S 0738 a APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
• BUILDING-ELECTRICAL PERMIT NO.
CITY OF CUPERTINO 7I� �k t
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MN:CIIANICAI• S 0,� K_X
BUILDING PROJECT'IDENTIFICATION V �/VVV
BUILDING ADDRESS: SANITARY NO. APPLLIICAATION SUBMITTAL DATE
Aii
OWNERS
10 11 1 \ST?
N E: PHONE: 'fr4.?, qONT ACfpR'S NAMIi:''.- ; LIC NO,
(1 1 ;{ 1 NIC CONTROha
INA-01— �' 1
ARCIIUEC7UNCI BER: •• LIC NO: ADD ESS: ❑
I, CONTACI:10 4 PHONE: '-;' BUILDING PERMIT INFO
hE' "❑ Consultant_Ftts Paid by Applicant(Initial) BLDG ELECT PLUMB SLdCbL,
❑ ..Q ❑ -EKY
L ENSEDCONTRACI'OR:SDECLARATIGN QTY ELECTRIC PERMIT FEE
1 hcdih; M.that 1 um licensed under porviaions of Chapter 9(commencing JOB DESCRIPTION
�0c) with Section7hWoof Division 3m,he Business and PrmPossinnsCNc.and my lidemscis RESIDENTIAL
Act wt .� PERMIT ISSUANCE
n full force unJ effect, ❑$IsDN'1. ❑KITCHIiN REMODEL
F�F--UU License Class Lica APPLIANCES-RISIDENTIAI. ❑ADDITION ❑PLUMBING RF.-PIPE
sen 6 6 are Conwnm
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
PANELS MODIFICATION
z C m,Z, I Andersmnd my pnmv shell h usW ve public records
oz=Q UP1O200AMPS ❑INTHRIOR [I CHIMNEY REPAIR
I,._W] Licensed Professional 201-BXXIAMPS IMPROVF:MIiNT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER]PAMPS ❑BATA RFMODELR IR ❑DEMOLITION
1 hereby uffirm that 1 am exempt form the Contmaors License Law ratio,
Nipy,�5d, cc O IiJlnwing reamn.(Section 7031.5.Business and Professions Code:Any city nr enumY SIGNS ELECTRICAL ❑OTHER
LL y which requires-e permit to corm er,ober,improve,demolish,or repair any slmctum
F_LL0g prior to in,issuance.Also requires the applicant for such Permit o rite a signedsialement SP17CIAL CIRCOITIMISC.
Wathat he is licensed pursuant to the provisions of toe Contractors License Law(Chapter 9 COMMERCIAL:
;C (commencing with Section 70(X1)of Div ision 3 of the Business and Professions Col e)or TEM P.MIT ER OR POLE INST.
(]ad he is exempt therefrom and the hmis far he alleged exemptinn.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
iLLCI_4• Semon 7031.5 by any applicant for a permit subjects the applicant to o civil lesolly of POWER DEVICES ❑TENANT ❑FOOD SERVICE
t more than five hundred dollars(SSW).
z 5. IMPROVEh1FNT
Q plo the work,the papery,or myemployees withwagesa'mi.((See.
compensation. SWIMMING MlOI.ELECTRIC
'ill do the work,and theheCostructure isnm intended or offered do for sole(Sec,to.an owner of ❑OTHER
Y1 and property
who b Code:The Contrscvtr's License o do does not applyne f owner of OU'1'LCfS>SWITCHES-FIXTURES
a 3 yropeny who builds or improves thereon,end who dates such work himself nr through s..
his own employees,provided that such improvements anot intended caroffercf for NEW RESIDENTIAL,ELEC IR SQ FT.
m
sale.IL howccer,the building or improvement is sold within one year cdcompletion,the SQ.FT.FLOOR AREA SISQ.I'1'.
ponerWilder will have Ohc burden mf proving that be did not build of improve lot parr-
se of role.).. PAI 4
❑ I,As owner of the propenY,am exclusively contracting with licensed contracmrs Nst C TOT?)♦.:
cnnwrucl the proart(Sec.70,14.Bminess and Pm(ersinns Cour,Inc Comas.....L, _-
ccoseLawdoesnl),apply to an owner or property whn molds or improves thereon,2114 'QTY. PLUMBINGPERMIT FEE EC lt5 ►' �
who contracts ear such projects with a caricaturist]icenceal pursuanOo the Common,a
License Law. PERMIT ISSUANCE
rl
I um exempt under Scc. .13&Y C rnr this reamn
ACHER-DRAIN&VENT-WATER(EA)
Owner Dom ON
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
1, here by afford under penalty ofpenday oneof the following decimations:
t
] I have and will maintain u Certificate of Consent ort cel6insum lou Workers Compen- DRAINS-FLOOR,ROORAREA,COND. STORIES TY PE CONSTRUCTIOI
anon,as provided for by Section 37(m of the Labor Code,for the perfomunuc mf the
.,.,it for which this pemtit is issued. FIXTURES-PER TRAP
❑1 have and will rained.Workee,Compensation Insurance,ns disputed by Section
37W ofthc l.yyyNo C.R.for the performanceofthe work for
which
jt�hiisspcnnit its issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.CROUP APN
My d:_ ,ric �aly,p,y, mmr,-__pyygyand Policy No.: F#r1IL/ u GAS-LA.SYS'1'1?M-OV2R 4(PA)
Cemex: 1N.fIgJ11 n7
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF/INDURTNL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION PL•LsS
(This section need not he completed if are permit is for one hundred dollnrs(S 100) GREASETRAP
nr leased PLANCHECK FEE certify that iothe perfomumerofthework fit,which this permit is issued,],hall SEWER-SANITARY-STORh1EA.200 Pr.
not employ any Person in any manner m as to become subject o the Workers'Compen- ENERGY FEE
Z ,Z amion Laws of Califomin.Date WA'IBR HEATER WNEM'/17LECIR
Applicant I GRADING FEB
h NOTICE TO APPLICANT:IL after making this Cer ificare of Exemption,you should WAI ER SYSTEMOREATING
a ; hecmme subject m the Workers Compensation pmvisions am
of the Lollar CNA,you t SOILS FEF.
forthwith comply with such provisions or this Permit shalt he deemed revoked. WATER SERVICE
•y CONSTRUC'T'ION LENDING AGENCY NEW RESIDEiN'f1AL PLM R. SQ.Pf. PAID
U O Dam Receipt a
]Herbyichthi metmem iso issued
lnmm�ding usenet for the performance of
,� thcwork dca'sNrwhich this permit is issued lSec.lW7,Civ.CJ
U. U lender's Name TOTAL:
yyyO Lenders AJJre.w 'TOTAL:
p y I cenify that I have read this application and state that the above information is BUILDING FEIi
r Vl coned.l agree to comply with all city and county ordinances and sure laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mnninned inspcc'tint purp.m, PERMIT ISSUANCE ELECTRIC FEE
(Wc res m sav ndemnify and keep harmless the City of CuPerinn against
IiaM1ilitiex nJexpcnus whit nvyinany way accrue against mid City ALTER OR ADD TO MFCH.
n mnsequng of an
PLUMBING FF.B
APPLICAND. NI L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TD 10.(MCFM) -
MECHANICAL FEE
Ra
AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCTION TAX
Signaturl nrnpplicantlContrecmr Date EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURF.
Will the Applicantor future building occupiedstore orhunJle hamNous material HEATING UNI'T(TO IALAX)Bruttop P
m
Code,
Section
by the Cuperinn Municipal CNB,Chapmr 9.12,and me Health and Safety
ina 25532(ut7 HEAL ING UNIT(OVER❑Xt.gM)BTU)
EDYcs No I PAID -
VUN'I'ILATIONPAN(SINGLERES ID) Uute Rcdxiptp
X
Will the applicant or future building occupant use equipment or devi¢s whish
nit hzzaNnus air contaminants as defined by the Bay Arca Air Quality Management BOILER-CUh1P pHP OR 11X),000 BTU)
TOTAL.:
tjimriet7 BOILER-COME(OVER 100,000 BTU)
❑No
I base readte
hhamplous moor],requirementp
under Chopper 6.95 of the Cai- AIR CONDITIONER ISSUANCE DATE
fomia Heullh&Safety Code,Sections 25505,25533 and 25534.1 ima erouml that if the NEW RESIDENTIAL MUCH. SQ.FT.
building dsws not currently have a team(that it is my responsibility to notify the occupant
of the rGuirements which must rte mea prior to issuance of a Certificate a]Occupancy.
Owner or authorized Agent Date TOTAL: ISSUED BY:
OFFICE