30743 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL,
BUILDING PROJECT IDENTIFICATION
743
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
1 14_$ �lV✓I S-�ord �� . 2 lq q
OWNER'S NAM- Pf{I NE: COJAOII R'SNA Ic L N
�` lot &wl `4'oS l9Iv J Vv�< S Y1/\ G�SIn. �o3Sy NIC COMIHOLN
ARCHITECDF.NGIN R: LIC NO: ADDRESS: ❑
! 0S S c arc . call, c
coNT'ncr: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG F.LECIPLUMB MECH
❑ ❑ ❑
LICENSED CONI'RAC'i'OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
FW0Z with Section 700(Pmf Division 3oflhn Business and Professions Cods.andmy license is
!�-1= in fu 11 force esus cffe /J y PERMIT ISSUANCIi RESIDENTIAL:
C-F Z S� U�S I ❑SFDWL ❑KITCHEN REMODEL
F Z w Liccnsc1 Liu.M
ec Q d Dam ConunmO 4 f •`T• APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION C3 MULTI-UNIT ❑STRUCTURAL
'Diet
Iunderstand m Tans shall be used as blit records PANELS MODIFICATION
OZ=p yP public UPT02MAMPS ❑INTERIOR � 1MNEY REPAIR
F4E"ul Licensed Prnkaional 201-1000AMPS IMPROVEMENT r'�/'f_`11
OWNER-BUILDER DECLARATION OVER["AMPS ❑BATH REM
EUREPAIR DEMOLITION
C Q 1 herby affirm that I am exempt from the Coatroom's License Law for the �(
X3 L F following reason.(Section 703LS.Besides,and Professions Cuda:Any city or county SIGNS ELECTRICAL ❑OTHER
uu11 u.y which requires u pewit m conswa,alter,Improve,demolish,or rcpuir any swemre /1 I s�Ls /CC
maT/�p�7-p
E-'��� pnnnniis dmen.alto requires the applicant rnrdell permit filen signed statement SPECIAL CIRCUITIMISC. S LtOst I 4 J -- -
that he is licensed pursuant m the provisions of the Contractor's License Law(Chapter9
�3.1
ap0
(commencing with Section?000)df Division 3 ntthr Bohinmsimd Pndcesinns Code)or TEMP.METER OR POLE INST. COMMERCIAL:
d y Ihat he is exentpl Ihcmfrom unJ the bans Int the alleged cxcmptlnn.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Y• Section 7031 S by any applicant fora pewit subjects the applicant to a civil penalty of POWER DEVICES
^m ❑TENANT ❑FOOD SERVICE
n marc than lift hendmd dollars y employees
IMPROVEMENT
ZO ❑Las nwnerofthapmpeny,ormymonerlees withma wages ndhalitheir(Sec. 0,14.Bsitmi, SWIMMING POOL ELECTRIC
p. will Bothe work.ande:The turcknol intended mainland halide apply to aounerof ❑OTHER
I�il w and Profesnob Code:The n.,moor,License Low dem not apply to if owner of OUTLCT'S-SWIT ES-FIXTURES
a'3 progeny who builds or improves Thereon,and who tet such work himself or through
his own employees.provided that such improvements estisolw a2 not intended or offered for NEW R6SIDLNTI ECfR SQ FT. d
oder(.M1ower will have
thnburden rovcmcnt ithat he ithinon wild or fmmpletiom.the ($FT.FLOOR AREA SISQ.FT.
cm'aiWcr will have The burden of proving that be did not buil)or improve for per- B
pose of w(e)s a
❑ 1,m tweet of the n y contracting with TOTAL:
prole y,am exclusive( ronin th liccnecd contractors m
r,nxwn the project(sec.7644.Badmedd and vrtrmsmn,code:)The canwcmrs Li- 6
u Law sloes not apply to an owner of pmpeny who builds or improves thereon,and QTY. PLU B P FEE
who contracts for such projects with a control I emsed pursuunuo the Comms fir's rEyr�hO
License Law. PERMIT ISSUANCE /
I am usanpl under Sec. .B&P C Iia Ihis mason
ALTFR—DRAIN&VF,NT—W ( VALUATION
Owner Date
WORKERS COMPENSATION DIiC1.ANA'I'lON BACK PLOW PROTECT.DEVICE
1 hereby salient under penalty of perjury one of the following deelmotlun,:
F1Ihevc and will maintain aCenifcate of ConunnosclGinwrc fur Worker's Comped- DRAINS—FLOOR,ROOK Alt GOND. STORIES TYPE CONSTRUCTIOI
cation,at provided for by Section 3700 of the Luba Code,for the Performance of the
work for which This Permit is issued. FIXTURES—PER TRAP
I have and will maintain W'orker's Compensation Insurance.as required by Section
37M ofthe utror Code.for the Performance of The workfor which this permit is issued. GAS—EA.SYSTEM-I INC.A OUTLETS OCC GROUP AVN
My Cam`errkRsSs �n"p is-T IO+ta .S olcy No.nd :nfi`r[iYLd Sid o✓ GAS—FA.SYSTEM-OVER 4(EA)
.J LCt
CERTIFICATE OF EXEMPPFPION FROM WORKERS'
COMPENSATION INSURANCE GREASEBNDUSTRI.WASTE INTERCEPTOR
(This section need not be completed ifthe permit is forme hundred dollars S Into BUILDING DIVISION FEES
w less) GREASE TRAP PLANCHECK FEE
I cemy that in the Performance ofthe work for which this permit is issued,I shall SEWIik—SANITARY—STORM EA. FT.
not employ any person in any manner so as m become subject to the Wurkms'Cumpeo- ENERGY HE
zZ whoa f.awsor Cullfomia.Dote WATER[MATTER WIVI?N/ELF.CTR
O Applicant GRADING FEE
NOTICE TO APPLICAN P.If,after making(his C,nifcam or Exennvo,you should WAIT ER SYS I'Emn BEATING
a > luvmt subject in the Workers Cr,mpenw.ian provisions of the Labor Code,you must SOILS FEE
forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
CONSTRUCTIONisaconLENDINGAG agency
NEW RESIDENTIAL PLMB. SQ,FT. PAID
U 0 Iherehy affirm that there is acr,nswaion lending agency fur the Performance of Died ReceiplM
V. F the work for which this permit is issued(Sec.3097.Civ,C.)
Oleasers Name TOTAL:
L) Landers Address TOTAL:
Fy 1 artily that I have read this application and state Lha the above information is BUILDING FEE
TAT correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
1J z building conduction,and hereby auNonze representatives of this city to enter upon the SEISMIC FEE
Arve-men ioned property for inspection purposes. PERMIT ISSUANCE
(We)agree Tows,indemnify and keep harmlcsd the City of Culmina agaid,, ELECTRIC FEE
fabil'tied.jodgmmnls,costs and extortions which mnay in any way accord against sold City
to c n. int m of the granting Firda,prowl. ALTER OR ADD T(3 MECH. PLUMBING FEE
APPLICAf Il ElSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE/x rONS, 2 f 14
I/6 Ill AIR HANDLING UNIT(OVER 10.11011 CFM) CONSTRUCTION TAX
Signmmeo'A,deanJComeactor date EXHAUST-HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSUR17
Willne applicant w Tomre buildingwcupam smmor handle he>.ordnut mammal HEATING ON]r(TO I00.000 BTU)
as defined by the Calendar,Municipal Code,Chapter 9.12,and The Health and Safety
Code.Sound 25532(x)? HEATING UNIT(OVER 100.000 BTU)
E]yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or device,which Date Rmeipt M
:mit hamNous air contaminants as defined by the Buy Area Air Quality Management BOILER—COMP OHP OR 100.00(p BTU)
TOTAL:
District?
❑Yet ❑Nt BOILER—COMP(OVER 100,000 BTU)
I have read the hazmdr,us nationals requirements under Chapter 6.95 of The Cali- AIR CONDITIONER ISSUANCE DATE.
p grin Health&Safety Code,Se tions 25505,25.533 and 25534.I understand that if the NEW R17S I DEE NTIAL MECH. SQ.FT '
building Jam dol err sly haves mount,ohm it is my rexpndsihillrym not(((YYY the xcyygpppant
est the mgal¢ ..1 nmu,l lk tt unarm lxauawe of.cera iwt(rq�l¢upki
Ownerar uuni e t ilk.\\.y,�C1l\ TOTAL: ISSUED BY: sztpe
OFFICE