B 0629 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILT)NG
APPLICATION/PERMIT C-11F.ELECBANICACTRICAL PERMIT NO. �L
PLUNKI - I.
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION sew
BUILDING ADDRESS
SANITARY NO. APPLIC PION SUBMITTAL.DATE
va3s oANS 4LVO.
OWNER'S NAME: P ONI: 610
oL?9 CONTRACTOR'S NAME: Q E LIC NO: NIC CONTROLk
LD' A G AI
ARCHITECT'/'NGINEER: .� LICNO: ADDRESS:
6
corvTAc'f: PHONE: BUILDING PERMIT INFO
MII A�" 0 Consultant Fees Paid by Applicant(Initial) BLDG 2LECT _ PLUMB ME❑CH
IRLR /�tgNScl{ �iSo 967.0Z97 f� C�
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby aRrm Nat 1 am licensed under provisions of Chapter 9(commencing
Op with Section]IXK)nfDivision Solite Business and Professions Code,and my license is RESIDE NTIAL:
PERMIT ISSUANCE
y full force and ell.(. ❑SFDWL ❑KITCHEN REMODEL.
6UC�j License Class Lick APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
HGS
Date Conlmm.r
ARCHITECTS DECLARATION PANEIS Cl MULTI-UNIT ❑STRUCNRAI.
Z p tieZ 'I understand my plans shall W used as public records MODIFICATION
_ UPT02MAMN ❑INTERIOR ❑CHIMNEY REPAIR
OHF"W Licensed Professional 201-IINX)AMPS IMPROVEMENT ❑SWIMMINGPOOLS
?J O •] OWNER-BUILDER DECLARATION OVER IfNN1AMP5 ElBATH REMODF.UREPAIR ED DEMOLITION
wy V .I botchy nffrm Nat 1 am exempt fru.the Corinmenr's License Low fill the [I OTHER following nano..(Station]031 S,Business and Professions Coda.Any city nr county SIGNS ELECTRICAL
a LL which requires a Permit to contact,alter,improve,demolish,or repair any structure
0 prior to itsissuance.also acquires the applicant for such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
sss Mw that be is licensed putamen to the provisions of the Commences License Law(Chapter 9 COMMERCIAL:
BOO fcommencing with Section 7")of Division Sof Ne Business and Professions Cede)or TEMP.METER OR POLE INST.
q c pf ❑ EW BLDG/ADDITION El DEMOLITION
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
^+,N Section 9031.5 by anymplicanr fora permm
lt� itsubjes lhcapplicanno scivil peaultyar POWI7R DEVICES jENANT ❑FWD SERVICE
�. tmon:Nun live hundred dollam($500), IMPROVEMENT
Qas owner of the property,or my employees with wages as their sole compens.inn, SWIMMING POOL RIC THEK �<PA/J2
ill do the work.and the structure is not intendedor ofiered for snin(See.9044.Business
ad SQ
and Professions Code:The Contmctnf s License Law does non apply W an owner of OUTLETS-SW IT 4)TURES �a_3.a._,-�O.,pA q� 46w4�P.
.. property who builds or improves thmenn,and who does such work himself m through _- �' A
his own employees,provided that such improvements am not intended or oRmed for NEW RESIDENTIAL ELE SQ FT.
SQ,FT.FLOOR AREA LSQ.FT.
sale.If,however,the building or improvement is sold within one yearaf completion,the
ter-huilder will have the burden of proving that he did not build or improve for pur-
pase of saleJ. .AL, �.
1,as owner of the property,am exclusively conducting with licensed contractors to
...sear the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense law does not apply to an owner of pmpmy who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
wh.conlmctsforsuchp acts wiNucommcmr(s)li¢nsd pursuanno Ne Camrwmfs
License Law. PERMIT ISSUANCE
❑lam exemplund S ,B&P C for linnocason ,
ALI'BE-DRAIN&VENT-WATER lf?A7 VALUATION
��
Owner
R 'S OMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
❑ ERIhereb un erpe Ilyof,sequryoneof elllowing dtalmeniom.
I have end will main., rificate of Canso to IF so for Workces Comped- DRAINS-FLUOR.ROOK AREA,CONO STORlEf 'TYPE CONSTRUCTION
section,as provided for by Section 3100 of the Labor CWe,for the performance of Ne /
work for which his pemit is issued. FIXTURES-PER TRAP
r
❑I have and will maintain Worker's Cnmpemetiou Insurance,as required by Section
3900orme Labor Code,fon he perfa.iumn.f the work for which IM1is pencil is issued OAS-IiA.SYSTEM-I INC:40UTLETS OCC,GROUP APN
My Workers Compensation]as...me eerier and Policy number are:
Cartier. Policy Nn: GAS-EA.SYSTEM-OVER 41PA)
CERTIFICATE OP EXEMPTION FROM WORKERSR
COMPENSATION INSURANCE BUILDING DIVISION PEES
(This section need not W completed ifNe Permit is farads,hundreddollars($10() REAS 'PftA
or less.) PLANCHF.CK FEE
I certify that in the pon.moreaccof the work for which Nis permit is issued,l shall HWER-SANITARY-STORM 2 FT. ENERGY FEE
--!
not employ any person in any manner so as to become subject to the Workers'Contpeti-
zz aanion Lows of California.Dam Wq kj*TIR CT GRADING ME
Applicant I .may
Vj NOTICE TO APPLICANT:If,after making this Cerificnm of Exemption,you should WATER SYSTEM/TREYGNG SOILS FEE I
I^ became subjectm pcnaor the Wallace,Comrtion provisions of the LabCale,you must I
a forthwith comply with such pmvisinns or this pmmhadaill W deemed revoked. WATER SERVICE
W Q
VO
CONSTRUCTION LENDING AGENCY SQ.IT. PAID
1 herebyN
uforn at the.,,.construction lending agency for the,perfo..ace of Receipt k
Ne work for which this permit is issue)(Sta.3091,Civ.C.) TOTAL:
0 I'" Lenders Name
yyy� I.J ImnderI Address A k ^f
p y 1 certify that I have read this application and stem ces the above information meting is S L s FEE
r V1
correct. agrx no comply with all city and county ordinances and sole laws miming to QTY. MECHANICAL PERMIT �E SEISM FEE
r•s
Uz M1uildingam,tmclion,and herchyumhorize repremnmdvcr oflhisdrymenmrupnn the y� -�
above-.entioned property for inspection proposes. PERMIT ISSUANCE F.LE RICIEM 3 S l:J'�
(We)ogle m save,indemnify end keep harmless the,ar of Cu aired,nd City
Iiabiliniex.juJ6 nmo corns and eapcnses which may in any way seems against said City ALTER OR ADD TO MECH. PL BING FEE C
in consequcnc Ne granting of this peer..
APPLE xNT ERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITO'O 10."CFM) MECN NICALME
S URC' EC . TIONS.
AIR HANDLING UNIT(OVER 10,tNN)CPM) CONSTR ION TAX
Si tumofA icon mart., Dote EXHAUST HOOD(W)DUCT) HOUSING MITIGATION FEE
HA RDOUS MATERIALS DISCLOSURE
i ant or human Wildingoecupum store or handle invariants material H12ATING UNIT(TO 100.000 BTU)
as defined by the Cupenme Municipal Code,Chapter 9,11,and the Health and Safety HEATING UNIT(OVER I(X),INNI BTU)Cade.genian 25532m)? HEATING
❑Yes VENTI LATION FAN(SINGLE RESID) PAID
Doc Receipt
jaWill the applicant.rfuture building occupant use equipment or de,kas which BOILER-COMP(311P OR I of"BTU)
emit hamNnus air correlation.as claimed by the Bay Area Air Quality M...gemenl
Dimict? BOILER-COMP(OVER 100,000 BTU)
Cl Ye, fa?a
I have toad the hazaN.us materials nNuimmcros under Chapter fi 95 of the Cali- AIR CONDITIONER ISSUANCE/DAT`
put Hcaltt Sc Safety Code,Sections 25505,25533 and 15534.1 understand Thal"'he NEW RESIDENTIAL MICH, SQ.FT
bdildingdnes nm currently hove:Uenunt,Nmit is my respmniM1ility mn.ify the occupant v
ofrherequireme.s hie moebemer prior to issuance 9t aCenificale fOccupancy.
Dam TOTAL: ISSUED BY:
Owner or amht ' --
_ OFFI E_ -