S 2959 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT' PLUMB NG.MECHANICAL .
BUILDING.PROJECT IDENTIFICATION 2959
BUILDING ADDRESS.
SANITARY NO. AI' LICATION SUBMITTAL DATE
10101 N. SDC ic,.11-L OLv 0 Z
O ER'S NAME:
ONE O TRACTOR'S#AMC: LIC NO: NIC CONI'ROLp
• A-yC, .zv ��� c_.RLL� 9So�eO C7012S0
V oT1:GT,ENGIrA)Ztrt+T GL 1 r�� ADDRESS ❑ Z2 D
CON't PHONE.; BUILDING PERMIT INFO
Proy M C 14BQ Q77_�� ❑ Consultant Fees Paid by Applicant(initial) IrJx/
l) IBJH'i� ELECT PLUMB h1:1
LICENSED CONTRACTOR'S DTIC ARA'I ION Q'rY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed uMer prvisions of Chapter 9lcomusencing JOB DESCRIPTION
05z with Section of the Bunineaand Profession,Codaand my license is RFSIIJENTIAL'
1]00 w c FERMI T'ISSUANCE
F�P in full force and el m �-70If"L D SPOWI, ❑KITCHEN REMODEL.
RubLiv,%40.s � IJcq APPLIANCES-RESIDENTIAL ❑ADDITION -El PLUMBING RE-PIPIT
F Z.W TrueCommcmr
`r'?y ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT 0STRUCILRAL
Z8.z l ondarswndmy plans shall be used ns puhlkrecoNs MODIFICATION
04-140 UP TO 300 AMI'S DINTERIOR [I CHIMNEY REPAIR
P:a,IOW Licensed Proficsional 201-1000AMPS IMPROVFME•NT ❑SWIMMINGPOOIS
OWNER-BUILDER DECLARATION OVEk 11x)0 AMPS O BATH REMODEURFPA1R 0DEMOLITION
d C Q I hereby million that 1;on exempt from the Contractors License Law for the [I OTHER
XX 04 U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
W 3 y which requires a permit to construct,alter,improve,demolish,or repair any suunure
O� Vitoria its issuance,also restores lheapplkml fm,wh pennita,file amlgmednaemsmt SPECIAL CIRCUI VMISC.
} that he is licensed pursuamm the pmemnnsofthe Conttncmr's license law(Chupler9 COMMERCIAL;
n1=00 (commencing with$cnion IlXXD of Division3 ofthe Bosinessand Professions Cnx1e)m TEMP.METER OR POLE INST.
ay�4 CE that he is vae.,,Ihcref lou and the basis far the ullcged exrntpeon.Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION
EM Sermon 703 l S by any applicant for a VLnmh subjects the ol,dwart to a civil pinatyol' POWER DEVICES C]yLµANT [I FOOD SERVICE
^=Om mare than five hundred dollars($500). IMPROVEMENT
rl1,as evince of the pmpeny,or myemplayees with wages as their sole compensation, SWIMMING POOL ELECTRIC GOTHER
will du Thu work,and the nmawre is not intended ondfcred tae sole(Sec.]144,Business
yl^ and Professions Cube:T'he Contractors License law dues nal apply In an owner of OUTLH'I'S-SWUCHFS-FIXTUR
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such inspmveonse ents anot intended or offered for NEW RESIDGNHAL ELECT R FT.
eL1o.R;hnwava.the huildne,or impmvemmt is sold witninor,ycarol'eontpletion,the SQ.FT.FLOOR AREA $/SQ.IT.
owner-builder will have the burden of proving that he did not build or improve far par-
"e of soled.
E]I,as owner of the property,um exclusively cammcning with Licensedumtmaors m TOTAL' ^ ^
rmtfucI the pod,rr(Sea 7044.Business and P.. soms Calc)T1mc Cnntmctur's le- V t1J
use W w does not apply to an owner of property who builds or improves thereon,and QTY. PI M NG PERMIT F.
Li-
cease
contracts for such pmjmtn with a commutator)licensed pursuant m the Commences
License Law. PERMIT ISS A
❑I amexempt under Sec. ,B&PC forthis reason
ALTER-DRAIN& -
TER(CA) VALUATION
Owner Data
WORKERS COMPENSATION DECLARATION BACK PLOW PROTECT. ICE
ff % ®�
• Ihenebyun.under Penally ofperjury nuc of the fnlhwing dadamtinns: Cat
I have and will maintain a Certificate ofConsem m self-insure fnr R'orkers Campion- DRAINS-FLOOR,ROOF ARE, COND. STORIF_S TYPECONSTRUCHOE
saber,as provided for by Seen,,.3]1X1 of the Labor Cttde,for the peofnrommoc of tire
work for which this permit is issued FIXTU RES-ME R'TRAP
0 1 hose and will tmtimarm Worked Compensation lnmmnce,as required by Section
3700ofthe L.almrCale,for the perfummnceof Ne work for which this permit is issued GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Wor C pgn Insa nee canierand Policy numbs
Cartier. nsa Policy No.:9 VIM. 4T GAS-PA.SYSTEM-OVER 4 RA1
CERTIFICATE OF EXEMPTION FROM WORKERS GREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
('ibis wmionncul nothvcmr,ldcdif0epennitisf..a ochundealdolloo($100) GREASE TRAPC
.rhes,.)
C C i
orhesm '
I cenify that in the dommanceof,he work for which his permit is issued,Ishall SEWER-SANITARY-STORM EA.200 FT. O
E
not employ any parson in my manna eo us m become sWoccl to the Workers'Court F O
z smian Laws of Cnliromia.Data WATER HEN[FR W/VBN'VHLEC'I'R
z O Applicant GRADING PEE
r+ to NOTICE TO APPLICANT:If,after making this Cenific ac of Ecemption,you shuald WATER SYSTT:MRTtEATING SOILS FEE
ai becnnw nunject R:the Wmkcnb Contpensnrion V o,,,w is a1 the Labor Carle,you most
forthwith comply with such provisions or This Permit shall rte deemed revoked. WATER SERVICE
m0.ti. z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAI Date Rtteipa
U O wail
hick hiNot lhouieaeenslruminn lending mgancy fortht Perrunnmmo of
W the wad.Por which this permit is,issuud[See.3097,civ.C.7
Lenders Name 'I OTAL:
U Lender's Address TOTAL:
I candy that 1 have rand this uppla,afon and senna W,Tho ahovu'mfnnnmiou is s Lp1 'EI:
i..h tortaLlagreewamtply with all city and coumy ordinances and none laws relmingm Z IQ
QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U Z building construction,and hereby authors representatives ofthis city In enter upon the
ahovo-n rtakned properly t'on inspection papulas, PERMIT ISSUANCE. ELECTRIC FBI?
(We)ogres or save,indemnify and keep harmless tau City of CL,mno against
liabilitics,judgmems.cons end expenses whit ay in anyway came against said City ALTER OR ADD TO MECIL PLUMBING ITE
nor...ecionerofthe gr a of this;omit.
AW'I ANT 11NDER5 'A )S AND WIL OMPLY WITH ALL NON.POINT AIR HANDLING UNITITO 10,11000:1) MECHANICAL FEE
SOL<CE EGULATI0I S,
/L�•'f 9+� AIR HANDLING UNIT(OVER 10.00ECFM) CONSTRUCTION TAX
td,munren Ap,Iw mVCm mucor G� Date EXHAUST HOOD(W/DUCT) HOUSING MI'I'IGATION FEE
HAZARDOUS MA . AIS DISCLOSURE
Will the applicamorfuture building occupxm pore nr handle hazardousmamriel HEATING USE r(TO 100,000 BTL)
as defined by the CLpenino Munlci 11,11 Cade,Chapter 9.12,and the IIcahh and Safety
Codc.Station 25532m),I 11 17KI 1 NO UNIT(OV ER 11X0,0110 B LE
❑Yen ❑No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Will Lha appfiwnl on Tums.building oo,opicn use ugriparent ordevice,which BOILER-COMP(311P OR100,1X10 BTL)
emit hazardous air connotations as defined by the Bay Arca Air Quality Management
District! BOILER-COMP(OVER 100.0,Y)HTLE
r7 Y. No
I have read the hamrdo 1,materials to um omens under Chapter 6.95 of the Cali- AIR CONDITIONER //' ISSUANCE.DATE
fo alth&Sufery C c.Sections 2550. 25113 and 25531.I understand that if the NEW RESIDENTIAL MECH. SQ.FT. ILK—
Z 7— -
an'tg< a anteutreml bus•amnant,that lis myt prnsibility m notify the occupant
them smems whirl mu he arc,pilo ce olaCer ificm¢nL( c-pancy. �-
nor awhnizcdagum Dam TOTAL: ISSUED BY:
OFFICE