29836APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - ORE BALL POINT PEN DNI v^ -
CITY OF CUPERTINO - HUILDING-ELECTRICAL
BUILDING DIVISION •. APPLICATION/PERMIT PLUMRING-MKCH
- PERMITNO. w w6•;
L'ANICAL
' HUILDING PROJECT IDENTIFICATION
'
BUILDING ADDRESS: ^�
- - -
SANITARY NO.
APPIACATONSUB TTA TE
EN[i R:S NAME: /I THIO — o53 -CO
l/JI
RA (HIS NAME: LIC NO:
NIC
❑
CO OLp
ARCH\HIITWEECTY'l1IN`GINEER: -i LICNO:
AU RISS: I
S, �, S
„
CONTACT. PHONE:
BUILDING PERMIT INFO
- -
❑ Consultant Fees Paid by Applicant (Initial) -
BLDG ELECT ' P UMB MECH
o
LICENSED CONTRACTOR'S DECLARATION
'I hereby affum than t um IiansM under prnvisioos of Chop[er 9 fcummencing
with').... 7d IufD vmm�J of tha dullness nn i f a s e, unJm license is
y
. in full force end H
J Litt"a Lic.p
d Dae Conwa�r
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
.q.
APPLIANCES RESI DIiNT1AL
A C TGCI'$ DECLA ATIO
IunJcmtmam Hans shall be used as public Ad
Y P P
❑ MULD-UNIT ❑ STRUCTURAL
- MODIFICATION
LS
- '
UPTO20AMPS •'
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
I] BATH REMODELIREPAIR O DEMOLITION
Licensed Professional
- -Oor r.RI am eU impt from the
t I hereby affirm OW 1 em esmrpt from the GoATIONr'R License Law for the
, 201.1000 AMPS
'OVIiR IMM AMPS ,
SIGNS ELECTRICAL
J following mawm. (Section 7031.5. Hairiness and Professions Code: Any city or county
which requires a permit to consumer. altem improve, demolish, or repair any structure
TH
z
prior to its issuance, also requires Ncappllcant for such peotil to file a signed statement
SPECIAL CIRCUIT/MISC.
^ than he is ticeased putxaam or the provisions bfine Commel,as License Law (Chapter 9
(commencing with Section 7")of Division Sof the Business and Professions Code) or
'HEMP, METER OR POLE INST,
COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 70313 by any applicant for a permit subjects the opplimatoo civil penalty of
a., snore loan live hundreddo11ess(9500).'
I]1, as owner of the propeny, or my employees with wages as their sole compensation.
will do the work, end the stmcturi isnot intended or offered for sale (See. 70141, Business
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT.. - [j FOODSERVICE
IMPROVEMENT
�cs.,�� ,
LfK�ER
POWER DEVICES
- SWIMMING POOL ELECTRIC
o and Professions Code: The Commmar'p License Low does not apply to an owner of
r
OUTLETS — SWITCHES — FIXTURES
property who b.i IN or improves thereon, and who does such work h rrealI or through
his own a mployecs, provided that such improvements are not intended or offered for
NEW RESIDENTIAL RLELTR SQ FT.
sale. If,however. the building or improvement is sold within one year ofcompletion,the
FLOOR AREA
S/SQ.IT.
owner-huilder will have the burden of proving that he did not build or improve for pur.
pose ofsane.). ,. •I:
(p
—
-
TOTALerty, :
1, owner of Ne propm
C] as am exclusively contracting with licensed contractors
!!��
..N
swat the project (See. 7044, Business mad Professions CMe:) The Centimeters Li-
cense Use Joos nm apply to an owner of property who builds or improves thereon, and
QTY, PLUMBING PERMIT FEE
whuconnaels linsuch prnjeelowilh a coutrneoos) Fcamed pervuanno the Contractor's
Lieensc Law.
exempt under Sec. , R & P C for this rsons
0 1 am ea
C/p1 9
Y �h o
PERMIT ISSUANCE
AL'I'F:R7 DRAIN & VENT — WATER EA)
BACK 17 OW PROTECT, DEVICE
Owner -- Ulna
tvN
VALUy(/
d .�
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pennhy of perjury one of the following decbattioms:
/t]
DRAINS DRAINS— FLUOR, ROOF, AREA, COND.
I have and will maintain a Certificate ofConscnt to self -insure for Workers Coupes.
sntian, as provided for by Section 3700 of the Labor Code, for the performance of ilia
STORIES
TYPE CONSTRUCTION
FIXTURES—E'ER TRAP
work for whioh,hia permit is ismed.
I] H have and will maintain Workers Compensation Insurance, as raTyima by Section
3700of[he Lmm CMe, fanh0, rata ce of Ncwork fur which this permit is issued.
My Wnr er'n an 1 m c I Policy
G mr
Carrier' n��,, n Policy No.: It r
GAS — EA. SYSTEM -t INC. 4OUTLETS
-
DEC. GROUP.,
APN
-
GAS— EA, S YSTEM OVER A(EA)
CERTIFI A IS OF EXIT PTION FROM WORKERS'
COMPENSATION INSORANCH
(This section need not . becanancled if the permit is fur one hundfal dolotrs S 100)
art less)
OREASPANDUSTRI. WASTE INTERCEPTOR
BUILDING DIVES ION FEES
� ORIiASC 9'I1AP,
-
PLANCHECKFEE "
SEWER—SANITARY— STORM HAA. 2311 PT.
for which this permitrkersued. I shallCadman.
nm employ any person in
Hoy tiny that in the pn,raccnnceo no 1. became
any manner, sous [o become subjauo Ne Workers' Compcm
ENERGY HE
WATER HEATER W/VEWN..I.ECTR r
talion Laws of California. Uom
u
Applicant
GRADING FEE 0
NOTICE. TOAPPLICANT; If. after making this Certificate of Exemption, Latin,
become subjm0 the Worker's Compensation ardyouu mod
of the Labor CMe, you most
WATER SYSTEM/IREATING
_
SOILS; IEE ,
el title ... it shal
timhwiN comply with such provision.v rnhis permit shall be Jecmetl revnkN,
y
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hereby affirm thauhete isnc.newnion lending agency Taube performance of
PAID
Date Remi,o
NEW RESIOENTIAC PLMB. SQ. FT.
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Nome
TOTAL:
Landers Address
TOTAL:
. I acuity that I have read this apPlication and suite that the above information is
BUILDING FEE
QTY. MECHANICAL PERMIT FEE
compact. I agree to comply with all city and county ordinances and slate laws relating at
building aonstmction, and hereby uudtorim representatives nt ON city In enter upon No
SEISMIC PER
move mentioned property, for inspection purposes.
(We)agrec to save, imlemnify and keep hvmlcss the City of Cupcnino against
PERMIT ISSUANCE' �
T:LECfRIC FEE '
Iiubilities,juJgments,cox0s and expenses which may in any way mama against said City
gmmingothx permlL
eSM
ALTER OR ADD TO MECH. n
PLUMBING FEE,APRST
AIR HANDLING UNIT(10 IB M)CFM)
DS AND WI I. CGMPI WITH ALL NONE INT
SOOP
MECHANICAL FEE
AIR HANDLING UNIT(OVER IOA(Ifb CFM)
CONSTRUCTION TAX_ '
Signaure of A t nUCmuract D'c
HAZARDOUS MATERIALS DISCLOSURE
LXHAUSTIIOOD(W/UUCP)
HOUSING MITIGATION FEE
HEATING UNIT TO I00,000 BTU)
Will the applicant or fuwre building wcupunutorc or handle hazardous macmil
as defined by the C.Perino Municipal Code, Chapter 9.12, and the Health had Safety
Code, Section 25532(0)7
HEATING UNI'1.(OVIfR 100,000 BTU)
_
E] Year No _
Will the applicant or future building occupant use equipment or devices which
femir hazardous nor contaminants as defined by the Bay Area Air Quality Management
Uomcr?
PAID
Date - Receipt M .
VENTILATION FANS INGLE RCSIDI
BOILER — COMP (HIP OR 100,000 BTU)
TOTAL I
BOILER— COMP (OVER 100,000 BTU)
I]Ye.s - EjNo
AIRCONDI'1'IONEH
oteriolsreyuirl:mentiumler ChapterfiJS of the Coli-
Ihave read the bu/h.,,,
fomia Heal &Safety Cons +550 , 25533 and 53a. I understand that if Ne
builaingd tcurrtmlth it ie myre nsibility mnmify the upmt ereq.' me uCadifcateofOce ponyti
ISSU EDATF
-
ISSO HY
NEW RESIDHNTIAh MECN. • SQ. fT.
Owner arumoori em Dae
t TOTAL:
OFFICE a