30531 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL. PERMITNO. O
BUILDING DIVISION APPLICATIONITERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
// SANITARY NO. APPLICATION SUBMITTAL D
BUILDING ADDRESS: Oti IG A'1'fi
�410� r 1e.rH C&fe-r oro I c'l
.ERS NAME: Y > ' PHONE: CO /OR'S NAME: LIC NO: NIC C R M
L c _ C
1RCIIITECf/ENGINIiIiR; LI NO: ADDRESS:(_/� I 1 p /pf,rL ❑
I CONTACT: Y I J h"gyg 0s. PHONIi: L l{yAl-snv`Nt7rI BUILDING PERMIT INFO
mS''77 qry� n''G ❑ Consultant Fees Paid by Applicant(Initial) B,kL_U.,G ELECT PLUMB MECH
e5 d' 7. a U N; ❑ ❑ ❑
LICENSED CONTRAC'I'm I DELLARATIII QTY ELECTRIC PERMIT FEE r
1 hereby affirm that I am licensed under Provisions of Chapter 9 fconunenmrg JOB DESCRIPTION
WOO wird Secdon]l1IXHof Divisinn3 of the Boniness unJ l'nffosions Crdq and my licanxc is RESIDENTIAL,
to O PERMIT ISSUANCE
mut- intense and effect. O OSFDWL O KITCHEN REMODEL
aUU License Cl.Clazs Lie. gPl'LIANCES-RESIUGNT'1A1. ❑ADDITION OPI,UM131NO RE-PIPE
I�Z W Dam Common
Fah HCHI'IEC'1"S DIiCLARA'1'IUN PANELS
OhfULT1-UNIT OSTRUCTIIRAL
Z Oy� 1 understand my plans shall be used as public records ,,tt�t,,M..ODIFICATION
OZ—O UPTO 200 AMPS [I INTERIOR &¢CHIMNEY REPAIR
W Licensed Professional 201-IO01)AMPSIMPROVEMENT
C C¢ 1 hereby oOrtm Nm Ilam le elmpt fnrmF Ne C mrautar's License law for the OVER 1000AMPS 0 HATH REMODRIAEPAIR 0 DEMOLITION
axpy5,O y ❑OTNER
U Ibllowing moron.(Section]B3IS, sinessand plot ..ion,Code: city or county SIGNS ELECTRICAL
mBu ��• 1��-rr au Ar
n+31L f- which requires a permit i construct,ager,improve,demolish,or repair any structure / �Onl/' OYI'��./�wTJ /i n
„E]�O priunn in issuuncc,also mynires(he vpplicvm brach permit,filcusigacd stmcnsCnt SPECIAL CIRCUIT/MILL—Ni
flythat he is licensed pursuant o Ne provisions of the Contmelo's License Law(Chapter 9
a�j CEQp (commencing whh Seaiun](X)Ouf Division 3 of the Business and Professions Cost), TEMP,METHR RPOI :1 COMMERCIAL:
f1 y o ty Nat he is exempt machos.and the basis for be alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
Y%1 4,�•
Section 7031.5 by any appllcunt litre pcnnitwbjensthis applieum to a civil penally of POWER DEVICES ❑TENANT ❑FOOD SERVICE
but more than five hunlred dollars 05500).SIMPROVEMENT D ❑ ownerxw
I.as of be pmpeny.or my einployecilhwager astheiruBc ennpemmiun, SWIMMING PO01, ECfRIC ❑OTHER
F.9 . will do Ne work,and me.vuc,re is not intended proffered formle(Sec.704,,Business
Wto and I'rofc,ions Code:The Contractor's License law Nes not apply to an owner of OUTLETS-SW CHCS-FIX RES
la, popery who builds or improves thereon,and who docs such work himself or NnmgM1
hisuwn employees,provided Nat such impmvcmems arc In, imm�--J ar offered for NEW HESID.NTIAL ELECfR SQ
Wt.If.howtheever.the building or improvement is sold within uncyem of cnmpletian. SO�Prp FLOORAREA EISQ.PI'.
o builJer will have the burden of proving that he did not build or improve for per- V`F/) O
prose of sale,. /� 19
I,as owner of Nen
e propy,am exclusively commnmm
ing with licensed comorsto TOTAL' rf 96
camstm.,, .,be project(See If.,Businessland Professions Cade:)ThC Cantmcurr's Li- � {9
roe Law Jots not apply to an owner of pmpny who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
m N
who contracts for such pmjecrs with a enntraclnds)licensed pursuant e Ctmol cter's v
License Law. PERMIT ISSUANCE
Aft1 am exempl under See. .B&P C for this rcmnn
ALTER-DRAIN EVENT-WATER(EA) VALUATION
Mr DNC
WORKERS COMPENSATION DECLARATION BACK h10W PROTECTDEVICE ` ysQ, 00
I hereby short underPenalty It perjuy
one of the following Amlamtionv.
❑Ihme andwill maimain uCcnificmc of Consvm msdGinaure for Workers Cumpcn- DRAINS-FLOOR.ROOEAHFA,COND. STORIES TYPE CONSTRUCTION
stain,as provided 1'or by Seeds 1 3]W of the Ldan C de.By Ne perl'ornanc,of the
dx
w5ork for which this permit is issaed. FD7URES-PER TRAP
have and will maintain Worker's Compensation Insurance,as.tquire)M1y Section
I
3])0efthe tabu Cot fill the perfomtancc of Ne work for which his permit is icaN. GAS-EA.SYSTEM-ll C. O TLE . OCC.GROUP MIN
My Worker's C����l Jpro�painn lnsurunc c 11'nl..y numb�,Laryry..�
Cartier. ,�9• �+-^lfrrm Policy No.: IAV/Z [WATER
S-EA.SYSTIi - :R )
CERTI FICATE Of:EXEMPTION I7ROM WORKERS' q/j/fr
COMPENSATION INSURANCE 7///( EASIVINDUS1 RL STEL I'E IiPI'OIt BUILDING DIVISION FEES
IT his scctlon need not lw mmr,led ilNc permit is for one hundred dollam P6 Old) EASETRAP
or Icss.l I'LANCIIECK PEti
Icenify(he,,.,the In,bramsecofthework I olnelihie permit iNlxnued.[,hall WER-SANITARY-STO EA.200FT.
nut employ any pe map in any manner m as,become subject,Ne Workers'Compo. ENERGY FETE
O�Z satin Laws nl Califnmiu.Dim TER HEATER WIVE /ELECfR GRADING FEE
Z Q Applicant
NO I'IC1i'1'0 APPLICANT:If,after making this Cenificnm of Exemption,you should ATI3R SYSTEM/BE LNG SOILS IFF,
a become object to the Worker's Compensation provisions of the Labor Codc.you must
fonhwiNcmn,ly withsuch tarokict,or this permil,mil be deemed revoked. SERVICE
5Z CONSTNUCI'ION LF.NDINGACENCY NEW RESIDENTI LPLMB. SQ.Fr. PAID Date Receipt
U� Ihercby alfinn Nm@Cm isarnnxwction lending agency for the prformance of
F the work for which this permit is ls,ucd(Sea.3097.Civ.C)
Lenders Name TOTAL:
LeadIr'N Address TOTAL:
1 1 canify that 1 have read this application and stem that the roswe bar..maim.is BUILDING FEE
y Cuncn.1 agree m comply with all city and county ordinances and state laws relaing to QTY MECHANICAL PERMIT FEE
U Z building contraction.and hereby notation,repreuntatives of Nis city to enter upon the SEISMIC HE
move-intentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep hande,Ne City of Crisman,against
ELECTRIC PEE
Iiabilitien,juAgmmats,csn.seed Cxpennen which may in any way acerae against said City ALTI!R OR ADD TO MECH.
in consequence of the gmnting of his permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UN T(TO IO CFM) MECHANICAL FEE
SOURCE REGULATIONS. q
' I/E �q,---az/��A AIR HANDLING U I f0 E CC_M-j CONSTRUCTION TAX
Sitio.,. j�timcun AN4/ pale E%HAUST HOOD HOUSING MITIGATION FEE
HAZARDOUS MATERIA S DISCLOSURE
W 1l the opplimm Orluutrc builJing:ecupum store or hanJl<havNuus material HEA' IT IW.gMI RTU)
tlgjft
as Uc.d, Sthe Cupnino Municipal Cute Chap¢r').12,and the HCalth vnA Salcty
$6tccYi on 25532(a)'! HFA'11NG UNIT(OVER 100-91061-TU)
eso
0 VENTILATION FAN(SI 'LE R[SIU) LAID Dart Haciptx
Will the applicant or future building oeevpvnt use equipment or deviscn which BOILER-COMP POR I W.WO BTU)
emit hveardous air contaminants as defined by the Ray Area Air Quality Management TOTAL:
District!
❑Yes BOILER-C P(OVGR 100.0n)BTU))
I have ad the heraaarials tm
equirccros under Chapter 6.95 oldie Cali- AIR C/AI IONLIt ISSUANCE DATE
fomia HCalth dt Sulcry Csda Scetions 25505.25533 and 25534. undcrnbmJ Nut itch° NE RESIDENTIALMECH. SQ.pT.
building loas not cumcmly have atenant,Nm it is my teapomibility to unify Us,onvpmt
of Ne palmrcmm:s which mug he Fact Pr nr ns issuance rola Cenitic:ne nflkcu nay.
11/1
Owner or auNorixcd gent Dale TOTAL: ISSUED BY:
OFFICE