S0018 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONTERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDEN'1'IF'ICATION �+�X�)4r
SANITARY NO. APPLICATION SU11MIl nki.DATE
BUILDING ADDRESS: �
20400 M Ax #'A iv I A "445
�-
OWNER' 59,,4R I NC7 pi^PH NosTits CONTRAC'TOR:S NAME: LIC NO: NIC CON'TRULM
LCHETECDENGINEER: LIC NO: ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
Qh) MGIC /� .3 G G- 392! ❑ Corm@aat Fees Paid by Applicant(Initial) BLDG El.lil:'I' PI,UMH MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby unarm that 1 am licensed under provisions of Chapter 9(....unsealing
Z NSection90f1(paf OivisionJofNe Business and Rofcssinns code.and my liccntt is RESIDENTIAL
W PERMIT ISSUANCF.
F in wfull Infrared all", ❑SPOWL ❑KITCHEN REMODEL
W�
aVV License Class Lie. APPLIANCES-RESIDENTIAL El ADDITION [I PLUMBING RE-11111E
L.ZILI Dam Cnntrmmr
NQ6
ARCHCUCI-S DECLARATION PANELS E]MULTI-UNIT ❑STRUCTURAL
TION
O Z y Z I undersand my plums deall he used a,public records CHIMNMODIFEY
UP'TU 2118 AM PS ❑INTERIOR ❑CHIMNEY kEPAIR
Licensed Professional 201-11"AMPS IMPROVEMENT E]SWIMMING POOLS
s1 f J OWNER-BUILDER DECLARATION OVER HIS AMl ❑HATH RFMODEL/REPAIR ❑DEMOLITION
C 6 T hereby aM m that 1 am exempt from the Comracmr's License law for the ❑OTHER
X O6 O following myon.(Section 7131.5.Rosiness and profosxioilS GBL:Any city or cotuny SIGNS ELECTRIC
W LL y which requires a permit to construct,ghee improve,demolish,or repair any%Wfure
1—•st prior in ils issuance.also requires the applicant for such profit rile n signed statement SPECIAL CIRCUIT/. ISC.
to that he is licensed pursuant to Ne pmvi:iom or me Commcmrs license Law(Chapter 9 COMMERCIAL'
��yp0 (cmmncneing it h Section700(IIuf Division 3oflhe BuArcound profession,Cale)of TEMP.MISTER OR POLE "r.
W a e C that he is exempt Ihercfrmn and the basis tart the alleged exempting Any violation of ❑NFW IH.DG/ADDITION ❑DEMOLITION
C. �mSection 9031.5 by any applicant for a periasubjefsthe appliniqui a civil penalty of POWER DEVICES ❑1FNANT El 1:00D SERVICE
not more than five hundred dollars IS50M. IMPROVEMIENT
❑ La%owner ofthe pmpeny,or my employees with wages as their sole compcnmtion. SWIMNINGPOOLELLCTRIC El OTHER
F.. will Jo the work,andthesaueum rs not inteadedoroff red formle(Set.7044.Business
W we and Pmfcssiom Code The ComtmcumI License law aces nor apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or interiors tharcon,and who docs such work himself or through
his own employees,provided that such improvements art not intended lir offered for NEW BESIDES"1'IAt.I!LEC'I'R SQ I-L
sole.If,however.the houldingorimpruvemmat issald within one year ofoompletion.the SQFT.FLOOR AREA $IRQ.IrI
.
nenboilder will have the burden of proving Nat he did out Mold or improve for par- f1 A I R
posaofsolc.). AL. P- Yi L/
[J I,m nwmer of the Past for exclusively convaedng with licensed core ri of
instruct the project(Sec.744,Business and Professions Cala:)The Conaaamra Li-
censelawdoesnotapplytoanownerofpr,aftywhonuild.sorimproveslllecml,and QTY. PLUMBING PE I / FEE AUG WC1
whocontracts forsuch pmjcats with a conrraft s)licensed insurerto the Commusepr'.s
License Aw. - PERMIT ISSUANCE /s
/ Dlamenendcr Set �1f'rWMIAm
ALTER-TRAIN&VENT-WATER(EA) VALUATION
if ft
Did
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WORKER 'S COMPENSATIOECLARATION BACK FLOW PPOTECT.DEVICE
Ihereby affirm under penally of perjury one of the fallowing declaration.:
L]Ihavcand will maintain a Certificate of Chosen,m rel f-arum for Workers Camper- DRAINS-FL(�R,ROOIs,ARFA.CONI� STORIES 'TYPE CONSTRUCTION
.film,as provided for by Section 3710 of the Labor Gds,for Ne pert nonce of the
work for which this permit in issued. FIXTURES-PER TRAP
C]1 have and will maintain Workers Compervfton Insurance,as required by Section
3700 of the labor Code,far the perhsrmancc of the work for which Nis permit is iasucrl. GAS-IEA.SYSTEM-I INCA OUTLETS OCC.GROUT' AIN
My Worker's Compensation Insure¢,gamier and Policy number are:
Caries Policy No.: GAS-L'A.SYSTEM-OV 4 HEA)
CERTII:ICAfE Op EXEMPTION FROM WORKERS' GREASEIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE If 1 ) [VISION IVES
(I[its section need not N completed lithe permit is foronehundred dollars($100) GREASE TRAP
PLANCIIIECK F
vr Itax)I
Loy say that in the performance aarewhe work
e,....abje this permit irkao' onipenl , WER-SANITARY-STORMEA.200FT.
mm employ any pcnnn in any manner m as to hunmc xubjml to Ibc Wnrkcrs'Compel- ENERGY FE
Z cation Laws of California.Date WATER HEATER WNENT/ELECTR GRADIN FE
ZO Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMA REAL ING SOII FL
becnme.wbjecna Ne Worker's Cumpensamon provisions of the Tabor Code.you muss
forthwith comply with such provisions or this permit shallbo decnxd revoked. WATER SERVICE
QPAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMI3. SQ.IrT. D, c Receipt p
U O 1 hereby affirm that them is a cormmetion lending agency for the performance of
W the work for which this permit is issued(Sec.3197.Civ.C.) 'TOTAL:
I-" Lender's Name TOTAL:
U Landers Address BUILDING FLEA �r
P 1 certify that I have read This application and store and the above information is
iF. tot convert.I agree to comply with all city and county ordinances and state lawn relating or TY MECHANICAL PERMIT FEE SEISMIC FEE
U Z building construction,and hereby andmi representatives of this city to enter upon the
above-mentioned property for inspection putposcs. TERM IT ISSUANCE ELECTRIC PEI?
(We)apace to smc,indemnify and keep harmless the City of Calcium.,.,a"
liabilities.judgments,costs and expenses which may in anyway accrue againfsaid City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the grunting of this permit.
APPLICANTI; ANDS AND WILL COMP.Y WITH LL NOS'1'[ AIR HANDLING UNIT(TO 10.WU CFM) MECHANICAL FEE
IL{ AI'10 mak'
AIR HANDLING UNIT(OVER 10.00 CFM) CONSTRUCTION TAX
pogrom of ApplicanUContmcmr Date EXHAUST HOOU IWfDUCT) HOUSING MI'1'IGATION"L
IIALARDOIIS MATERIALS DI. "WE
Wllthe applicant orfuture Wilding occupant store or handle hutardons Louvain HEAD NO UNIT('101 N0,000 111 Of
as defined by tht,Cupcmno Municipal Code,Chapter 9.12,and the Health and Safety HEAPING I1NIT LOVER 100.000 BTU)
Code.Section 2553200?
❑Ycs No VENTILATION FAN(SINGLE RESIDE PAID
Data Reacita#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP 13HPOR II LWO BTUI
pit ha minus air c..neminamn as defined by the Buy Arca Air Quality Management T(HA.:
OCsmif9 BOILER-COMP(OVER that"BTUI
E3 Yes No
I holt,rcadlhe hamalmix mseri9ls requirements under Chapter 6.95 of the Cali- AIR CONDI'I'IONF-R ISSUANCE DATE
fomi.Health&Safety Gde.Sections 25505.25533 and 25534.I unokmsnd the if the NEW RESIDENTIAL MECH. SQ FT.
building Jtcs not curtcntly hove a mnnnl,that it ie my respmeibiliry m notify Ne treupam
of the acrtmoth eau'which must M met prior m1 issuance of a Cenilicate It Occupancy,
Owner lir authodxd agent Dam TOTAL: ISSUED BY: y�\1
OFFICE