30605 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY k�•+� r^
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 30605 O V O V
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: s ' l SANITARY NO. APPLICATION SUBMITTAL DATE
Aa- c I _1?TIN0 . CqU t=o2rl;1+ riSOI � . QaG
(WNER'S NAML �lPHONE: CONTRACTORS'TOR /NSAMF LIC NO0
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ARCHITEk77ENC IIIIH: LCNO: ADDRESS: s LJ
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CONTACT PHONE: BUILDING PERMIT INFO
}} ^ pp ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
1, iN513U CONI'RACTORN DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby#rims mm I am licensed ander provisions of chapter 9(rommteneing JOB f5ESCRIPTION
DMZ with Section 70gris'Division 3 ofthe Business and Profession:Code,and my license is RESIDENTIAL,
F1O fPERMIT ISSUANCE ���
W in full force mind eeel. ❑SFDWL ❑KITCHEN REMODEL
aUU License Class Lica
N Dale Contractor
APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Q on
ARCHITECTS use DECLARATION [I MULTI-UNIT ❑STRUCTURAL
F D m PANELS
Zp HZ IundcrsmnJ my plans shallhused as public records MODIFICATIOCHIMNEY
p4 4_Qt:W UP'TO 2fIBAMPS El INTERIOR ❑CHIMNF,Y RfiPA1R
F.h..F.W Licensed Professional 201-IIXXIAMPS IMPROVEMENT
OWNER-BUILDERUECLARATION OVERIOWAMPS ❑BATH REMODEIIREPAIR ❑DEMOLITION
C C Q 1 hereby affirm that I um exempt from the Contractors License Law fur the
X3 6 U following mason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHGR
W "� which requires a permit m construct,alter,improve,demolisM1,or rryvr any swdum
,E-LL Q, prior m its issuance,aim)requires the applicant for such Permit m file a signed statement SPECIAL CIRCUPUMISE
� y that he is licensed pursuant to me provisions ofthe ContreiLicenseLow(Chapter 9
Ul..no (commencing with Section 700)of Division3 ofthe Businessman Professions Ctdelor TEMR METER OR POLF:INST.
6 ry,o¢ ohm he is exempt therd'rnm wJ the basis fur the alleged csemptian.AnY viulwinn of - ADDITION El DEMOLITION
W..y Section 703 L5 by any opplirnl for a permit subjects the applicann,#evil penally of POWER DEVICES ❑TENAN'1Cl FOOD SERVICE
ru thw five hundred dollars($SW).
FZY " "tt IMI'ROVIiMP
Q 1,es owner of hand
itn"Humyemployms with wegex as their sole cnmpensminn, SWIMMING POOL ELECTRIC
EF w: do the work,and the samence is not intended oroffered for mile(See71NW,Business ❑OTHER
4�1_ and Professions Code:The Contractor's License taw does not apply m an owner o OUTLETS-SWITCHES-FIXTURES
C 3 property who builds or improves Hereon,and who docs such work himself or through
his awn employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.ILhowever,the hadding or improvement in sold within one year of completion.the SQ.FT.FLOOR AREA SISQ.FT.
owner-builder will have the burden of proving chat he did not buildo,improve lir par-
o"' ccolorle). P A E D
1,as owner of the ptoper ,am exclusively commarting with licensed contract to f
construct the proj a(Sec.909,Business and Professions Code:)The Contractor's Li-
c u, does tepPlyvs ten owner of property who builds or improve.,theater,and QTY. PLUMBING PERMIT FEE
w„ucmount t such Pmjnrs with acommnngs)IiccnaJ pursuannothc Commcmrx OCT 291996
License La PE RMI'T ISSUANCE
❑lam a to rSe .B&PCfnr Nis
O r Dem - van ALTHR-DRAIN&V WAI ER HDO T Ur bUIVACUAMJN
( KFR:SC .AI'I N DECLARATION BACK FLOW PROTECT.D: E
I 're ufimtunder of 'u one ofthe l'ollawingd lura ons:
•C]Ihim dwillcomemin ificateofConsemit)self-iroum for Worker's Compen- DRAINS-FLOOR.R F,AREA, D. S'IY)RIIS 'TYPHCONSTRUMION
.ratio
w n.as Provided for by Section 37W of the Lista,Code,for Ne performance of the
o for which his Permit is issued. FXTURF_S-PER
1 have and will maintain Workers Compensation Insurance,as required by Senion
X)of Ne labor Code.for the performance ofthe work for which Nis permit is issued. GAS-EA.SYSTEM-1 IN OCC.GROUP APN
My W
Carrier: Policy Nu:orkers Compensation Insurance commercial Policy number,arc:
GAS-EA SYSTEM-OVER i(EA)
CHIC FICN'12 OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCLi I GRLASHIINDUSTRLWASTE INIPRCF OR
BUILDING UIV 'IOYlli135
(This sution seal solMwmplctW if Na pcnnit islbr oncbundrcd notion($l W) GRI3ASETRAP
in los.) PLANCfIECK PEE its
I certify that in the performance ofthe work for which this permit is issuvil.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any Peon in any manner so na to become subject to Ne Worker'Compen- ENERGY FEE
Z cation laws of California.Dam WATER HGN
TER WNEILLECIIt
0 2 Applicant GRADING
Z
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
(-” Menne subject nt the Workers Compensation provisions of the Labor Code,you mad SOILS 093'
Iimbwith comply with.suuli provisions or this permit shall ire deemed revoked. WATER SERVICE
Q
Z Z
CONSTRUCTION LENDING AGENCY NEW RESID[iNT1AL PCMB. SQ.FT. PAID Date Receipt#
U 0 l hereby affirm that Them is a construction lending agency for the pem
dbranm of
Ne work for rm
which this peit is issued(Sec.3097,Civ.C.)
F
lamlers Name TOTAL:
U landcr's Address TOTAL:
} WBUILDING tT;
1 rtify that I have read This application and state that the abuse information is
f` y cecorrect.l agree veeomply wait alliany andcaunty ordinances and state lawsmlatinEto QTY. MECHANICAL PERMIT FEE
U z mildo,c.darectinn,and henbyanthorize reposenlative%of this city to enter spm the SEISMIC FHE
above-mesio Tl prory'ny lir inspetlum purposes. PHRMII'ISSUANCF.
Inde) ee ut u y imJnnnify end keep harmless the City of Caperina against ELECTRIC PIiL'
liabilities,'d menu,costs and expenses wbich may in any way accrue ageing sail City AIAFRORADDTOMECH.
a. e of Ne gramilig studs permit. PLUMBING FEE
A"
PLIVKN)r UNDERSIANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOU E 'GU ATIO
AIR HANDLING UNIT(OVER 10,00 CFM) CONSTRUCTION TAX
Signator• d p' unVCnnvaamr are HXIIAUS'T fI00D(WIDUCI} HOUSING MITIGATION PEP.
IfALAR)0 UTERI kiS DISCLOSURE
it he applicuni or fu re building recupanLdnre or handle harnrdoum mmenal HEATING UNI'T(TO IW,000 BTU)
as dein y the Cupenino Municipal Code.Chapter 9.12,and Ne Deana and Safety
Code,Section 25532(0)! HEATING UNIT(OVER 100.010 BTU)
Yes 0 No
VENTILATION FAN(SINGLE RGSID) PAID Date Receipt#
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Buy Arca Air Quality Management BOILI7R-COMP(3HP OR 100,000 BTU) TOl'AL:
Di'n't? BOILER-COMP(OVER 1110,0111 BTU)
E]Yes No
AIR CONDITIONER
I all the haQ' i-ino
rireyulremcntsutWer Chapter 695of the Cali- ISSUANCE DATE
Tomas &Safety an05.25533 arW 25534.1 urWcrsland Nat if Ne NEW RF_SIDENTIAL MICH. SQ.FT.
buil gd�xnotfbrten0t.Nitivny respmsibilitymnotify Ne ouuWm
of Crept (( vJiIt Isuanceofa CeM1lficut of(kc ny.
Ownent .di 'mJ.,car )arc TOTAL: ISSUED BY:
OFFICE