99110078 PPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL RMI N . 14
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIT NICAI,
BUILDING PROJECT IDENTIEICATWN
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DE
C6�G� ATs
OWN71'S NAME CONTRnCTRA�M? �I �Q1 aC L-ZIC N.SOY ^ ✓ ^
�✓� NIC COM'ROL p
wn Ok ,
ARCHITECT/ENGINEER: LIC NO. A S: ❑
NTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLO MECH
MECH
❑ ❑ J ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm mat I.,it licensed under prod:ion,of chant,9(commencing JOB DESCRIPTION
{�{�l�Z with Section](100)of Division 3 of the Business and Professions Cale.and my license is RESIDENTIAL:
F00 -n full force and ep'y PERMIT ISSUANCE
ato UtFCJ1 Lieen,e C1§ 2U C36LieN 25 ❑SFl)WL ❑KITCHEN REMODEL
F.in< Dat I`�! Contract, fr APPLIANCES—RESIDENTIAL. El ADDITION C3 PLUMBING RE-PIPE
FOy ARCHITECTS DECLARATION PANELS ❑MULTLUNTT []STRUCTURALy O h Z 1 undersand my plans shall be used as public records MODIFICATION
OZ4O UPTO200AMPS [I INTERIOR [I CHIMNEY REPAIR
<4 uU1 Licensed Professional 201-I00OAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER BUILDER DECLARATION
OVER IOOIIAMPS ❑BATH REMODEUREPAIR DEMOLITION
I hereby affimt that 1 am exempt from the Contracmr's License Law for the
U following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL [I OTHER
l J /
MO o' which requires a permit m construct,ghee improve,demolish,or repair any structure
ail I
_ Q prior lm its issuance, fan ex,ires their,heant TOT such pe round,filen inned,tatement SPECIALCIRCIAT/MISC.
S, y that he isIrmirwd,momemwheprovisionsohheContcdcroraLicenseLow(Cbapmi)
�aGC (commenciagwith Section 7000)of Division Jofthe Busindmand Professions Code). TEMP.METER OR POLE INST. 140, 4111cleo
that he is exempt therefrom and the basis for the alleged exemption.Any violation or W BLDG/ADDITION ❑DEMOLITION
YX1 4. Section 91131.5 by any applicant lora pumm,ammts be applicant mucivil penalty of POWER DEVICES TENANT FWD SERVICE
FZ not more than rive hundred dollars($500f PROVEMENT
< Lus owner of the property,or my employees wird wagesmNeir sole cnmpcnsmion, SWIMMING POOL ELECTRIC
O will do the work,and the amctt is not intended mothered for sale(Sm.I0a4,Business ❑OTHER
W and Professions Cale:The Contractor's License Law does not apply In an owner of OUTLETS—SWITCHES—FIXTURES
6'3 property who builds or improves thereon,and who does such work himself or through
his awn employees,Provided Ozal such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
aide.If,however,the building or improvement is sold within one year ofcompletion.the SQ.FT FLOOR AREA :1:7
owner-builder will have the burden of proving that he did not build or improve for pur-
pose ofmle.).
El I,a,owner of the property,am exclusively contracting with licensed contraetrs m TOTAL:
construct me project(Sec.IIH4,Business and Professions Code)The Condit Li-
end.Law does notapnlyto an owner of property who builds or narrow.thereon,and QTY. PLUMBING PERMIT FEE
who mntrans mrsuch projects with a cnntmcrod s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. •B&P C fonhis reason
ALTER—DRAIN&VENT—WATER GIA) VALUATION
Owner Date
gift
WOR KER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby afTrm under penalty of perjury one of the following declarations:
I have and will maintain.Certificate of Consent to self-insure for Worker's Cooper- DRAINS—FLOOR,ROOF AREA,COND. STORIES TYPE CONSTRUCTION
14 Won,as provided for by Section 3900 of the Labor Code,for the performance of the
ak ,which this permit is issued, FIXTURES—PER TRAP
have and will maintain Workers Compensation Insurance,as required by Section
3lWoffie Lehr Code,for theterinnnanceof the work for which this pemtit is lssuod. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC GROUP
My Workers Coryjs ium vane i<r and Policy myybq�are a.
Cnrrier:�Policy No:-LL5 . X — a— Cr GAS—G.SYSTEM-OVER 4(EA) O
CERTIFICATE OF EXEMPTION FROM WORK•t GREASF/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thissmdon need not be completed ifine permit is faro.hundred dollars(SIM) GREASETRAP
or less.) PLANCHECK FEB
I cenily that in the performance aftne work for whichthi,permit is issued,l shall SEWER—SANITARY—STORM EA,200 FT.
not employ any person in any manner so as to become subject in the Winders Compen- ENERGY FEE
Oz cation Laws of Calilmon Dare WATER HEATER W/VENT/ELECfR
Applicant GRADING FEE
O
y NOTICE TO APPLICANT:If,aft,making this Certificate of Exemption,you should WATER SYSTEMGREATING
a ; become subjecto the Worker's Compensation f the Labor Cale,you must SOILS FEE
pens provisions
LkI forthwith comply with such provisions or this permit shall be deemed revoked. WATER SfiftVlCli
4 Q
7 Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID ate Ree t p
L) O (hereby affirm that them is a construction lending agency for the Performance of L] t p
(•' the week for which this permit is issued(Sec.10 7,Cis.Cl ' TOTA
Lenders Name
O U Lenders Address TOTAL: as
r 1 I cenify that 1 have reed this application and state that the shove nominated is
F y correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEEJ
(.) z building construction,and hereby authorbe representatives of this city to enter upon the SMIC FEE
ahove-mentioned prapeny for inspection purposes. PERMIT ISSUANCE
(We) We fm save.Indemnify and keep hamtics,the City of Capertiun.,aid,t LECTRIC FEE
liabilities,judgments,c nnJ aspenses which may in any way accrue against said City AITERORADOTOMECH.
oenceo ungof this permit. L I
APPI NT R EA AND WILL COMPLY WITH ALL NON-PO1NI' AIR HANDLING UNIT(TO 10,000CFM)
I
MECHANICAL FEE
SOU C LATI
!� /� AIR HANDLING UNIT(OVER HOOOCFM) CONSTRUCTION TAX
Signature of ApplicanUComachor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Willme appliceme,futmebuildingmccupant,hoomhandle haaard.marraedal HEATING UNIT(TO K0,001)IT U)
as defined by the Crisman Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)'! HEATING UNIT(OVER 100,000 BTU)
❑Yes ( VENTILATION FAN(SINGLE RESID) PAID "
Dam Receipp
Will the applicant future building use equipment or davit,which
I hawdnus air romaminamu by the Bs as defred by the Buy Area Air Quality Management BOILER—COMP(JHP OR IW,OOU B'I'U) TOTAL:
'Inct'! Col. BOILER—COMP(OVER 100.000 BTU)
AIR CONDITIONER
ad the hum n otorial,reyuircmena under Chapter 6.95 of Cali- ISSUA CE DATE
/^fI
C
Health fery.0 Se to O5,2553].nd 255]4.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
bu dingdoe: core ave runs,mat it is my responsibility m notify ll occupant /
n thercqui mus K Indium is...nceofa Ccoff, �f ulPn
O umhnriaeJ.gem Dat` TOTAL: ISSUED BY:
OFFICE