S 1046 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PISMITNO. O A
BUILDING DIVISION APPLICATIONIPERMIT PLUMB INC-MIICHAS[CAI, J 4
BUILDING PROJECT IDENTIFICATION
BUIL--0)+'_S5: - "7 &� � J+i SANT I'ANY NO. A1 ,119
'LICA'1l 1 SUDpA1TIA1.UAI'I
5 4 �" =L 8
OWNER'S ZNAME: ONE: CONACTOR'S NAME LIC NO:
NIC -
-,
ARCHITECT/ENGINLER', r LICNO: ADDRESS: ❑
F Z G
CONTACT. PHONE.: BUILDING PERMIT'INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MI':CF{,
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE rLJ,/ Lw rL--,J LwJf
I hereby affirm that I inn hcenwil miner provisions el chapter 9(commencing JOB DESCRIPTION
O=Z with Section7000) Uivision3uf the Business end Pod'csxions Code.and mylicrnse is R IDE TIAL
m O O PERMIT ISSUANCE
in full forecsnde@ct. R 'FDWL ❑KITCHEN REMODEL.
�UU License Clens J Lick Z�Nk'Lh APPLIANCES-RESIDEINTIAL []ADDITION El PLUMBING RE-PIPE
F Z al Date Conuanm
rn6a ❑MULTI-UNIT El STRUCTURAL
ARCHI'ItiCTS DECLARAi'ION
PANIiLS MODIFICATION
OZZ0 Z 1 understand my plane shall be orad m public records
NO UPT02W AM11P5 ❑INTERIOR ❑CHIMNEY REPAIR
W La.bord Prnt,,inual 201-1000AMI'S IMPROVEMENT E]SWIMMING POOLS
C Y 7; OWNER-BUILDER DECLARn'1'ION OVER IOW AMPS ❑BATH RFAIODEIIREPAIR ❑DEMOLITION
C Q 1 hereby affir that I am exempt from the Contractor's License Law for the
Y O following roman.(Section 90315,Business i I Prof..iota Cn I,Any city or ectomy SIGNS ELECrDUCAL ❑OILER —
LL13 W N which requires a permit to construct,after,improve,demolish or repair any structure
^, 0-5 prior to iu issuance.also inquires the applicant for such permit to fila a signed statement SPECIAL CIRCUFUMISC.
�ythat heislicensed pursuant mthe provisions ofthe GmtrolsLicemol.aw(Chapter 9 OMM�FR I•AL.
puW (commencing with Section]IMid)of Division of the liminess and Professions Crde)or TEM P.MEI'ER OR POLE INS'T.
W Dat e c that he is exempt therefrom and the basis for the allrged exemption.Any violation of C1 NEW BLDG/ADDITION [IDHM01.1'f10N
X�h Se, it 70.11.5 by any applicant far a pemrit subjects the appliuvnt to n civil florally of POWER DEVICES ❑'I IiNAF;�I q n ❑I'OOD SERVICC
t mom man five hundred dollars($500), IMPROVE
Sp has owner of the prnpeny,mmy cmpinyccs with wages as thcinalc compemation, SWIMMING POOLELECTRIC
L.. will dome wnrk.and thaatrutare is nut imendednnJTemJ forsale(Scu.9044.14aincca �J R
13 m and Professions Code:The Commdnr',License law doss not apply In as owner of OUTLETS-SWITCHES-FIXTURES
progeny whir builds or improves thereon,and who does such work himself a through r
his awn employees,provided that snub impnoemcntv ora not intended it
intended lin NEW BESIDES HAL FLECTR SQ I7.
hB�
soft.If.however.me huildingor improvement ismld within one yeerof completion.he
PI FLOORA SISG.IT
.builder will have me burden of proving that he did bill build nr improve for par-
pilot
ar- Cr
pilot.1 sale.).
Fl I,as owner of the property,am exclusively contracting with licensed contmcmrsto I( )/� /
6
consumer the project(Sec.9(1W,Business and Professions Crdc:)The Contractors Li- /3 !77(�) Y
reave Law docs not apply to an owner of property is hen builds or improves thereon,and QTY. PLUMBING PERMIT FEE
whir contracts for such pmjecls with a connotations)licensed pursuant o the Contractors �-y
license tau'. PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this mason
ALTER-DRAIN&VENT-WATER(F: VALUATION
True
Da
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DI—IPF
appearappearf
I hereby aunder penalty ofperjury one of the mowing declarations: 7 `
❑ dta"Contpem DRAINS-FLOOR,ROOF,AREA.COND. S'TO :S 'TYPE CONST RUCIO
,cation,as provided for by Section 394)of the Labor Code,fonhe performance ofine
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compcnsmion Proton-,as rcquircd by Suction
3700 ofthe Labor Gude.for the performance ofthework for which this permit is ismed. GAS-EA.SYSTEM.I INC.4 OUTLEIS OCC.GROUT' APN
My Worker's Compcnsmion pmarance carrier and Policy number are:
Currier: Policy Na.: OAS-EA.SYSTEMOVER 4 TLA)
CERTIIICAI 1:OF EXEMPTION FROM WORKERS' GREASF%INDUBTRI,0.'A SI'EINTERCT:PUR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thieacclionmcd not her l(thc permit is Torre hundred ra,hars($IOI) GREASE TRAYl
) PLANCHECK FEE
or lees
ormlythal in the TcnmrmanccidDhe work for which this peril is joined,l shall SEWI7R-SAN]TARY-STORM EA.204 FT.
not employ any person in any manner sir as In became subject to the Workers Compcn, ENERGY FETE
O Z If..laws of California.Done WATER HEATER W/VENT/ELECTR GRADING FEE
Z Q Applicant
NOTICE TO APPLICANT:Il,after making this Ccnitiente of lowtoplion,you should WATER SYSI ENVTREATING
become idjea m the Wmkce,Compensation provisions of the Lx1.n Code, no most
SOILS FEE
fonlrwith comply with such.......tons or this peril shall bedeemcd revoked. WA'I ER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RFSIUIiNTIAI.PIMtl. SQ.IT. PAID
Iherehy affna that is o conslmnian lending agency for the perfonnarecof Doe pto
[U2. ice+ the work for which this permit is issued(Sec.3097.Ci,CJ
T(YIAh.
Q V families Name
r U Lender,Address TOTAL'.
S 1 comity that I have read this application and stale that the above intonnauo.is BUILDING Irli
.F. N correct.l agree to comply with all city and county ordinances andsmle laws retailig to QTY. MECHANICAL PERMIT FF,E
U Z beildingisnseacnion,and hereby ralum-arpresenmtivcr ofthiv ch"licnmr nlwndre SEISMIC 1?li
aMve mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree as save,indemnify and keep hamdos the City of Cupcnino against ELECTRIC PEE
liahiliticgjndgmenls,ante and espouses on,bulay In any way uccme against slid City ALI1',R OR ADD'1'0 M HCH.
PLUMBING hli
in nICAN<e Nthe RSTAranti., Siris pcWIt.
SOURCANTUNULRSTANUS AND WILL COMI'1 WITH ALL NON-POINT AIR HANDLING UNIT(TO III,fMIBCFM)
SOURCE,REGULA'l10 S MF,CIInNICA
- AIR HANDLING UNIT(OVER 10.000 CFA) CONSTRUCTION TAX
raCa
Signature of A.PlicuHAZARD J Doc EXHAUST HOOUfW/DUCT) HOUSING MI'OGATIUN FEE
HAZARDOUS MATERIALS n wore o SURE
Willy heCliNmrnfmurclmal CoeChamsmrcor handle HerithmmSafety HF,ALNGUNIT(TO IIM),gMIBTU)
as ddinee by the Cupcnino Municipal Crdc,Chapter 9.12,marine llculth and Safety
Cale,Section 25532(0y HEATING UNIT(OVER 100,001)BTU)
Yes Nn
� VEN'I'IhATION FAN(SINGLE?REBID) PAID Doc Reeciptp
Will the applicam or furore ha ilding occupant use equipment or devices which
emit hazardous tar contaminants an defined by the Bay Area Air Quality Management BOIhCR-COMP(3HP OR 100.000 BTU) Hll'AI
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑Nn
I have read the hvaN..us materials requirements under Chapter 6,95 of Cull- AIR CONDITIONER ISSUANCE DATE
Portia Health&Safety Code,Sections 25505.25533 and 255}L I understand that if the NEW RESIDENTIAL MECH. SQ.FT
building encs not currently have it icnum.that it Lo my ruvgm,milily m notify the occupant
of the mRairemenls which moa he nut prior to issuance of a Certificum of Occupancy. �'
Owner or uulhmieod agent Date 'IOSAL: ISSUED BY —op--A ^ v O
OFFICE