S 0066 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIIANICAL ---�14556
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BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
OW/N�Et o IRSNof!?� ��y�.�I �O� I'liOArv� ' CONTRACION'S NA / LIC NO: � cl
I..p� �f V ,-• Z -Ll� 1 NIC CGYIRGI.#
r/ VRCHITECT/ENGINEER: LIC NO: AUU _'S: ❑
OVI'ACF: PBONIE: RU ILDING PERMIT INFO
❑ Consultant FCC.,Paid by Applicant(Initial) HLDG 17I,IEC1 PLUNIH MEGA
LICENSED I a CONnsed u der DECLARATION QTY. ELECTRIC PERMIT' FEE
1 n�ny affirm tont 1 am licensed under provisions of Chapter v(commencing JOB DESCRIPTION
Z with Seaionlf0(0nl Division3nfthc Business and vrnleainns Code.and my license iu RESIDENTIAL:
Irl O FERMII F ISSUANCE
in full forceanJ effect. ❑SFUWL KITCHEN REMODEL
QUU Liccnu Class Lw. APPLIANCES-RIESIDENTIAI. ❑ADDITION *KITCHEN
k&PIPE
H 6 W Date Conn.,
ARCHITIECPS DECLARATION ❑NIULTI-UNIT ❑STRUCTURAL
Z O�'Z I understand my plan—lar ll ht uuJ as public record. PANELS MODIFICATIONOZt/_tQ UV'H)2(XlAMPS El INTERIOR [I CHIMNEY REPAIR
F Ent M Licenced Pmfemlunal I 201-l0k)AMPS INIPROVEMENT 0 SWIMMING POOLS
xY OWNER-BUILDER DECLARATION OVER I(XXIAMIR [_1 PATH REMODEIJREPAIR DEMOLITION
5 Q 1 hereby affirm that I am exempt fmm the Contractor's License Law for the
yxj3%U following reason.(Section]8315.Business and professions Codi.Any city,,.)arty SHINS(ELECTRICAL � ❑OI'Hlik
y which requires a Permit to construct,alter,improve.demolish or repair any swcmre W
F u'OQ prior to its issuance.also requires the applicant for such permit n file a signed statement SPECIAL CIRCUIT/MISC.
that hpursuant e is licenced pursuano the provi.inn.of the Contractors License Law(Chapter 9
fU�MC (commencing with Section 10(0)of Division 3 ofthe Business and Pmfeo'ions Code)or 'rEMR.METER OR POLE,INST. COMMFRCIAI'
a a o C Nat he is exempt therefrom and the Basi.for the alleged exemption.Any violation of E)NEW HLDG/ADIIITION ❑DEMOLITION
-m
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
not more than five hundred dollars($510). biPROVEb1ENT
Sp ❑ I.as owner of the property.or my employees with wages as their s)Ie compensation. SW IMNI ING POOL ELECT R IC
p. will do are work,and the structure is not intended or offered for sale(Sec:7014,Business
W_m and Profession.Coca The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES to,
a 3— Trani who builds or improves thereon,and who does such work himself Lir though
his own employees,provided that such improvements me not intended or offered for NEW RESIDENTIAL.ELECFR SQ FF.
sale.If.how'esxr.the building or improvement is sold within one year of complction.lhc SQ.h1',FLOO'ARIT LSQ.FT.
mer-builder will have the burden of proving that he did not build Lir improve for put- P A D
pose of.W e.).
❑1,as owner of the progeny,am exclusively convicting with licensed concoction nm T
consumer the project(Sec.7O ,Business and Profession.C de:)The Contractor's Li- JUN: 2
sc law does not apply to an owner ufproeny pwho tudd,or improves Hereon,and QTY. PLUMBING PERMIT FEE •C 'IWU
who eommees fursuch pmjects with a rmomeor(s)licenced p nowarat to the Contractors
License law. PERMIT ISSUANCE CITY
E] I am exempt under Sec. .B&P C for ima Vr GUYrpTIN0
ot In e1� ALTER-DRAIN&VEVF-WATER(HAT VALUATION
D.10
W'ORKER'S COMPENSATION DECLARATION 13ACK FLOW PROTECT.DEVICE �.yfl/'r '
I hereby aWi r under penalty of perjury one of the following declarations: VV
i)have and will maintain a Certificate of Coneem to ulf-insure for Wurkefs Compen- DRAINS-FLOORROOFAREA.COND' S'IORIIS TYPL CONSTRUCTION
as pmvidcJ for M1y$aorto J100 of the Tatar Crile,for the perfmmencc of the
work for which his permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Immune, as required by Sauun
37Mafthe LaMSCode,for the performance ofthe work for which this vanciti.iouW. GAS-EA.SYSTEM-IINC.i OUTLITS �� OCC.GROUP APN
My W)deA Compensation Insuran.e cannot and Policy member are:
Carrie,: Policy No.: GAS-EA.SYSTEM.0VIik q(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRI:OSE/INOUSTRL WAS TF.INTF-RCEYTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section neNnot be.)mpland!ifthc permit is f...me hundeaddollum(8110) GREASEARAP
or he".) PLANCHECK PET! /s
I certify that in the performance office work for which this Permit is issued.)shall SEWER-SANITARY-STORM F.A.203 FT
hot cmplay any person in any manner so as to Mane subject)the Wodcri Compcn- F:NFRGY PEI:
O Z saran Laws of California.Data WADER HEATER WNE,VUHLECTR GRADING FEE
z 2 Applicant
N NOTICE TO APPLICANT:If,alter making this Cri ificate of Exemption.you should WATER SYSTEM/IRIEA'1'ING SOILS FEE
F become subject to the Worker'.Compensation previsions of the labor Crile,you Inst
forthwith comply with such previsions or this permit shall be deemed revoked. WA'IT:R SERVICE
Q
a
z CONSTRUCTION aconstruction ONLEWINGAGENCY NIEW RGSIDIEVI'IAI.I'LMH. SQ 17. PAIDIhereDy affirm that thereem i. onsnperm
inn lending agency Tia the rfoance or Date Recciprp
V - the work 6r which this permit is issued(Set.3091.Ci,C.)
QLenders Name TOTAL'
U} Li:ndert Addres<W
1 cerify that I have read this application and state that the above infnmtam,n is
HUB.DING I;Fri
F ran comin
et.l agree to comply with all city and county on anees and slate laws refuting M
luting QTY. FCHANICAL PERMI'P e LE
U Z huilding eonswction.and hereby author ie<repmsemrr,r,cl this city to enter upon the SIEISMIG PET;
above-mentioned property for in.penlou purposes. PERMIT ISSUANCE
(Wa)agree to at,indemnify and keep harmless the City of Cuperinn against 131.1iC'I'RIC FIJI
liabilities.judgments,etntc and expenses which mayin any way acerae against said City ALTER OR ADDTO MECll. /
in asequence of the granting of This permit. PLUM RING FC:C
APPLICANT UNDERSTANDS AND Will.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('1'010,01X)CFM)
MECIIANICAh FEESOURCE REGULAIONS.
T
AR HANDLING UNIT(OVER 10.000 CFEA) CONSTRUCTION TAX
Signature of Applicant/Gmwemr Dare EXHAUST FOOD(W/DUCry HOUSING MITIGATION FRT?
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant stareorhandle hazardous material HEA'T'ING LIM P(TO 01.00013'1'U)
as defined by the Cupcnino Municipal Calc,Chapter 9.12,and rhe Health and Safety
Cod,Sectio 25532(.)! I IIADNG UNIT(()VIER 100,000 BTU)
Ycs D No
V13N'HLA'I'ION FAN(SINGLF RESID) PAID Ilett R.acin# -_
it Will the applicant or future building occupant use equipnmm(it devices when li(111.E1t-COMP(311P(llt IIIII,(1011 BTU)
.f it hamrdumu air conwmimmou,ac Jcfmad by the lie,Awa Alt Quality Manugcntanl ,fry,
idc1f BOILIJt-COME'((IVHR 100,000 BTU) ii
❑Yrs E]No
I hese land the hzmrdnLoncerarb,r der Chute,6.95)1'the Culi- AIR CONDI'I'IONER ISSUANCE:DATP.
,25533 ms un p
humin Hcahh&rSolelycome Gilt.eatSri,ume 255(15,ismy and...hil.Iundcetwnd Nalifthe NEW RE$IUIEN'f1A1.MECII. SQ.PI'.
buildingquirenoneua hich have ni ort or to is myce of
Canclylu nrnf theteacart /)
til the rcyuirementx which must M)met prior m issuance of n Ctrifiwne ul(kcupancy. �X✓
1 Owner m aathori'r.cd agent Drse TOTAL', ISSUED BY:
OFFICE