29049 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL n(] O A A
BUILDING PROJECT'IDENTIFICAPI
' ON G J 4 J
ILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
/aS1S "DE yiv�aR BJwD WErAf riNO~/,� C)CAIN 900
O NER' N/A�ME:. w PHONH- "� NTRACfO NAME: - LIC NO:
a. i�R—RJ N/C CONTROL#
ARCHITECT/ENGINF:F:R: LICNO: ADDRESS: t �❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB , MECH
LIC17NSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEF. El
I hereby affirm that 1 nm lsansed more,provisions of Chapter 9(commencing JOB DESCRIPTION
1OCZ with Section 7")of Division 3 ofthe Business and Professions Code.and my license is RFSIDFN I IAL
- full tome and effect. PERMITISSUANCE
W ❑SFDWL ❑KRCHPN REMODEL
U License Class Lic,0 . ' -
APPLIANCES RESIDENTIAL []ADDITIONElPLUMBING RE-PIPE
F Zj a Do. Contractor
F�7N ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT' ❑STRUCTURAL
1 understand my plans shall be used o public records MODIFICATION
CZ4O UP T0200 AMPS C1 INTERIOR - El CHIMNEY REPAIR
r: F. Licensed Professional 201-1000AMPS IMPROVEMENT
Syr OWNER-BUILDER DECLARATION OVER Iqp AMPS [I BATH REMODEL/REPAIR [I DEMOLITION
��SS OOLL a 1 hereby affirm that I elm exempt from she Commctnfs License Law for the
YppYS5,�O U following narrator(Section 7031.5,Business and Professions Core:Any city ser count, SIGNS ELECTRICAL
on ... - ❑OTHER
o+u3.O F which"if.a permit to cstrue,am
tter.improve,deolish,or repstructureir any structure
•'
poor o its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
ythat he is licensed pursuant to the provisions of the Comractors License Law(Chapter 9
(commencing wit Section 101101 of Division 3 oldne Besinessand Professions Cmde)nr TEMP.MITI'ER OR POLE INST. COMMERCIAL:
p,o K tmp
the,he is exat treGo
em and to basis for no nfailed exemption.An,violation of El NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant far a permit mIjo,o to applicam m it civil penalty of POWER DEVICES Q TENANT ❑FOOD SERVICE
y pN„ t more than five hundred dollars($500). IMPROVEMENT
6 �1,es owner of the properly,or my employees with wages es their soleamtpe...[ms, SWIMMING POOL ELECTRIC
will dote work,and to swctute is a.intended moffrred ferrule(Sec.7044,Business ODTHER _
W and Profusions Code:The Contractor's License Lew does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Q' properly who builds m improves thereon,and who docs such work himself or trough
his own employees,provided that such improvemems are not intended or offered for NEW RESIDENTIAL ELECTR SQ Pf.
sale.If.however.to building or improvement is mid within one year ofcompletitn,the 'SQ,FTFUCHRAIRA. r $/SQ.FT.'
mweenbuild,r will have the burden of proving that be did not build or improve for put- 16
poseof rola.)
'0 1,o owner of the properly,am exclusively estimating with licensed contractors In wY B fh.
awe the project(Sem.7044,Business and Pmfeasitns Cade:)The Conwcmr's Li- f l•
come Laweoes not apply to an owner alpmprmy who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contracmr(s)licensed pursuant she Contreras's Nay �8 y r
License Low. PERMIT ISSUANCE f•�n• /9(�5
lameaemptunder Sec. ,B&PCfnrtisreasam LF z V
Owner Oals .
ALTER-DRAIN&VENT-WATER(EA) "VY,zVtALrIUTATION
WORKER' COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ��FT /'YU
• I herebyaffitm order pcnshy of perjury oneof to following declarations:
❑ Ih...and will maintaino Cenifcse of Consent mself-insure for Worker's Cmmpen- DRAINS-FI-COR.ROOF,AREA,COND, STORIES TYPE CONSTRUCTION
Basion,as provided for by Section 37M of the Labor Code,for the performance of the -
welds far which tia permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,o required by Section
37W of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM I INCA OUTLETS OCCGROUP APN
My Workers Compensation Insurance earlier and Policy number ore:
Cama Policy No.: i GAS-IIA.SYSTEM-OVER 4(EA) ,
CERTIFICATE OF E%EMI'f10N FROM WORKERS' GREASEIINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE. BUILDING DIVISION FEES
(This laden..deal he completed ifthe permit is forms,hundred it.]].($100) GREASETRAP
or less,) P NCHECK FEE
I ramify that in the performance ofthe work it),which this pemdt is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
no,employ any person in any manner so as to become subject m the Workers'Compcn- ENERGY FEE
satins Iswsof Califomla.Data WATER BEATER WNENT/ELEGTR
Applicant GRADING ME
G NOTICE TO APPLICANT.If,after making Nis Canities.of Ioannina,you should WATER SYSTIEM?REATING
a [' hecnme'mHect m she Worker's Com tion f the Labor Code,you must - SOILS FEE
c ) psora provisions n
�
forthwith comply with such provisions or this permit shop be deemed revoked. WATER SERVICE.
Q
UV0 CONSONLENDING AGENCY NEW RESIDENTIAL PCMB. SQ.IT. - PAID
Data , Receipt#
Q Thereby affirm that
ere is s aconstruction lending agency for the prm
erfoance of
H to web fm which this permit is issued(Sec.3097,Civ.C.) ,
TOTAL:
Lender's Name
0 V, Lender's Address TOTAL:
�r W
I certify that 1 have read tis application and slam than the above information is BUILDING FEE
.F.t TVA correct.I agreem comply with all city and county ordinances sed state laws relating to QTY, MECHANICAL PERMIT FEE
V building construction,and hereby authorize representatives of this city to enter upon she SEISMIC FEE
above-mentioned progeny for inspection purposes. PERMIT ISSUANCR ELECTRIC FEE
(We)agree to save,indemnify and keep harmless the City of Calsoin,against
Iiabilitics.judgmenss,costs and expenses which may in any way accrue erosion mid City ALTER ORADDTO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIN HANDLING UNIT(TO 10,000 CFM) -' MECHANICAL FEF.
SOURCE REGULATIONS.
a,� / 04-9-va"' AIR HANDLING UNIT(OVER 10,000,CFM) CONSTRUCTION TAX
I.,
ignature ofApplicam/Ctmmuor ('• Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I flo"BTU)
def nod by the Cuperlint Municipal Cade,Chapter 9.12,and the Health and Safetyode.Saturn 25532(a)? " HEAT]NG ON IT(OVER IW,000 BTU)
❑Yes ❑No VL•NTILATION FAN(SWGLF.RFSID) PAID
Data Receipt#
Will Use epplicanl br Tuttle building twcupant use equipment ran devices which•emit hazardous air contaminants as definedb the Ba Area Air Quality Management BOILER-COMP(3HP ON IW,Of100TU7
Y, Y Y B TOTAL;
District? BOILER-COMP(OVER Hit"BTU)
❑Yes ❑Na
I have read the hmrd
aous materials,yuimmcna under Chapter 6.95 of to Cali- AIR CONDITIONER ISSUANCE DATE'
fomio Health&Safety Cade,Sections 25505,25533 sed 25534.1 understand tat if the NEW RESIDENTIAL MECH.
building does non cumandy have a tenant,hat it is my responsibility to notify the occupant
of the requisemenss which must be ms prior to issuance of a Ccnificate of Occupancy.
Denaturant.dead agent Dam TOTAL ISSUED BY
OFFICE