S 0258 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD INO-ELECTRICAL PF7eNITN(1. 0258
BUILDING DIVISION APPLICATIONPERMIT PLUMBING-MECHANICAL J
INILDING PROJECT IDENTIFICATION
BUILDING ADDR�ScS: SANITARY NO, APPLICATION SUBMITTAL DATE,
ce 172
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OWNL' " MF' PHO 13: n CONTRACI'OR:S NAME: LIC NOj
L_ 2` 0. NIC CON ROLN
ANC{IIT CT/ENGINEER: ^ LIC NO: A RF.SS: ❑
N 1 y
C AQr`.M 4W PHONE: /-ti� BUILDING PERMIT INFO
"'77��// ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
gb�l✓G.�4 c S ZS' _o L �`
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
0:4Z wish Section 7(ItlO)of Division Sof the Rosiness and PmfesainnsCode,unJ mylicense is RESIDENTIAL'
LL O 1'13RMI'I'ISSUANCE.
W is full force and effectsS 15-
Z
S ❑SPDWI. 11 KITCHEN RE•MODGI.
�Upp Liceme Clu. contractor
APPLIANCES-RESIDENTIAL. []ADDITION [I PLUMBING RE-PIPE
F Z aj pate Cnmmmor
Nay ARCHITCC`CS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
t1rri�Z 1 un lmou nd my plans shall be used as public records MODIFICATION
OZ 1Ls OPT0200AMPS EJ INTERIOR DCHIMNEYREPAIR
[,�_ Licensed Professional 201-_I AMPS IMPROVEMENT DSWIMMING POOLS
yes± OWNER-BUILDER DECLARATION OVEk IIRp AMPg HREMODELREPAIR ❑DEMOLITION
r C G 1 hereby affirm that 1 am exempt from the Contractor's License Low for the
ON following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS HLECIRECAL OTHER
which requires a permit to conatrucl,alter,improve,demolish,or repair any structure
W C
poorto its ionmee,almrequims theopplicom forsuch perron tefileaeignedstatemtat SPECIAL CIRCUIT/MISC.
that he is license) pnrvlxin p
y pursuant to mnfine c.mmnew License Law(Cha tug COMMERCIAL:
� C 0 (commencing he is xempwith herefromon and of basis for oftheeged examphon.Any mo Code)of T13MP.MI3'fER OR POLE INST.
a Oo 1 that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDGIADDITION ❑DEMOLITION
L� Section103LS by any appliomafor upolin itsuhjec.s the applies",,,acivil penalty of POWER DEVICES []TENANT ❑FOODSERVICE
H ,y not mare than rive hundred dollars S500L IMPROVEMENT
Sap D1,as owner of the property,or my employees with wages mimic.,to crnnpensmion, SWIMMING POOL ELECTRIC
will do the work,and the summer is not interMedorolfered for sole(Sec.]DW,Rosiness C1 OTHER
~ and Professions Code:The Contmcmes License law does not apply to am owner of OUTLETS-SWITCHES-FIXTURES
6 3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not imendrd or offered for NEW RESIDENTilAVLECTR SQ IT. _
ma.If.however the building or improvement issold sidairmeycomeonplodom,the SQ.MPLWIRI5 $/SQ.IT.
wnerhuilder will have the motion of proving that he did not build or improve for pur- �YY A u
pose.f tele,).
D 1,as owner of the pmperty,am exclusively contracting with licensed ennnectols m IOIAL: JUL - as
construct the Project(Sm.7WJU 4,Business and Professions Code:)no Contractor's Li- Vd! v
cense Low does not applyram an owner of property who builds or improves thereon,and QTY PLUM P RMIT FEE /� (�
who cvmtcts for such prontmra
projects with a cnctor(s)licensed pursuant to the Contractors CITY 1 /I1 L
License Law. PERMIT ISSUANCE V r VV r`�r�N/s
❑lamexemptundm Sm. ,R&PCforthisrea n V
AMER-DRAIN&VENT-WATI3 Ili VALUA'T'ION
Owner UIO
WORnder p COMPENSATION DECLARA'T'ION BACK IH,OW PROTECT.DL•VICIi s /V_ I
thereby affirm under penalty to perjury one ofthefollowing decWorkers
(IYPE
(have and will maintain Selitim icme ofConsent toLabor Cod i,bathe
for
seflor seem er-(fie DRAINS-FLGDN,R00F,ARP.A,COND' STORIES 'I'YPF.CONSTRUCTION
eamnr,r nviJul for by Sedinn 3]Igl of me Labor Cale,for the�rlimnancc of the
w r hick this permit is issued. PIXTURp,-PER TRAP
have and will maintain Worker's Compensation Insurance,as required by Senior
3]11(1 ofthe Labor Cause,for the perfammme ofthe work for which this pcomil is issued GAS-EA.SYSTEM-1 INC.J OUTLETS OCC.GROUP APN
My Worker sari Ins -epg*ir
cand Policy ytrfpr.r a-,ab/tg� _1
Cartier, g"y Pelic ,9 GAS-EA.SYSTEM-OVERYIRA) /try
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASI'IINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE B%LW DIVISION FEES
(This section most nm he completed Bae pemtil is for one hundred dollars IS I W) GRF.ASETRAP
or lets.) PLANCHECK FEE P.
I certify that in the Performance ofthe work for which this pmmil is issued,l shall SEWER-SANITARY-STORM 13A.200 FT.
not employ any person in any Insurer so as hs become subject to the Workers'Compen- ENERGY FE
union Laws.[California Door WATIi1t HEA'I'Iik WIVHN'DEL F.C'I'R GRADI :E
sz Applicurt
way NOTICE TO APPLICANT:If,after making this Ctnificma of Exemption,you should WA'I'17R SYSTEMOREATING
become subject to the Worker's Co opensaion previsions of the Latin Crate,you most S011 S FL'
{CSK7 forthwith comply with such pmvisionsm this permit shat[M decared revoked WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RIiSIDLM'IAL PLMH. SQ.FT. PNU
L10l hombyaflimr that mete iso construction lending agency femhe pmmonence of Dim Rcceipla
the work for which this pormil is issued(Sec.3097,Civ.C.)
ULenders Name TOTAL
U Lenders Address TOTAL:
1 cenify that I have rend this application and state that the"hove information is HUILDIN FEE
55l) con"M 1 agree to comply with.11 city and enmmy ordimmmex and s,me Iawx reining m Q Y. MECHANICAL PERMIT FEE It
V Z building conmmction,and hereby autharim representatives of this city to enter upon the SEISMIC 1d
uMwe-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cnpenim against ELECTN C FEE
Iiabililies,judgments,costs and exNnms which may in anyway aceme against said City ALTERORADDTOMECH' PLUMPING E s
inconsequence of the granting cations permit. a Is
AI' IS, UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.00i'CfMI
S( C GULATIONS. MECHANICAL F.
S, C, "U'AT'ONS2
AIN HANDLING UNIT(OVER[II,IKIII CI'M) CONSTRUCTION X
Si mare of A,phmrt/CmImcmr Dno, HXHAUSTHOOD(W/DUCT) HOUSING MITIGATIt FEE
HAZARDOUS MA'T'ERIALS DISCLOSUREi
Will the applicant or Rare building occupant more or handle timorous remand HBATING UNIT(TO 1011,000 BT 1I)
us J6mil by the Captain.Municipal Cole.Chapter 9.12,and the Health and Safety
Code.Section 25532(a)Y HEATING UNIT(OVER If a),00d BTID
❑Yes Chin VRNTILATION FAN[SINGLE RES I DI PAID
1� Will the xi,jicam or future building occupant use clImpnorm or devices which Dam ill x
emit hnerdous air ocautur roma as defined b me Be Area Air Quality Management BOILER-COMP(3HP OR 100.000 BTU)
Y Y Y TOTAL: l
Dimim] BOILER-COMP(OVER 100.0110RTU)
❑Yea No
I have read the hcelimusmaterial,requirements under Chapter 695 of Ilse Cali- AIR CONDITIONER ISSUANCE:DATE
Ire'a Hwlm&Safety lisle.S Minns 25505,25533 and 25534. unJerstanJ that if the NEW RI'SIDEN'TIAL MHCIi. SQ.PP.
h ngJce,nm curtentlyhav mnan6 mm it is my resrymsihility tenntil' the ewcupant
s m meets which he met tion ertifjyk�tR arc.
( net or aumonzed agent // Doe TOTAL: ISSUED BY:
OFFICE
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