29316 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL - PERMITNO. /� /N /1
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL. L 3F6
BUILDING PROJECT IDENTuTcxrION
BUILDING ADDRESS: - - SANITARY NO. - APPLICATION SUBMITTAL DATI
10301 Gyro►,] r1:2_
O'WN,SR'SNAMIR OHP.: CONTRA 0 "ZAME:
yuccM(u, .I• )Zl -7T 5�7 GLJ55/G 5 5 Z1i N/C' CONTROL#
\ RCHI 'C'VESGINEER: LIC NO: ADDRESS: �y Ell CON't PHONE: BUILDING PERMIT INFO
/Tev,�_"A<iq Zd11 ❑ Consultant Fees Paid by Applicant(Initial) PLUME EL_F.q. MECA
LICENSED CONTRACTOR'S DECLARATIONQTY. ELECTRIC PERMIT (`T_
�, 1 hereby affirm Cast I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
z int Section Division 3oDhe ffiemassanpd l5asfeasians Codaind my license is RESIDENTIAL:
W W E
' w PERMIT ISSUANCE
n full ToL�rc7eooasaasnd effect. �17 ZZ El SCOWL ❑KITCHEN REMODEL
aU 'r0tmso.:IJf Lic.0 cror APPLIANCES-RESIDENTIAL ❑ADDITION ElPLUMBING RbPIPE
[.p�nRl ARCHITF.CTSDECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z O P1 Y� I understand my plans shall be used as public records MODIFICATION
�Oz 0 'UPT02g1AMPS ❑INTERIOR [I CHIMNEY REPAIR
5M�q Licensed Professional - 201-1000AMPS 1 ROVEMENT
"5 •� - OWNER-BUILDER DR Ce CuffsRAT ON OVER[NO AMPS REMODRAEPAIR ❑DEMOLITION
1 hereby.(Serffirm tam 1 am exempts and Pr Canwcmrx License Law far the - ❑OTHER -
3 L V following reason.(Section]011.5.Business and Professions Code Any city or county SIGNS ELECTRICAL
.LL.C which requires a permit m canaWct,uRer,improve,demolish,or repair any structure
issuance,priooita issuan ,also requires the applicant nn
for permit fileeeigneJ ostomate SPECIAL CIRCUIT/MISC. -
Nat he is licensed pursuant to the pouramm of the Convaztor's License Law(Chapter 9
00 (commencing with Section]000)of Division 3 ofthe Business end Promsslonh Code)or TEMP.METER OR POLE INST. COMMERCIAL
that he is exempt Nerefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDrnON ❑DEMOLITION
Y• Section]031.5 by any applicant for a permit suhjects the applicant m a civil penally of POWER DEVICES
^ TF.NANf [j FWD SERVICE
not mare than five hundred dollen l55WJ. - IMPRO EMENT
�a ❑I,as owner ofNe pmpcxt,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
O will dote work,and the structure is not intended proffered forsde(Sm.'/044,Business O OTH
and Professions Code:The Contmcmes License Law dssrs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
progeny who builds err improves Nerean,and who does such work himself a through -
his own employees.provided that such improvements are not intended or oQered fm NEW RESIDENTIAL ELECTR SQ FT.
ask.If,however,the building or improvement is sold within one year of enmpletion.the (j.f f..FLOOR AREA E/SQ.Fn
ter-builder will havethe burden of proving Nat he did not build m improve for par.� (,Jg•'s' 'ss
posc of mIcn). f�
❑ss 1, ow r of the property,am exclusively contracting with licensed contractors to
construes the project(Sec.1044,Business it Professions Cede:)TIm Contractors Li. e
reme Law does nm apply to on owner of property who huilds or impraves thereon,and QTY PLUMBING PERMIT FEE ,V ��
who contracts for such projmis with a caricaturist licensed pursuant 8
o the Contractors /aT v ��
License Law, PERMIT ISSUANCE CI J `
❑I a o exempt under Sec. ,B at P C for this reason VP
Owner Orae ALTER-DRAIN&VENT-WATER(EA) /s AL N
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE' /I1
I hereby affirm under penalty of perjury one of the fallowing declaration., V
iw I have and will maintain a Certificate of Consul to self-insum for Worker's Compcn- ' DRAINS-FLOOR,ROOF,AREA,COND. Y. Sl'ORI TYPECONSTRUCION
von,as provided for by Section 3]0(1 of the Lalrtu Code,far the Performance of Ne
work for which this gauto is issued. 37FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37M f,hc Union,,CCeode.far am psif.muyncre of the work far
whichthis
apgerion I,issued GAS-EA.SYSTEM-I INC.4 OUTLETS _ OCC.GROUP APN
Is '
Carier,S s_7(Sl r�s[ykI•u1't-f.D1 Pol cy No.it y�L/ ,/n e� OAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMISDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FGI'S
(This arm need not he completed if Ne permit is Income hundred dollars(SIo10
or less) GRCASETRAP PLANCHECK FEE
I ociifythat in the performanceof the work for which this permit is issue J,Ishut SEWER-SANITARY-STORM EA.2fK1 FT.
not employ any perassn in any manner as as to became subject to the Workers Camper- ENERGY FEE
,� sation Laws of California.Date WATER HEATER W/VENT/ELECPR
Z Q Applicant GRADING FEE
AJ NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should WATER SYSTEM/IREATING
abecome subjem to the Workers Compensation provisions of the Lobar Cade,you muat SOILS ME
W forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
11 G
UO CONSTRUCDONLENDING AGENCY NEW RESIDENTIAL PEWS. SQ,FT. PAID Date Receipt#
Ihaffum that there isconstruction lending agency for Performance of
I-+ the work fororwhich this permit is issued(Sec.31197.Civ.C.)
F^ Lende(e Name TOTAL:
LUkI Lender's Address TOTAL:
I
certify that I have revel this application and stem that the rMvc information is BUILDING FEE �e
tn correct.1 agree to comply with all city and county ordinances and sura laws relating to QTY MECHANICAL PERMIT I
U building construction,and herebyarborize representatives ofthis city to enter upon the SEISMIC FEE
In
rkuee<n cmim and property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cipshu n against ELECTRIC FEE
liabilities,' s,rANWILL
which mayinany way acemeagainslsaid City ALTER OR ADD TO MECH.
in con enf th PLUMBING FEEAPPL 'AN UNDE COMPLY WITH ALI,NON-POINT AIRHANpLING UNIT(TO IggpCFM) MECHANICALFEE
SOW !3ULATI I a
ist /V AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUCTION TAX
cr
Si is of plica naw Date EXHAUST HOOD(WMUCD
AZARD S MATERIALS DISCLOS RE HOUSING MITIGATION FEE
filth applix morfute buildingoecupam score rehandle hazardous material HEATINGUNIT('fOW0.000B1'U)
- as defin by t e Cu ino Mu cipal Cade,Chapter 9.12,and the Hutt and Safety HGTING UNIT(OVER I W,(qU BTU)
r
Ccde,S on 5320.)
❑ v ❑No VENTILATION FAN(SINGLE RESID) PAID a
W II th licam or future building ant use a tai t air devices which Date Receipt#
pp goey me q Amen BOILER-COMP(3HP OR 100.001 BTU)
it hazardous air contaminant as def reed by me Bay Areo Air Quality Management
TOTAL:
pisain]
EJ Yes No
BOILER-COMP(OVER IBLOW BTU)
❑
I have lead the tadems materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomite Health&Safcry Cale,Sections 25505,M533 and 25534,1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not urrently have a tenant,Nat it is my responsibility to notify the secupmt
of the requirements which must he met prior to issuance of a Certificate of Occuponcy. '
Owner or authorized a gent Date kk L L ISSUED BY:
OFFICE