31333 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO3
. 31^ 3
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG-MECunNICAL �KJ JK 3 V{
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O -�,9 V1 -erVlw LA b , IOU
OWNER'S NAN4 PHONE: CONTRACTOR'S NAME: LIC NO.
LL `, \ ) ✓. �S� O N/C COM'ROLg
ARCHTTECF/ENGINEER: LIC NO: ADDRESS: V ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
� ❑ ❑ ❑
LICENSED CONTRACT'OR'S UECLARA'1'PON QTY ELECTRIC PERMIT FEE
1 hereby ullinn then I am licenxrd under provisions of Chapter 9(commencing JOB DESCRIPTION
��Z mSection]fN10)of Uivonam of the Buxinesx send Professions Code,and mylicense ix RESIDENTIAL:
in full force send e�JRR t. PERMIT ISSUANCE
AVE" [.teems Clens lc-�— Lic.p LIZ 5-`C.)O G ❑SFDWL [I KITCHEN REMODEL
Q U ���� APPLIANCES-RESIDENTIAL ❑ApDIT10N [I PLUMBING RE-PIPE.
FFi Z L Dale Contractor�N I!f,,f
ARCHITECTS DECLARATION ❑MULTI UNIT [I STRUCTURAL
p.DN PANELS
Z n Z 1 understand my plans shall be used as public records MODIFICATION
OZ—� IIP T02(0 AMPS El INTERIOR [I CHIMNEY REPAIR
M W Licensed l'rulessin Out 2(11-11X0 AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 10OAMPS ❑BATH REMODEDREPAIR El DEMOLITION
Q I hereby affirm that I um exempt from the Contractor',License Law for the
edC E U following reason.(Section 7031.5,Business and Professions Code:Any city of county SIGNS ELECTRICAL ❑OT HEk
which requires a permit m construct,alter,improve,demolish,or repair any structure
l i:0q pd., issuance.also cocaine,me ap,licaml'or,uch permit m filcasigned,mmmcm SPECIAL CIRCUIT'/MISC.
SMy that he is licensed pantion .,heptrosmati-d the Counci 's License Los(Chapter 9
ad 0.0 (commencing with Section 7")of Division 3 of the Business and Professions Code)(it 'IHMHMETERORPOLEINin COMMERCIAL:
6 iaG K mnm
at he is exnpl Iherefruand me basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION (3 DEMOLITION
W2n y Isaion701 LS hyany applicant lot a permitsubjects the applicant m a civil penalty of POWER DEVICES OTENANT El FOOD SRRVICE
not more man five hundred dollars($50E.
.F.Z i IMPROVEMENT
Lo the work,and
propcactim not
intended withwagcsos (Sm.
compensiiess SWIMMING POOL ELECTRIC
W will Jothewon,ande The,Connector,
Limdnrowdoeffered s r nale,apply 70,W,Business
[j OTHER
KF o
L3 adProfession,hio b Code Theove,menet Licenselaw,esusnotapply himself
ownerof OUThEI'S-tiWITCHF,S-FlXTURES
his nwy who builds rot improves thmOlf i and who Jsa such work himsd(or through
his own oweverces,provided]that such improv sold o are not iyearofi n oBemJ lin NEW RESIDI!NTIAL IiLELTR SQ FT.
ownia,howeveelhess,the burdingor enpmvement isat be
non wild or improve flat
SQ.FT.FLO &gQ.PC
pocer-huildvr will have m,•burden of proving that he Jid not build or improve Bu pur-
id'saleJ.
C31,as owner of the property,am licen
exclusively contracting with sed contractor,to TOTAL: ■Vp�/:��
mswn the protect(Sea]M4,Business and Profession,CoMe9 The Conuacmis Li-
c ¢Law does not apply to an owner ofpmpeny who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
ho contends f,rsnch projcma with o cnmrucmrls)licensed purmant m the Contractors r
VV!
License Law. PERMIT ISSUANCE 1, Ur.
V
I am exempt our,Sec. .B&P C for this reason
Owner Data ALTER-DRAIN&VENT-WATER i�B VALUATION
•
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT.DEVICE
I hereby
andwaffirm under penalty of perjuryoneofthefollowing declarations:s
Ihave...Is..wialfornainaCenifcae of he Li no self-insure foreffmacs Contain- DRAINS-PhOOR,ROOKAREA.COND. STORIES TYPE CONSTRUCf10Y
worn,os which this
for by Sermon 3]1X1 of the Lobnr Cade,for the pn[onnuncc of the
work for which this permitis ink), FIXTURES-PER TRAP
11 I have a0)will maintain Worker's norm of the w Insurance, h required by Section
J/W of me Labor Code,litnhe perfannance of me work for which this prtnnit is issued. GAS-EA,SYSTEM.I INC.JOUTLETS (K:C,GROUP AI'N
My Workq CJ+mpcnsI Insurance carrier and Policynu bcrv¢
Cartier:STHTu i—rau A Policy Nu.:/4cs,r--I^ GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATE OP EXEMPTION FROM WORKERS' GRIiASI%INUUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thisseaimitumd not he complemd if he pc unit i,for one hundred JuBar.,61(01 GREASE TRAP
nr Iess.J PLANCHL'CK Nf?li
Icenifythat in the perfortnunce ofthc work for which this p:rminnissued.[,hall SEWER-SANITARY-STORM EA.20)IR.
not employ any person in any m iumn-,o a,,.been nc objafto the Workers'Compcn- ANERGY FEB
O Z 'wino Laws of California.Dam WATER HEATER WNEN MLECTR GRADING FEE
Z Applicant
NOTICE TO APPLICANT:If.alter making this Cenifcate of Exemption,you should WATER SYSTEMOTtEATING
became,object .,he worker,Compensation poolkion,of the Labor Cods, no most SOILS ME
forthwith comply with such provisions or this permit%hall be deemed revoked WAI ER SERVICE
Z. CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL PLMB. SG,FT. PAID Date Remits a
L) Thereby affirm that there isaronswdion lending agency for the perhsrmancc of
rthe work Our which his crant is oniol Sea 3(9].Cl,C 7
Cs TOTAL:
ULender's nd 's Name
LJ Lender,Addass TOTAL:
�s CLI BUILDING ItiE
rL. 1 certify mm I have mad thirty and coup and state that the above information is
Z building agree to comply and with all cityand countyyounivesces and itytame la r upn the QTY. MECHANICAL PERMIT FEE
LJ Z building cmnstrvnion,send M1cmhy umhuriw rcprcmntwivcs of this Citymenterupm the SEISMIC PEE
those-mcntioneJ progeny for in,pection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify amt keep harmless theof City Cupcnim,against ELECTRIC FEE
Iiahilities,judgments.costs and exPenses which may many way ammo against said City ALTER OR ADD TO MECH.
PLUMBING ITE
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY W11 If ALL NON-POINT AIR HANDLING UNIT(TO 10.00)CFMI
SOUR REGI TMECHANICAL PEE,
IONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signature of APPlicannCommcmr Uam �l EXHAUST HOLD OVIDUCT) HOUSING MITIGATION PER
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant(it more buildingrwcupant sore or handle hazardous mmcrial HEATING UNIT(1'010LOM BTU)
us define)by the Cupcnimo Municipal CWe,Chapmr 9.12,main,Health and Safety
Code,Section 25532(a)? 1117ATING UNIT(OVER 100,000 B]T)
❑Ye, ❑No PAID
VIi'DILMIONFANNINGLERESID) Date Rmcipta
Will the applicant or future building occupation use equipment or devices which
emit harardnus air contantinams as defined by the[In,Area Air Quality Management IlO1LER-COMP OHP OR 10111011 BTU) TOTAL:
District? BOILER-COMP(OVER 10000)B'TU)
❑Ya Fl No
I have read the hvnrdous materials mquiremena under Chapter 695 of me Call. AIR CONDITIONER ISSUANCE DATE
forma Health&Sandy Code,Sections 25505,25533 unit 25534.1 undersand that Taw NEW RESIDENTIAL MECH. SQ.FT.
building does not euacn0y have a uni t,Ebel it i,my responsibility to notify the occupant
of the requiremenu which must he met prior m issvanum of a Cmificate of IRcupuncy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE