00030152 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..ELRC'IRICAL Ni
MaIiiiIiiiiialsi
BUILDING DIVISION APPLICATION/PERMIT
PLUMBING-MECHANICAL 50001
' IfU1Lt11Nq 1'NOJN:CT II1FN'IIIrICA'PION '
BUILDINGADDRESS: � � � SANITARY NO. APPLICAT ION SUBMITTAL DRFE
W E/qU'S NAME: PHONE: CO 'IRAC'IOR:S NAMIi LIC NO
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CON'T'ACT: PHONE: BUJ-44W ILUING PERMIT INFO
Sz ❑ Consultant Fees Paid by AppliCant(Initial) G EPLUMB MEGA
\J a-S'3 LECT IT �-
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
{hereby afforded I mm licensed made,provinium of Chapter 9 aa.hummemg JOB DESCRIPTION
Matz Section 9000)of Division 3 of the Business and Professions Codgand my licenPERMIT is RESIDENTIAL,
WOO with ISSUANCE
F1_ in full force end effect ❑SFDWL .,,rp�'TCHEN REMODEL
QUU LmeaseLic.N APPLIANCES-RESIDENTIAL ❑ADDITION JfJ PLUMBING RE-PIPE
y 6 a Dme Comracmr //
ARCHITECTS DECLARATIO ❑MULTI-UNIT ❑STRUCTURAL
F m I•ANELS
Z O ZI anders,and my plans shall he used m ppublicrccnN MODIFICATION
OZ—�O UI'TD 200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
CC W Licensed ProfeS
ssional 201.100AMPS IMPROVEMENT SWIMMING POOP
OWNER-BUILDER DECLARATION OVER]Bud AMES O BATH REMODEUREPAIR El DEMOLITION
C Q I hereby an Ihm 1 am eactnpt from tM Camw racou's License laf^r the
K36 (!U following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
41 LL.yQ which requires a permit to mnnmct,alter,improve,demolish,ce repair any swnnre
��'O.] pdonoi¢issuance,also requires the applicam fursuchpemlinofileasigmdsuemem SPECIAL CIRCUIT/MISC.
f'�} that he is licensed promnto the provisions of the Conammes License Law(Chapter 9
(commencing with Seion 7010)of Division 3 of Business and Professions Code)or 'TEMP.MITTER OR POLE INST ER I 1'
ct
a a o that he is exempt therefrom and the basis for the alleged exemption.Any violation of BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit sii the applicant o a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
=0not more than five hundred dollars(5500), IMPROVEMENT
0Lax sswneraf Ne property,or my employees with wages as thcirsolecompensatio^, SWIMMING POOL ELECTRIC ❑OTHER
d,^m will do the work,and the structure is not intended oroafered mrsale Six, Rhone's
6 3 and Profess{om Cale:The Contractors Cicero,Law does not apply to on sswncr of OUILEI:S-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himselfor through
his own employees,prnvidod that such improvemems me nm intend W or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however the building or improvement is sold within one year ofermpletion.the SQ,FT,+Fl:OOR ARREA S..Q ET
er-builder will have the burden of pmving that he did not build or improve for or
j
pose of sale.). ,�!
❑ 1.as owner of the property,em exclusively enmmcting with licensed ron one .1 t
Ell
construct the pravel(Sec.7044,Business and Professions Gwle:)The Cnmmcto',l.i- QA&WUMAR 2 4 2000
c se law does not apply to an owner ofpropery who builds or improves thereon,and T F IT E
who nommco for such projects with a compact I ceps dl pursuant m the Contractors
Licenx law. 11 PCR UA
❑I am exempt under Seo. ,11&P C for this reason
Date
A:TIER-DRAIN&V1:NT-WATER(IEA) )� VALUATION
WORKER'S COMPENSATION DECLARATION pl; -r•
Ihereby aflirmunder penalty ofperjury one of the following declamtiom:
F7cate I have and will maintain a Certifimf CousennO self-instin far Worker's Compca - f STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3700 of the LOMr Cale,for the porlimmnce of the
wen k far which this permit is issued. FIXTURES-PER TRAP
have and will immodn Workers Compcasaour Insumnce,as reunited by Section
ofthe Labor Code,for thepofornionce ofthe work for which this pennh is issued, GAS-IEA.SYSTEM-1 INC.4 OU'I LE'I$ OCC GROUP AI'N
My WorkC align lnsum�y JyNo.: Mrart:
Cartier: �nInsum came and Nn.: GAS-IIA SYSTP.M-OVER4(IiA)
a CERTIFlCATP.OF EXEMPTION FROM V IIKIERS' GItIEASI?IINDUS'1'RL WASTE INTERCEPTOR
COMPENSATION INSURANCE
- BUILUING-DIVISION(Ofl"cOian need nm he,ohn ediOhe Innil is for an ehundred dolhms IS l00) FEP.S
or less) ORIiABH'1'ItAP PLANCHECK FEE
I eerily that In the pofnnnmtw of the ,,,it for which this pcnoitlx insunl,I I Il SEWER-SANITARY-SlDIiM IIA.21X1 FI'.
not employ any person in any manner sn as to hosrare,onsd to lite Worksn,'Co n
Z sation Laws of California.Date WATER HEATER W/VEN'I/NTC'FR
(] Applicant i GRADING FEE
rj NOTICE TO APPLICANT:IL alter making this Cedifinnu of Bxclnplion,you sbmdd WRI'L'RSYS'IFIvI R1iAPING
become subject to the Worker's Compcmmion pmvirions ol'the LaN a Codc,you must SOILS FEE
forthwith comply with such provisions or this person shall he deemed revukcd. WATER SERVICE
0. Q
�.z CONSTRUCTION LENDING AGENCY NEW HIiS11JIEN'1'IAl.PhMB. SQ.ET PAID
I h,,,which
thi Nanhere isaernst.30 l7,Cln.agency for the performance of
Date Receipts
U the work for which This permit is i.vsuod S. 3097,3097,Civ.C.)
O Lendcr's Name - TOTAL:
LUT) Lender's Address T(G'AL:
I certify that I hove it this application and s,am that the ahi inmmwdn^is - - - BUILDING FEF
sF. v51) correa.l agree wcomply with all city and c^mmy ordinances and xmm lows lchninsm QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby autnno,opraentmivcvmfmk city tomer upon the SEISMIC FEE
above-mentioned property for inspection purposes -
(We)o to save,indemnify and harmless the Co, Cu rtinwt•ainst PERMIT ISSUANCE ELECTRIC FEE
gree y ans P Y a Pe b
limilities,judgmetas,costs and expenses which may in any way occmutguinct said City ALTER OR ADD'1'O MECH, PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('10 W.000 CFM)
SOURCE REGULAT�E/ry�IS. MECHANICAL FEE
AIRI{ANDLING UNIT(OVI?R 10.00i CONSTRUCHON TAX
nature OfAVIlemaXonneen, 1
t7_O-Date f EXHAUST HflOfl(W/D11C1) HOUSING MITIGATION FEE -
HAZARDO' fATER1ALS DISCLOSURE -
Willlheapplicamor future building oecumadmoreor handle havardnu.v mamdal HEATING UNIT GO 100.001 BT U)
as defined by the Caliendo Municipal Code,Chapter 9.12,and the Health and Safety _
Code,Section 25532(a)P ��s HEATING UNIT(OVER 100,000 BTU) - .+
❑Yes W. NIPAID
VENT PAN RES Dme Receipts
Will the air contaminants
or antra building by the Day
use ea Air entQu ordevices which BOILER (3HP OR 100,000 RTU)
mitict' lair contaminants as defined by the Bay Amo Air Quality Management
s
District?
❑Yes ►/�/-J1 1X1BOILER 1 ,000 BTU)
I have mend the hvurdovi materials rcquirememe under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505.2553 and]5534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FE
buildingdoe, acunemlyhave mrst.thmitis resparsihility to nmifythewri pant
ouiZrcmenu ash i ust be met prion ami,of a C'mr, E�nI
ft
or au o agent s 1Dole nc TOTAL: ISSUED 8
OFFICE