S 1769 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POI PEN-ONLY
CITY OF CUPERTINO ,-,BUILDING-ELECTRICAL PflIT No
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1769
''BUILDING PROJECT IDENTIFICATION
nrim.NG RDD.feo, SANITARY NO. APPLICATION SUBMITTAL DATE
7, 0.// Clr/G� a •n v (— s-QV .
OWNER'S NAME: p1t CONTRACTOR'S NAME: LIC NO: w+
.s NA3 L( V) '� � NIC CONTROL#
tICHTTECf/ENGINEER: VY LIC NO ADDRESS: ❑Kt r.e G � �1
Is on J`k -Z e o (o
'ONTACIC PHONE:
'BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) �@Lnq� EhECT PLUMB MECH
Ml �. 't/ V : YO$ 90— �Z/ 1'j—y(Q `IOCN
LICEN. :DCONTR OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby arum mat 1 ani licensed under prnvisi.na or Chapter 9 t➢nmmenaidg JOB DESCRIPTION
4X00 with Seetian7000rorDivision 3.Ulm B-mrs,red Professions Cade,add mylicctsso is RESIDENTIAL
CQ In full force and affect. PERMIT ISSUANCE
00
p(�(JJ' Llcensc Class lee.# I ❑SPDWL Ll KITCHEN REMODEL
yGL Dam Contractor APPLIANCES-RESIDENTIAL I ❑ DITION El PLUMBING RE-PIPE
ARCHITECT'S DECLARATION PANELS
p.7 mm ULTI-UNIT ❑MODIFICATION
Z O
❑ 1 undemand my plane shall he useA republic recors
d
`Oy u UP TO 200 AMPS El INTERIOR E3 CHIMNEY REPAIR
F4tul Licensed Professional 201-1000AMPS IMPROVEMENT
W$,'1 OWNER-BUILDER DECLARATION ❑SWIMMING POOLSmm� i hereby affirm Thal 1 am exempt from the Contractor's License Law for the OVER IIXI1 AMPS ❑BATH RP,MODBI/REPAIR El DEMOLITION
Ott; which
nquim,.a aeration erratical.
alter and improve,
demolish,
Gu le:Any city or county SIGNS ELECTRIC OTHER
H wh'mh required t narration i n.'hel,alien improv.,dd rdait 1,or repair any structure
AtommIlacensed pals.squires rhoapions o for suchd i License
Law
rl
m� SPP.CIAL CIRCUITIMISC.
7+ Thal he is licensed nuc,unm to the provisions of the Comamors Licenu Law(CM1anler9
(commencing with Section](1W)or Division 3 ofma Be,inessvnd Profession.Code)Or TEMP METER OR POLIS MST. COMMERCIAL'
iC m W the,he is axempt therefrom add the,basis for the alleged esenmion.A.y violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
w-y Section 7031.5 by any applicant for a permit subjects the applicant to a civil penallyof POWER DEVICES
t more than five hundred dollars($500). ❑TENANT FOOD SERVICE
FZD ❑ I.a,owner of the progeny,or my employees with wage,m,their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
E+ will Aotbow.rk.and thesructareisnot intended.,offered forsde(Sec.70L0.Business El OTHER
aand Professions Codd The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Q' property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELP,CTR SQ
vale If.however, building p nId ' y' fc pl forum SQ.FT.FLOOR AREA $ISQ.FT
own r-b 'IA will
llhave th burden fp gthat hdid
d tb der p for par .1[7IT,L7_►
pose f.ql ).
❑ 1en Of Property, IYcontracting Th licensed t tots In
.
morel l theperfect
j tt(9 7044 B d Prof ns Cod )11 C l ora L
cane Law does not apply to an owner of property who builds or imparvespaccon,and QTY PLUMBING PERMIT
who eontmets Tor such pmlwts with o comramorts7 licensed pursumm to the Contractors
License Law. -pERMIT ISSUAN E
El the exdnpt under Sec. B&P C for This re:aan
ALTER-DRAI NT-WAT. AI
Own - Dom � � VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTF - E
I hereby affirm under Penalty of perjury one of the following dwlaalionc
Ibavc and will maintains Ccrtifice,e ofConsent toself-insure for Workers CnmPcn- DRAINS-FLOOR,ROO . NO, S'TORIE' TYPE CONSTRUCTION
Compeer-
he..as provided far by Section 3700 of he Labor Oda,for rho performance of th.
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker'a Compensation Insurance,as required by Section
3900 ofthe Labor Code,for the performance of rho work for which this pereart sissued. GAS-EA.SYSTEM-I INC.40UTLETS OCC.OkOUp APN
My Worker's Compensation Insurance carrier and Policy number arc:
Currie: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPT ION FROM WORKERS'
I COMPENSATION INSURANCE GREASOINDUSTRI,WASTE INTERCEPTOR gUiL G DTVI N FEES
(Thi,section need not be c:mpletedifthe permit is permit hundred dollars($100) GREASETRAP
nr less.) PLANCHECK FEE
I certify that in the perf.rnance ofthe work for which this A
y lhoW i i'rssm.d,Isba- SEWER-SANITARY-S'TORM EA.200 FT.
of anLaw any person in any mound su us_m become suFlem m the Workers'Comport- ENERGY PEE
emi.n Laws Of Cvlifornia.Date
�O Applicant t WATER HEATER W/VENT/ELECTR GRADING PE
NOTICE TO APPLICANT:If,after making this Cenificale of Exemption,you should
siiI
become subject to the Workch Compensation WATER SYS'fBM/I'RBATINO
a ' permit
of the Labor sage you mull SOILS FEE
fmdhwilh comply with such provisions or This Fermit shall be decided evoked. WATER SERVICE. Ni
yo
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.F1'. PAID -
IherAnchthisfrtheaixsuedSecti.n lending agency for pdf.nnenco of Dvte Receipt#
w� the work for which this p.nnb Is Issuwl(Seo-3097,Civ.CJ
Q Lender's Name TOTAL:
U Lenders Address - TA .
CWi' - T certify that 1 have read this application and sate that the above information Is - - - BUILDING FE,
IA correct.1 agree to comply with all city and county ordinances anti state laws relating to QTYU MECHANICAL PERMIT FEE,'
��., building codswminn,and hereby authorizerepre,emalive,of thio city to enter upon the - SEISMIC PEB
abovcmentiened property for inspection prapews.
(We)agree to save,indemnify and keep harmless the City of Canadian against PERMIT ISSUANCE ELECTRIC PB
liabilities,judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT Oro 10,000 CPM)
MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CPM)
CONSTRUCTION TAX
7ofApphcanUCoptmtorApphcanUComreator Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PP,HAZARDOUS MATERIALS DISCLOSUREe applicant Or future boldingmcupam alone or handle hazardous material HEATING UNIT-(TO 100,001 BTU)athe Catania.Municipal Cale,Chanter 9.12,andthe Health and S.fety
C25532(a)? HEATING UNIT(OVER 100,00 B'FB
❑N. VENTILATION FAN(SINGLE RESID) PAID
he applicant or future building occupant use equipment ardevices whicM1Uate.,air ammandnau4 as defined by the Boy Area Air Quality Management BOILER-COMP(3HP OR IGF W II'U)
TOTAL:
❑Yes ❑No ROILBR-COMP(OVER 100,000BTU)
1 have dead the hazardous materials requirements under Chase,6.95 of the Cali- AIR CONDITIONER ISSUANCE.DATE
fomia Health&Safe,,Coca Sections 25505,25533 and 25534.1 understood the if the NEW RESIDENTIAL.MEGA. ,SQ.PT.
obfuith,requirements
eluircmenLs which
y must he
tmet
nthoant o issuance
ssuance ofa Cibeldliryificam e o ffOy ethme pancy.m
-
'
Owner or authorized agent - Date TAL ISSUEDBY:
OFFICE