29627 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P17RMIT NO,
BUILDING DIVISION APPLICATIONATERMITPLUMBING-MECHANICAL 29627
BUILDING PROJECT IDENT'IF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
/ O.3 / 7 /j7144 illi M aA•D U( v1Z l(:.
OWNS 'S NAME PHONE: CONTRACTOR'S NAME: IC NO:
GLva&H M L � l H NIC CONTROL#
%RCIE DicLY GIINEER: LIC NO: ADDRF_SS. ❑ 1 J'�
� f A 15y6s. Dk 42vz4 &wv. op mw- `v
CONTAC'B PHONE: BUILDING PERMIT INFO
a..0 Q/��i/ ❑ Conss iLTnt Fees Paid by Applicant(Initial) Bk ELECT. PLUMB MECH
tat ,LLIICE/NGSEDDICONfRACfO(R'S DECLARATION QTY. ELECTRIC PERMIT FEE IF—C'I(_t ❑ ❑
1 hereby uffinn that I ma licensed under pmvisions of Chapter 9(commencing JOB DESCRIPTION
WCZ with Section]IN10)of Uivision3.I'the 11 moss and Pmfcxsi.rt Codc,mm,uy lwease is RESIDENTIAL:
O in fullforee vn Icftea PERMIT ISSUANCE
�k.UE) Licenx a Lica ESFDWL D KITCHEN REMODEL
yGi Dam�Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT DSTRUCTURAL
H r� PANIiLS
Z O',�Z I undersmnd my plans shall parsed M Public records MODIFICATION
11FTO 230 AMPS
❑ ❑INTERIOR ❑CHIMNEY REPAIR
r„'!„('^w Licensed Pndissinnnl 201-100 AMPS IMPROVEMENT
5��d �4 OWNER-BUILDER DECLARATION OVER["AMPS D BATH REMODEURFPAIR 0DEMOLITION
f�,a 1 Lamb,affirm that I am exempt to.m the Contractors License Law for the
k36U following resume.(Section 703 IS,Business and Professions Code:Any city or county SIGNS E=RICAL DOTTER
LLLL]]
OJ 0u[- which requires permit m mnstnet,viten improve,demolish,or repair any strucwre
pF prinrto its issuvnce,also requites the applicant for such permit t.file stigma]statement SPECIAL CIRCUIT/M ISC. / ipgrs) „�s�
X y.7 Nm he is lirs
omcd puuau
no theprovisionsofthe Commnnr's Lice nee law(Chapmr9 ' •oO _
LLCI Q0 (w..... ng with Samion llXNl)Of Dlvlslon3oftho lluxim,,wrd Profession,Code)to TEMP.METER Olt POLE INST. OMM R IA
that he is exempt therefrom and the basis for me alleged exemption.Any violation of D NEW BLDG/ADDITION D DEMOLITION
+ �no Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of POWER DEVICES ETENANT ElFOOD SERVICE
not more than five hundred dollars($500).
GDhes Owner of Ne moperry,.nny employeeswith wages as Neirsoleennpensatioa SWIMMING POOL.ELECTRIC IMPROVEMENT
will do the work,and the swcmm is not intended or offered far sold Xer.]Oil,Business ❑OTHT:k
W 3 and Predications Cash:The Conarrun's License Law docs nm apply to as..at,of OUTLETS-SWITCHES-FIXTURES l
p,.Perry who hands or Improve.,ihermn,and who docs much work himself or through
his own employees,provided that such improvements arc not intended or oBered for NEW RESIDENTIAL ELEC R SQ FT.
sale.IL however,the building or improvement is sold withinone yearofcumpletion,the SQ,FT.FLOOR AREA VSQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of svleJ.
D I,as owner of the property,am exclusively contracting with Iirensed contractors to �. L �• v'
conswcnhe project(So,7(144,Businets and Professions Con,to.ConoactOrs � 199(x`
term Law does nut apply loam owncrofpmpeny who builds orimprovetihcamn,and QTY1\11UMBINC PERM IT FISP. V
who contracts for such projects with a enntmetor(s)licensed Pursuant to the Contractor's (]
License law. Pit ISSUANCE? ` (]
❑lam exempt under Sec. ,B&PCfurthismason s"I liar{I�r"e
Owner Dem AI.TF.k,D At VENT-WATER LEA) f. Y V^' VALUATION
WORKER:SCOMI'ENSATIONDECI.ARATION RACK FLOW PR 'C'1'.DEVICE 11� 1 M�s#y�
I huode
ereby union Penalty of perjury ane of the following declarmiont: o cr
D lhave and will mnimnin aCenilicure ofConsenuo sdf-insure for Workers Compen- DRAINS-FLOOIL EA,COND.
action,as Provided for by Section 3700 Of the labor Code,for the performance of the STORIES TYPECONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
D 1 have and will maintain Worker's Compensation Insamnce.as required by Section
37W ofthe Labor Code,for the performance of the work for which this Permit is issued. GAS-EA.SYSTEM-1 INC.40U'1
My WorOCC.GROUP APN
Policy Nnkcu�artie Policy are: OAS-EA,SYSTHM-OVER4(EA) x`
Carrier. �a Poli .:
C17RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRL'ASFIINDUSR'HI.WASTE INI'LHCEF"IDR
BUILDING DIVISION PL'ES
(This section mednot hm
ecapleted ifthe permit is(mane hundteddollars IS IN)
or GR
leu.) FASETRAP PLANCHECK FEE
I cenify thatmine performanceof,he work for which this permit is issued.I shall SEWER-SANITARY-STORM F.A.2, .1..
not employ any Person in any manner so as to become subject to the Worked
Compen- ENERGY FEE
zz town Lawn mf Culifomia.Dam WR'I'ER DEALER WNENT/F.LF.CTR
0 Applicant GRADING PER
V) NOTICE TO APPLICANT:If,atter making this Certificate of Exemption,you should WATER SYSTEMTTRFATING
a' become subject to the Workers Compensation previsions of the Labor Code,you most SOILS FEE
forthwith comply with such pmvisinmor Nis permitshill bedeemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLh1N. SQ-!>O PAID
L) k for
nniha0here isucol IS.,3nlending agency forthe Performance of Dam Receipt#
0 o-+ she work ha which this pemtlt is iasrmd(Sa.309],Civ.CJ
F•" Lenders Name TOTAL:
Londe IAddress •fOTAL:
I certify thvt I have mad this application aM stem that dm above information is ILDING FEE �
VV) correct.Iag.to,cmply with all city and county mdinanccs and stem laws rdming in QTY. MECHANICAL PERMIT FEE
L) 7 building consuuciinn,and hereby ammoniac representatives Ofthis city to enter upon Ne SEISMIC FEE co
above-mentioned pmpeny mf irupeeion l urta set PliRMIT ISSUANCE
(We).9.to save,.indemnify and keep Immdess the City of Cnpenina against Ei,l?CI'RIC FEE
liabilities,judgments,costs and expenses which may in any way aceme against said City ALT ER OR ADD TO MECH.
were Of the gmmimg Of this Permit PLUMBING FEE
APPLIC,qT UNDE TANDS AND WILL COMPLY W TH ALL NON-POINT AIR HANDLING UNIT(TO I0,00)CFM)
SOURCER .UL NS. MECHANICALFEE
✓! /l/ AIR HANDLING UNI'FLOVER 10.000CFM)
„L 7 '7.G CONSTRUCTION TAX
Sigrid A, rrrt/CmIm Date EXHAUST 11001)(W/DUC'17) HOUSING MITIGATION PCL'
HAZAR RIALS DISCLOSUR
Willthcap icant or future building occupant store or handle haromou.material HEATING UNIT CFO I100,000 BTU)
m defined by the penin.Municipal Code,Chapter 9.12,end Ne Healthend Safety
Code,Sutton 25532a)? HEALING UNIT(OVER 100,000 BTU)
❑Yes &tv, V17WILATION PAN(SINGLE RESID) PAID
Will tiro applicant or future building occupant use equipment or device%which Date Receipt#
catit hvmNons air contaminants as defined by the Bay Area Air Quality Management HOILRR'-COMP(31111 OR IN,"13 TO,
TOTAL:
District /
❑Yes BOILER-COMP(OVER 100.00 BTU)
' 11f•'"
I have must the havallousmunials requitetams under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Rom.builds does&Svfety Code tlyhaea tinan25 alit 25533o..25534.I umlersmnd thatif the NEW RESIDENTIAL MCCH. SQ.PT.
hnildingdoesnmcunemly have a tectum,thato ismyecof a ertiycanotifythepancy.:tm
of the requiremenn which must he met Prim m issuance of n Certificate of Occupancy.
Owner m umhosisd agent Ilam I ITOTAL: ISSUEDBY.
OFFICE