I0B000 B'TU)
p Yea ❑No
I have read dbe hicialuddermsrwtar is requirement under Chapor 6V5 of the Cali- AIR CONDITIONER ISSUANCEUATE �rpy
Landis Health&safety Code,Sections 25505.M533 word 255M.1 umdeamM amid Ne NEW RRSIUr:.N UAL MUCH. SQ.FT. 'Z (0/
building does not cunemly has L at it is my responsibility to notify the dmcupam
of th<myu.,,wh, or so costume,of a Ced"Ecme of Occupmcy.
r or authoaarissd ager as Dale TOTAL' ISSUED
OFFICE