30157 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO _ BUILDING-ELECTRICAL PHRMI'I'NO. O
NUII,UIN(iu1vISION APPIACATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS; SAN]'1'ANYNo, APPLICATION SI111MII'IALDATIi
ffi
2-12-'S NAMC1.J:1111 I,x 1Hx PHONE: CONTRACT 'S NAME:C LIC NO: (J�/
(tif 4IxN �CC'J& I (Li O J NIC C(JNIHOLa
RCHITECTANGINEER; LIC NO: ADD 'SS: ❑
W AI.nIIP'1 S+, rle-k-soi/tsf
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ISLECT PLUMB MECH
❑ ❑ ❑
LICENSEDmtatCONTRACnder p DECLARATION QTY ELECTRIC PERMIT FEE
I herby aGnn that 1 am liccnsel under pmviritm of Chapter Y Icomatencing JOB DESCRIPTION
WOO with Seaion]000)ofDmisitn Jnfthe Business and Professions Cale,and my license is R SIDS EN�TIAL
Fly- in full force and cffmt. (j PEHMRISSUANCE
�W" - License Clss _ Lica 1A 31171 ❑SFUWL ❑KITCHEN REMODEL.
Q U APPLIANCES-RESIDENTIAL OADDITION ❑PLUMBING RISpipE
aFQa Dam Contractor An ti
ARCHITECTS DECIARA'I'ION A1ULTLUNR ❑STRUCTURAL.
Z p'/=iZ I understand my plan%,1pdR be used as public accords PANELS --// MODIFICATION
V
�Za?0 UP TO 200 AMPS TERIOR ❑CHIMNEY REPAIR
[-�F-W Licensed Pmfcseinnal 201-10NAMPS IMPROVEMENT
wyf; OWNER-BUILDER DECLARATION OVER IOW AMPS -1BATHREMODEL/REPAIR [I DENIGRATION
,=6 5 1 herebffi
y arm that I sm exempt from the Contractor,License Lew for the
�°x4'C)aU following reason(Seeiun]OJLS,Business and Pmfexsinnx Cude:Any city or county SIGNS ELECTRICAL El OTHER
W 3 a y which requires a permit to contact,altar,improve,demolish,or repair any smucmre . (fin a ,r A
F=05 prior to its issuance,also require the applicant for such Permit file a signed,mrn¢m SPECIAL CIRCUIT/MISC, —�/
he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
115 C) mogracncing with Section]00(pol Division Jofthc Business and Pfnfessions Code)or TEMR METPOL
ER OR E INSL COMMERCIAL:
=M ey that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^N Section 7031.5 by any applicant far apsmit subjects the applicant ERo a civil Penalty of ro DEVICES
not room,h.five hundred dollar, ❑TENANT ❑FOODSERVICE.
F Z} IMPROVEMENT
=QUI,as ownertdlhe property,nr my cmpinyaswiN wagsasaleir rule romptnsatinn, S IM LNG POOL ELECTRIC
'EF.m will do Ne work,anJ theswcture is nm intended eroffereJ for gale(See.]I}M.9usiness [I OTHER
W0 ,- and Professions Cale:The Contractor's License Law does nm apply to an owner of O T SWITCHES-FIXTURES
0. r property who builds or improver thereon,and who does such work himself.through
his own employers,provided that such Improvements are not intended or offered fur NI?W RF,SID AL ELEKGZ SQ FT.
sale.If.however,the building or improvement it sold within one year nfcompletion.the SQ.FT.FLOOR AREA' vSQ.IT.
owner-builder will have the burden of proving that he did not build or improve liar par-
E)1,a soTOTAL
1,os ownewne r of the Pnspeny,nm exclusively contracting with IiccnseJ cnntructncr m
omuuct the prof«n(Sec.]014,Busssineand Prnl'G rinre CaxlcU The Conweror's i.i- l•/I 1JUL 1996
arse Law docs not apply to an ownerof property who builds or hoprovex thcrcnn.and QTY. Pl. MB IT FEE up
who contracts for such pmajects with a connaaons)I'acancd purseanna tht ConurnOnex LUNG
License Law. PERMIT ISSUANCE kV
❑ I am exempt under Sec. .H&PC for this reason
ALI'17R-DRAIN&VENT-WATER(EA) VALUATION
Owner Uure
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 herehy affirm ander penulry nfpurjury one el'the following doelurmimm,:
❑Ihaveandw'dl...main for Worker's Cnmpcn- DRAINS-FLOOR,ROOF,AREA,GOND. S'I OR117S TYPE CON59RUCTION
smion,us prnvidal for by Samoa 3700 of the Labor Code.Pose the performance of the
weak for which this pcnnit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
77110 of the labor Cade,for the Pcdonnanccuf the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.CROUP N'N
My Worker's Compensation Insurance comer and Policy number arc:
Cancer: Policy No, GAS-EA.SYSTEMOVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASIVINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This sceionnmd not he compliant]ifthe Permit is foram handled dollars($100) GREASETRAP
or less.) PLANCHECK FEE
I cenify that in the perGnmancc of rhe work for which this portant is issued,ishall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any reanner,o t a mbjat m the Worker'Cmanpen. ENERGY FEE
o Z lion lows of C � q y"1 � WATER HEATER WIVEN UELEC R
Z O ApPBcant ` 4.....�✓, GRADING FEE
h NOTICE TO APPLICANT,h,after making this enifcate of Exemption,you should WATER SYSTEM/IREATING
F ; become subject to the Worker's Compensation previsions of the Labor Code,you must SOILS ITE
fmnhwith comply wimatich pnrvisinns n,,his pcnnit shall he decimal revoked. WATER SERVICE
7z a CONSTRUCTION LENDING AGageCY NEW RESIDENTIAL PCMB. SQ.FT. PAID Date Receipt#
V 0 Thereby affirm that them isecomw«ion lending agency for the perfommanof
the walk for which this permit is issued(Sec.3W],Civ.C.)
0 F-' Lendcrx Name TOTAL:
W Ltances Addacss TOTAL BUILDING FEG
I certify that 1 have read this application and state that the above information is
F h Co.,.I agreed.comply with all city and county ordinances andme laws mining to QTY. MECHANICAL PERMIT FEE
C„) Z building construction.and hereby authorize repmsentztives of this city to enter upon the SEISMIC IEE
above mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep hamdt,"the pe
City of Cupertino against
ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way same againstsaid CityALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.1100 CFM) MECHANICAL PEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IO."CFM) CONSTRUCTION TAX
Signature nfAppiicant/Contracmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FF:E
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant m fated building occupant score or handle hazardous material HEATING UNIT CTO IWA00 BTU)
as defined by the Ca,mmo Municipal Cade,Chapter 912,and the Health and Safety
Calm,Section 25532mU HEATING UNIT(OVER 1 W,000 BTU)
E3 ye, [:I No VENTILATION FAN(SINGLE RESID) PAID
Date Rttcipmx
Will the applicant or future building occupant use ctimpmem or device,which HOLLER-COMP(7f{POR 100.(100 BTU)
rim hazardous air contaminants as demand by he Buy Arca Air Quality Management TO1AL:
Dirtied'
r 0Ye, F-1So BOILER-COMP(OVEH IIYJ,fy111BTU)
I have read the hazardous materia1v rcuiremcn U under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomite gHealthlow&Seerytly have
Sections 1,that,25577 and 25574. undcmmnJ thxt II mho NEW RESIDENTIAL MECH. SQ.PT.
buildingdoesrot cvrren0ybust Intenant,that Ixmyce of
clilycanomifythesparay. V
n[the reyuirnnnns which must Instruct prima to isxn;ume of n Ctrtiticae o(Uccupmey.
Owner or autheized agent Dom TOTAL ISSUE])BY:
OFFICE
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