30088 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.13LECfRICAL � PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.-MECHANICAL . .3100
8y8
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: . - - - SANITARY NO. APPLICATION UBMITIA.DATE
F. 2 An- C
OWNEI:S NAME: 1` ,` p PHONE: RACFO 'S NA 'LIC NO: -
PC 'f )Lp
4RCHITECT/ENG NE:•R: LIC NO: DDE ❑
CONTA - PHONE: - BUILDING PERMIT INFO
O �� .❑ Consultant Fees Paid by Applicant(initial) BL ELECT, PLUMB MECH
❑ ❑ - ❑
LICEAHD ED CON RACTOR'S DECTARAWN QTY ELECTRIC PERMIT FEE
I hereby affirmuitl m licensed under pmChpier 9(commencing JOB DESCRIPTION
Q=Z with Section 7")of Dm ' 3 ofthe llunnese end Pmfcss nn C d Jmylicensc is
._ WroO PERMIT'ISSUANCE RESIDENTIAL: .
full force and effect^
.Yu m E I ❑$FDWI. [D KITCHEN REMODI?I.
F�.V(J License Clus Lic.a
V;Z Dam Comment APPLIANCF_S-RFSIDIiNTIAL ❑ADDITION C1 PLUMBING RE-PIPE.
yy - cHITECTSDeC RATION ❑MULTI-UNIT ❑STRUCTURAL
OZJZ ' lundcrstand my`plans shall be used ex Public rernrds PANELS _ MODIFICATION
UP'10200AMPS El INTERIOR - ❑CHIMNEY REPAIR
.gn a Licensed Professional m. 201-101NtAMPS , IMPROVCMENT
�p�j+ Oat I am exempt ifr Ut Ce ContrRAIactor's
cto - OVER 10MAMP5 ❑BATH REMODEUREPAIR ❑DEMOLITION
Iy 6 I hereby affirm the 1 em exempt from the ComrnnoYs hicemc Low far the
�gq�S5�ILU following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OnTH/EnR ,.rt
w�0 F wish Iona
is a permit n t t h improve,J I sh repair ry structure,
......1d]JJ]]] utort 1. s:tun m l thepplc t1 h ' iu is g (Chapter
SPECIAL CIRCUITIMISC.
< e Nat he ci adv a n the of Division
i s fof Contractor'sl c I (Chupmr9 COMMERCIAL•
GCl that he ng nth Serefund ad ofUv mor (thcB irmssadP A iCmde)of TEMP.MISER OR POLI INST.
a a p�1 that he tar exempt therefrom trod the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^m
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES -
notmnrehe.five hundred dollars($500).
- ❑TENANT [I FOOD SERVICE
1;as owner od'the property,or my employees with wages us their sale compensation, SWIMMING POOL ELIiCI'RlG "/' IMPROVEMENT
will on,the work,and the structure is not Intended oroRered for sale(Sec.7044,Business []OTHER,
I and Professions Cede:The Contractors License.Law dimes not apply to an owner of OUTLETS-SWITCHES-FIXTURES -
property who builds or improves daemon,and who dins such work himself,r through
his own employees,provided that such improvements arc not intended nr offered for NEW RESIDENTUAL ELECTR SQ IT.
adrAf.however,thehuildingorinmprovenmint issald within one yeurnfcnmpl000,theSQ.Eq..FLOOR AREA S/SQ.FP.
ownerbuilder will have the burdenrf proving that he did not build or improve for pur- '
pose of sale.): .' R pq
❑ 1,u ownerof the property,a xdusi ro
Ptractm
Protracting with L
TOTA : J
constructwnsconstructthe project(S«.7(Na,Business and end Professions Code:)The Comracmrs Li-i- (�
Li-
cease se Law does not apply to anownerofpmpenywho builds orimproves hereon,and QTY. PLUMBING PERMIT' FEE SEP,
who contracts for such Projects with a cnulowla(s)licensed rotation dihc Contract3or's 0 q(Iea� -
Licens Law. r. - Ia7 s�
❑I am exemmpt under SCPERMIT ISSUANCE C. B&P C for this reason ...
ALTER-DRAIN&VENT-WATER(EAT
Owner, - Due - - rs m LVALUAJjQ�
.Wm anti r p COMPENSATION DECLAMATION RACK FLOW PROTGC'I',DEVICE
have
hereby affimmunder penalty of ofCoyeone ofnt to elf4s re for Worker's
ro - D V
' •fin...pro idefar by Se tion Certificate the Labor
Celan ndite Workers Compche DRAINS-Ff.00R.R00EAREA,COND.
smion,mpnrvided for by Section 3](I(Iohhc Labor Cale,fimliepMomance of he - SI-DRIES TYPE CONSTRUCTION
work for which this permit is ismed. FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
37M of the Labor Code,'uthup annmce of the work for which this penoil,a issued. GAS_RA.SYSTEM-]INC.4 OUTLETS
OCC.GROUP ,•APN
m My Work �oi •n. ire fffJJJ��re m n ie,No 9
Cadre (k ,ft SC7�1LPP ad1No!! rmlqoll GAS-M.SYSTEM-OVER 4(EA)
RTI KATE OP EXCMI'TION Fl20M WOR RS'
.. COMPENSAI ION INSURANCE GREASILINDUSTRLN'A,"T-INTERCIiMDR_
ft his section need not he completed n i e penton is formed hundred dollars I$Iran BUILDING DIVISION FF,1?S
or less.) GREASE TRAP
I'LANCHECK FEE
Loy ,mypersam m formoanymmumceofthewoc for which this the Wiisiss'Cierpr. SEWER-SANITARY-STORM EA.200 ET.
not employ any person in any manner m m to become abject m the Workers'Camper- ENERGY FEET -
Z cation Laws a Celifomis.Dam
-• Z Applicant m S WATER BEATER W/VI?Nf/ELECIR GRADING ITIE
h NOTICE TO APPLICANT.IL after making this Certilinnc of Exemption,you should WATER SYSTEM/1 BRAYING -
a' become subject m the Worker's Compensutinn provisions of the Labor Crowle,you mu.ii SOILS FEE
forthwith comply with such provisions or this permit shall 6e mkenmd revoked WATER SERVICEO
IDz CONS]RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
UI hereby affirm that is a commuetion lending agency for the performance of Date •ReceiptN _
� p-t Ne work for which this pcnnh is Issmd(Sw,3097,Civ.CJ
OU Lenders Nante TOTAL:
W Lenders Address TOTAL:
04 1 certify that I have read this application and state that the above Incubation's is BUILDING FEE
(A Purred.I agree to comply with all city and county ordinances and Stam laws relating to QTY, Mf:CHANICAI.PERMIT PEE
U building emmrvmion.and hechy euhnrixP representatives nl'this citym enter upon the SEISMICFEE
above-mentioned progeny for inspection purposes. PERMITISSUANCE
(We)agree to save,indemnify and keep harmless he City of Catania,against ELECTRIC PER
liabilities•judgmems.costsand espama. which may in any way scemeagaimt said City ALTER OR ADD TO MECH.
in consequence of the greening of hes permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT
SOURCE REGULATIONS. AIR HANDLING UNIT('1'O I(I,Wp CIrM) -
m - MECHANICAL FEE' I.
AIR BAN DLING UNIT(OVER 10,000 CFM) CONSTRUMIONT'AX
Signature of ApplirmC7.atmadm Data EXHAUST HOOD(W/DUGO HOUSING MITIGATION F1213,HAZARDOUS MATERIALS DISCLOSURE
Will he applicant of l'umacholdir,eenpant amrcm handle h....li ismmenul HEATING UNIT(10 100,000 BTU) '
as defined by the Cupertino Municipal Cate,Chapter 9.12 and the Health and Safety i
Cade,Section 25532(m? HEATING UNIT(OVER 100.000 BTU)
❑Yen ❑Nei VENTILATION FAN(SINGLE RESID) PAID
Will no applicant nr future building occupant use equipment or devaN which - I - Date Receipt a emithr,mlars alr untantimnts as defined by he Be,Arc,Air Quality Management 'BOILER=COMP(JHP OR 100,000 BTIL - t
DiL_amhdflz�
m erT' TOTAL: V_V1
E]No BOILER-COME(OVER 100,000 BTU) -
read the haeendous materials AIR CONIA HONER
requirements under Chapter undrbnual the Cali- - ISSUANCE DATE
HealthSafety Cale,Sections 25$05,25533 and 25,574.1 undcaamd that if the NEW RESIDENTIALMUCH. _ SQ.FI'.
tcu_a hu ents which mum he met prior tu issuance ofa Certificate ofOccupancy.onzed a gem Data TOTAL: ISSUED BY:
OFFICE '