S 0345 APPLICAT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICA]. PERMIT NG.
HUu,DING DIVISION APPLICATION/PERMIT YLU]1BING-\14:CIIAM21C C O�
BUILDING PROJECT[DENT J
45
Rl11LIJING ADDRES��u SANITARY NO. APPLICATION SUBTE
SUBMITTAL DA
OWNER'S NAME. PHONE: CONIAACT( SHAME: LIC NO: `-
p SIC COMAOI.X
•ARCHITECT/ENGINEER: LIC NO ADDRESS C/ ! ❑
/?l> 7 /,,0 &A,l
F7(0oofDivikion
PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG '.ECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. I>LECTRIC PERMIT' FEE
affo,than I me Iicenscd under provisions or Chapter 9(cummeaing JON DESCRIPTION
DMZlq of Divisinri3nRne Buxinessand PmfcsimmsGidc,and mY hcemels RESIDENTIAL:
WOO PERMIT ISSUANCE.�_ ereU~ � �n �dLie.p �$I'DWL ❑KITCIIIiN REMODEL.U / / APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RIi-PIPE
N Q Y.
Dalc Comm �'!- f G�
ARCHITECTS D,public.,ad, El MULTI-UNIT ❑MODIFI MODIFICATION FRAL
-O H PANELS
ZOm IunJenwnd my plans shall be uscA as public records MODIFICATION
OZ- `lam UP T02IXIAMPS ❑INTERIOR El CH IM NE REPAIR
F Com,.F.W I.iccnsed Nofcsslomal 201-100AMPS IMPROVEMENT EJSWIMMING POOLS
Q m, OWNER BUILDIiR DECLARATION
iY� -1 OVER IWOAMPS ❑BATH REMODEL/REPAIR (]DEMOLITION
Q 1 hereby affirm that I am exempt from the Contractor's License Law for the
XO y U following reason.(Section 9(131.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL El OTHER
.if,
]3 U.l- which memos,o penin,am mnshost.vher,improve,demolish,or repair any himcture
f'LL0QS prior i its issuance,also requires the applicant for such permit to file a signedsamment SP17CIAL CIRCUI I'/M ISC.
f y that he is licensed pursuant to the provision%or the Contractor's License Law(Chapter 9
alC) (commencing with Section700)of Division 3 of the Husimi=it Professions Cole)or TEMP.METER OR POLL INST.
C COMMERCIAL:
q 1 C that he is exemth
pt erefrom and the basis for the alleged csuoption.Any violation of C1 NEW BLDG/ADDITION El DEMOLITION
W m Section 703 L5 by any applicant for a permit subjects the applicant toa civil penahy of POWERDEVICES ❑TENANT ❑FOOD SERVICE
net more than rive hundred dollars(55(0).
[-Z Y IMPROVEMHN
of
❑Lathe work,and
pro pcnr,omrcmplended or
ages forsale
(See,
compensation. SWIMMING P(bLF.LECfRIC
W ea will do the work,and e:The ctureCont a nor intended oT nffLaw
dos not apply to air ownBuser ss []OTHER
W--'m and property
whie b Calor The Contractor's License Law does not apply s if owner of OUTLLTS-SWITCIIIiS-IIXTURCS
a 3^ his own whooyers,or improves thereon,and who does m n work himself orthrough
his own however,
h provided that men Inman —old
w arm:not intended or offered for NEW RESIDENTIAL ELECI'R SQ fT.
sale.rmilderwillhvi the burden
of when ithat he lid nonerdr malawc forthe SQ.FF.FLOOR AREA STSG.FT.
er-builder will have the buNcn of Proving that he did not build or improve far pur-
pose of sale.).
❑I,as owner of the propene ha,esclusivuly eoomari ng with licensed rainstorm I,, TOTAL p D
rmuva the prnlen(Sec 90.14,Bus mid Profess ns Cm Rf The Cnnracmr's Li- �'1
whoaLaw docs not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMT FEE
omrras In,such ini with a convacmr(s)licensed pursuant to the Contractor's _eA1a �� fir.
License Law. PERMIT ISSUANCE tl'(�(� IN CV
❑I am,stand,under See .B A,P C for tho(moan ra M4..0(�
If
Owner Date ALl'lik-DkNNAV - iA h VVXp.gAFION/�
WORKER'S COMPENSATION DECLARATION BACK FLOW 1'R(TFE(T ) I G( ,f V
1 hereby affirm under penalty of Perjury one of the following declaraaor:
❑ I have and will maintain a Cenificom of Consent toself-insure for Workces Cooper- DRAINS-FLOOR,ROOP,Ak BA, ( 3. STORIES TV PECONS'FRUCfIOI,
.cation,its provided for by Section 371X)of the LaNa Coot.for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will main tin M'arker's Compensation Insurance,as required by Section -
3]0(l of lie Lib or Core,rnrthe perlormance of rhe work for which this permit is wi GAS-EA.SYSTEM-1 INC.a OUTLETS
(xC.GROUP AIN
C Wnrko's C m motion Insuran a r and 1'alicy nut Mr' /
Cartier:J'ni crtm Policy
CERTIFICATE OF T N N
GAS-IA.SYSTEM-OVER q(FN
FROM WORKERS'
COMPENSATION INSURANCE
Gk1iASU1NI3USTRL WASTE INTERCEPTOR
(This section need nor be annpletul ifthc permit is fortune hundred dollars(SI W) BUILDING DIVISION FEES
in R Af GRF.ASIi TRAP
PLANCIIECK PEE
Loy ary tper,nthe anyrationerof the work for subjetto permitrimesucd.lshallpen- SI?W13R-SAN['fARV-S'l(1RM EA, IT.
nm employ any person in any munnervommhcome subject the Workeri Compcn- ENERGY FEF.
Q � sation Laws of Califomia.Date WATER HEATER W/VENTIELLCTR
Z 2 Applicant GRADING FEE
N NOTICE 10 APPLICANT:If,atter making this Ceniricate of Exemption,you should WATER SYS'TEMaREATING
abecame subject to the Workers Conifensmion provisions of Labor Cale,you most SOILS I'EL
forthwith comply with such provisions in this permit shall be decmedmvoked. WATIiR SERVICE
.UZ CUNSTRUC'i'[ON LENDING AGENCY NEW RESIDENTIALPLMIf. SQ.II'. PND
L) I f r which thi,permit i is sued ser,30 lending agency tonne perfonnuncc of Doc Recclp p
I"' the w'orkfor which this permit is issued(Sec.3119],Co,C.)
Q Ixiii Name 'I(ITA L:
} 0. hcnJcL1 Addresst TOTAL:
0. I certify moat I Hove read this application nnJ swan tow alt ubwu infammtinn is BUILDING It?L
F'01 correct.I agree to comply wise all city and county ordinances and.aate 1--defog ,, QTY. MECHANICAL PERMIT FEE
V Z building construction.and hereby authorize repmsemordives ofthls city toemeruponthe SEISMIC FEE
show-mcnlioned IF any for inspection Purposes. PERMIT ISSUANCE
(We)agree in save,indemnify and keep hanNes.s the City of Cu1'enino against I F.LECI'RIC FEE
lisbilities.judgmcnts.cosuand expenses which may in any way acme against said Ciry ALTER OR ADD TO MECH.
in consequence of the Braciii of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO IB,000 CFM)
SOURCE REGyLATIONS. MECHANICAL PEE
,, --2- e AIR I IANDLING LEE r(OVER Q(XOCFM) CONST RUCTION TAX
Simulate of Applican/Contmcmr ac 1 EXHAUST HOOD FW/DUCT) HOUSING MITIGATION FE[
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantatme or handle hazardous material HEATING UNIT(To 100.000 BTU)
us defined by the Cupenino Municipal Code.Chapter 9.12,and the Health send Safety
Code,Section 25532(n)? HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑Na
VENTILATION FAN(SINGLE RI'SID) PAID
Wbc aPPlitunt m mwbuilding overpaid equpment or devices which
lan, Receipt N
mit havodous air nmtuminanw us reined by the Bay Area Air Quality Management BOILER-WAP(3HP OR 110,4E {TU)
Ui.arim? T(YfAh:
❑Ye.. ❑Nm BOILER-COMP(OVER 100,001)BTU)
I have mai the bmuMnus mmcrialn reyuircmena under Chapter 6.95 of the Cali- AIR CONDITIONER
SSUAN ?TF
forma Health&Safety Code.Sarins.that i 25533 and 255N.1 to understand that if the NEW RESIDENTIAL SUCH. SQ.FT.
building nos me currently have a tcnanp that o is my ce of responsibility to notify the rhe,
seri the requiremcnw which ansa be sect ptiana lswuncu of a Ccnilicmc of(kcupvncy.
Owner m morwiacd agent Data TOTAL: ISSUED BY:
OFFICE