S 1061 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PE MnNO.
BUILDING DIVISION ' APPLICATIONIPERMIT PLUMBING.MECHANICAL 1061
BUILDING PROJECT IDENTIFICATION I" '
BUILDING ADDRESS:
pk SANITARY NO. APPLICATION SUBMITTAL DATE
l o L io Or. C�2,tt�1
OWNER'SNAM PHONE CONTRACTQR'S NAME: LIC NO'
I � c33s r N/C CONTROL#
of f0.RWCHITE VENGLNEER: LIC NO: AD RF.,SElA05l J: �x llvd I '
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) lr BLD ELECT PLUMB MUCH
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE 1
I hereby ME...mat I um licensed under powi m,33s,of Chapter 9(Commencing JOB DESCRIPTION
Boz with Section 70001of Division3ofinethsinessard Profession.)Codyan nylicenseis PERMIT ISSUANCE RESIDENTIAL:
aF1Or full force ander t. / El SCOWL ❑KITCHEN REMODEL
UZV License Class de3t6 Can APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
y G& Oam Can RCHITECT'S DECDECL gift - PANELS
p,prn ❑MULTI-UNIT ❑STRUCTURAL.
z O n 7, 1 understand my plans shall be used as public mai s MODIFICATION
Oz— UP TO 209)AMPS 1-1 INTERIOR El CHIMNEY REPAIR
r-40 Licensed Professional - 201-H00 AMPS IMPROVEMENT
C ❑SWIMMING POOLS
1{ .' OWNER-BUILDER DECLARATION
�W 6 I hereby a0inn that I um exempt from the Gmlrucmr's License Law for the OVER IIMIO AMPS BATH REMODEWREPAIft �DEMOLITION
3 O d U following reason.(Section 7031.5,Business and Profe,eamis Code:Any city Or county SIGNS ELECTRICAL ❑OTHER
C y which requires v permit m construct,alter,improve,demolish,or repair any structure
F�yOyd prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
y that he is licensed pursuant to the pme,ansof the Contractor's License Law(Chapter 9
� p0 (commencing with Swtion"IHIIO)oYDlvleinnJ of the Business and Pmfeesinnx Cale)or TEMP.METER OR POLE INST. COMMERCIAL:
d q o fy that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W%„'^,�Ir•
Section 7031.5 by any applicantfor u permit subjects the applicant to a civil penalty of POWER DEVICES
y not more than five hundred Sulfur,($5W). QTENANT ❑FOOD SERVICE
r_1I,as owner of the property.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC )/'RIP—VEMENT
i� will dothe work,and the stmcmre is not intended or offered forsele(Sec.7044,Business' [I OTHER
and professions Code.The Contractor's License Law docs nut apply to an owner of a OUTLETS—SWITCHES—FIXTURES
pmpmy who builds or improves thereon,and whe but.,such work himself or through ��U {I�la I/ �)
his own employees,provided that such Impmvemenm are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT
sale.If.however,the building or improvement is sold within one year ofmmpletion.Ihe .FYjF4QOR ARUA $/SQ.FL
owner builder will have the burdenofprovingmathedidactbuildorimproveforpur- �z� 199
prose of sale). 0. 11 I
❑I,as owner or the property,am exclusively contracting with licensed contractors m TOTAL: uLU sps
construct the project(Sar.7044,Businesx and Pmfotsions Code:)The Concavities Li- ,,,,aayy V
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE Ci rV OFC ON DEp R _
who contracts for such projects with a contmctor(s)licensed pursuant to the Contractor's OFC
A I�(/�EArf
License Law PERMITISSUANCE ERPA10 tY
❑I am exempt under Sec. ,B&P C for this reason
Owner - Date ALTER—DRAIN&VENT—WATER(EA) 6 lVALUATION
ATTIION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVI V jG0��
I hereby alTm under penalty of pefjuryone or the following declarations: `J VVV
El IM1ave and will maintain a Commence of Consent to self-insare for Worker's Compen- DRAINS—FLOOR.R EA,COND. STORIES TYPE CONSTRUCTION'
ornmr,as provided for by Section 3700 of the Labor Code,for the performance of the
w❑ 1 have ad will coommin Worke
ork for which this permit is issued. JCL FIXTURES—PER T
ars Compensation Insurance,as required by Seaion -
of-
3700o17the Labor Code,further permrmanceorlhe work for which this permit is issued. GAS—EA.SYSTEM-1 INC.40 T TS OCC GROUP APN
My Workers Compensation lnwmnce evrrierand Policy number am: ' '
Cartier: Policy No.: GAS—EA.SYSTEM-Oxo
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTR.WASTE INTo BUILDING DIVISION PEES _
This section need not becompleted Him permit is before hundred dollars SIDE) GREASE TRAP
or Costs.) PLANCHECKFEE
I certify that in the Performance ofthe work for which this Permit is issued,I shall SEWER—SANITARY—STORM EA.200 Up
rs
not employ any peon in any mann r s�JoJgrBmowtbjecl to the Workers'Compaq- ENERGY FEE
sation Laws of California. LZ.Vl
7 O Applicant t '0i ♦- WATER HEATER WNENT/F.LECTR GRADING FEE
r7 ti NOTICE TO APPI.ICANT a m c ircme of Exemption,you should WATER SYSTE CTREATING
a , become subject to the War Ors mpensation provisions of the Labor Code,you must SOILS FEE
W forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
¢C, Q
Jz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. $Q.FT. PAID
UO I he
rebywhich thi that them isaconstro,30lending agency for the Performance of Dvm cclpt#
the work for which this permj�ris isxued(Seo.]097,Civ.CJ
W Lenders Name '0((•�Fyy TOTAL:
IUIJ 'Lender's Addres�p• TOTAL:
1 certify that 1 have reed this application end smmthat die above information is BUILDING PE'
(ag] correct.l agree to comply with all city and county ordinances and state laws remtlngm QTY, MECHANICAL PERMIT FEE `
V z building contraction,and hereby authorize representatives of this city m enter apostolic SEISMIC FEE
.w above-mentioned property for inspection purposes, PERMIT ISSUANCE(We)agree m save,indcmnlfy and keep harmless the City of C.,mi o agmmat ELECTRIC FEE
liabilities,judgmenu,costs and penes which may in any way sceroeagxinstsaid City ALTER OR ADD qYI MECH.
in consequence of the grunting ofjlfis Per 'L PLUMBING
APPLICANT UNDERS / S AND ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'r(TO 10.00d CFM) MECHANICAI.
SOURCERF AT it Z�
q AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TA
Signurc TAppli nt/ omme (/ a EXHAUST HOOD(W/DUCF) HOUSING MITIGATION
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building crampant store or handle hazeNous material HEATING UNIT(TO 100,000 BTU)
as defined by the Calamine Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)P HEATING UNIT(OVER 010,000 B/
❑Yes No
VENTILATION PAN(SINGLE ,SID) PAID -'
Da¢ Rcceip #
Will the air cocant or ntaminants
a building by the occupant use Area
Alarmone or Maces Whichnagement
BOILER—COME CHP OR 0,(X10 BTU)
emit hazeNous air comaminnms es define)by the Bay Arca Air Quality Management
T AL:
District?
IVNo BOILER—COME(OV I00,000BTU)
AIR CONDITION
I have read the hazardous materials requimmean under .1 understand
rsta of the Cali- ISSUANCE DATE
betula HeehM1&Safes CM evtirons I5,25533 and 25534.I undemmnd that It'the NEW RESID TIAL SUCH. SQ.PF.
Code,
of ib ngof lb ng doe^cine tartan vt it is my responlbility tune Jy the nccupunttenon vt it is my responibility tune tfy the occupant
of theof the req�nN OR mustR 'onois-encenfa Ce 'tat a aOR mustR 'mails-eneeofa Ce 'tat a a�
Owner or utheriz ger a TOTAL: ISSUED BY:
OFFICE