31038 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY .
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. O^(J H
BUILDING DIVISION - APPLICATIONIPERMIT 'PLUMBING-MECHANICAL
r - ''�� BUILDING PROJECT IDENTIFICATION
BUILDING AI0yD� PESS55 /O5aPD 24 � ^ I _ , SANITARY NO. APPLICATION SUBMITTAL DATI
OW aYAME ��( � CO(/NTM/RA/'AvvRO'/_ E Z&OG 1 f k I q
NIL YYY CONTROL 0
ARCHITECT/ENGINEER: - LIC NO: / 5 /y - If • � -
/
CONTACT:/0'0 ' pHOrve BUILDING PERMIT INFO
L �/i'^ Q Consultant Fees Paid by Applicant(Initial) BLDG ELE P UMB MEC
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑
G C Z I hereby off m mal I am licenced under pmvisi ass m,Chapter1,i 9(commencing JOB DESCRIPTION _
WWO with Seorce ndef fDivisinn3 of the Rosiness and['9 fessions Gale,and Nylicenu ie - D RESIDENTIAL
1-
in force and ef�r 9J1 .// PERMIT ISSUANCE R SID
�VZF License CJp�/ lKr✓ Lic:b Va/ ❑SFDWL C3 KITCHEN REMODEL
yQDale y Contractor APPLIANCES-RESIDENTIAL
.Grn ARCHITECT'S DECLARATION . ❑AD➢ITION [I PLUMBING RE-PIPE
P
Z O Z 1 understand my plans shall be used as public records PANELS ❑MULTI-UNIT ❑STRUCTURAL
O XO _ MODIFICATION
UPT0200nMP5
y Licensed Pmfessmnal ❑ ❑INTERIOR CHIMNEY REPAIR
r 201-10ODAMPS IMPROVEMENT
G5 fffyEEEd Oat I am exempt fr m the Comment's
❑BATH REMODEL/REPAIR DEMOLITION
1 hereby.Them that I am exempt from the Comracmr's Llunsa Lew fur the OVER 1gk9AMPS
?p5�06 V following reason.(Section]031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OT' ER
Po mFe which requires a permit to concoct,alter,improve,demolish, a repm,any swcmbe
q mJ primo.it.issuance,also requires the apPlicant forsuchpermiuofile alignedstatement SPECIAL CIRC /M19C. Q
i Q [hal he is licensed pursuant to Ne provisions of the Contractors License Law(Chapter 9 L4�«
that he
exempt thereionIDW)of basis
for alleged
exemption.
Any
Cade)or TEMP.M LE INET. COMMERCIAL
d p,m ys that he is exempt therefrom and the basis far the alleged exemption.Any violation of [IN EW BLDG/ADDITION [].DEMOLITION
i {+y Sedinn]03LS by any applicantddllfor a rs($50rtnil subjects the applicammacivil penalty of POWER ICES ❑FOODSERVICE
mnrethan fivehondred dnllere($SOD). ❑TENANT
Ca 0 Las omom III It
or my employees with wages as their sole tempera[ion. SWIMMING CfRI IMPROVEMENT
C will do the work,and the structure is nor intended oroffered for sale(Sec,9044,Business ❑OTHER
and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SW C ES
3 r Property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are nn[intended cur offered for NEW RESIDENTIAL EL '•SQ FT.
sale.If,however,the building or improvement is sold within one yearof completion,the S RAREA $/SQ.FT.
w
oner-builder will have the burden of proving that he did not build or improve fur par- t
pose of salt.).
❑1,as owner of the properly,am exclusively contracting with
8 7,REu'D
wing with licensed contractors to - TOTAL: -
onsn the project(Sec.]1144,Business and Professions Cade)The C �
ontracture Li-
censeUsedoesnotapplymanownerofpropenywhabuildsorimpmve&devices,and QTY. PLUMBINGPERMIT FEE UL❑
who contracts for such practices with a contraemr(y)licensed pursuant to the Contractor I11-f�/Ur'VUI LRTIN0
License Low. PERMIT ISSUANCE
❑I nm exempt undo'Seo. ,B @ P C for thic reason '
OwnerALTER-DRAIN&VENT-WATER(EA)
Date VALUATION
CL
WORKER'S COMPENSATION DECLARATION - BACK FLOW PROTECT,DEVICE
I M1erehy affirm,WO under penalty of p jry uone ECL following declamations: ((J v -
❑I have and will maintain a Cenificaw of Cansent w selGinsure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,GOND.
-suite,as Provided for by Section 3700 of the Labor Cade,for Ne performance el the STORIES TYPE CONSTRUCTION
er for which this pemtit is issued. FIXTURES-PER TRAP
I
w have and will maintain Worker's Compensation Insurance,as required by Section - "
37M of dee Labor Cale;for dee performance of the work fmiwhich this permit is issued. 'GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP,. ,pPN'�
My Work 'i s ane r and Polic
Ie �eJ�M Af
Curtin:
Policy N a111/// . GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATED EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASDINDUSTRL WASTE INTERCEPTOR
(Thin section neWnot bewmplamd ifthepermi[Is foronehmtdredtlollam(Sloe) - BUILDING DIVISION FEES
or less) GREASETRAP „.
Icenif tha[in tha PLANCHECK FEE
y any
as
becomewhichthis'he Walker,'
- SEWER-SANITARY-STORM EA.2W FT.
of employ any person m any manner so as n,become subject rhe Workers'Compen- ENERGY FEE
12 Apparalicant
Laws of Califdmin.Date � WATER HEATER WNENT/ELECTR
y�� Applicant GRADING FEE
F7 Vl NOTICE TO APPLICANT:If,after making this Precision,
of of Exemption,you should WATER SYSTEM?BEATING
a become subject w the Worker's Compeor this provisions of the Labor Code,you most SOILS FEE
tla forthwith comply with each provisions or this permit shall we deemed revoked WATER SERVICE. '
6 Ca
i7. z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
Iherwhichaffirm that there issued(Saoi0lending agency for me performance of Dam o pt it
the work for which this permit is IceuW(Sec,7097,Civ.C.)
Q ,` Lenders Name T AL
f4L Lender's Address TOTAL:
(.y I certify that I have read this application and stare that the above information is BUILDING FEE ,
In correct.I agree to comply with all city and county ordinances and slow lows relating m QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authorize representatives ofthis city to amerupon the SEISMIC FEE
above-mentioned Property for inspection purposes.
(We)agree to save,indemnify p y o pe g PERMIT ISSUANCE36 50
g y and ked harmless the Cit f e a nano i aims ELECTRIC FEB 1
inolties,ar.of ts,the haic,sts and expenses thispemitch may inany way acme against said City ALTER OR ADD TO MUCH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0110 CFM)
SOURCE REGULATIONS. - � MECHANICAL FEE
` AIR HANDLING UNIT(OVER I0,010 Clint) CONSTRUCTION tX
Ssgnamreof ApphormuContrddor Dam EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGIIION FEE -
WillNeapplicanmrNmrebuildingoccupantsomemlendlehezardorematerial HEATING UNIT(TO IDQOfH)BTU)
as defined by the Canaries,Municipal Code,Chapter 9,12,caddie Heaah unit Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,000BTU)
❑Yes - ''IN. v -
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date_ Receipt a
emit hazardous it contaminant,ac defined by the Bay Area Air Quality Maaagemem BOILER-COMP(3HPOR 100,000 BTU)
District? TOTAL:
❑Yes I�No BOILER-CONE(OVER Hu"BTU)'
" 1 have rand the hazardous materiels myahzptms under Chapter 6.95 of the Cali- Y
AIR CONDITIONER $ •�� ISSUANCE DATE
forms Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the
boildinNEW RESIDENTIAL MF.CH. 9Q.PT.
gd t lh
noeutremy aveamnanWhat it is myresponsihility to uo[ify the cecupam-
of the a `Jr-s�w�hich mast be met prior m issuance of a Ceni'fi�///j(
y calmer of reparzle- d limo �v "•��
m - TOTAL: ISSUED BY. t
_ OFFICE