99120123 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL f Q q PF
BUILD11GG DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJ f:C'I'IDF.NI'IFICATION
B INC'.LDADDRESS: SANITARY NO. A ATION SUBMI 17AL DATE
WNIi 'S NAME S PIIUNE: '� „7 WN'IHAC'OR AME: LI O
CHII£CT/ENGINIiHR: LIC NO: ADDE.Ski w / ❑
CON'I'ACC PHONE BUILDING PERMIT INFO
73q_0_% ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ z g 1*5
LICENSED CONT'RACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby are",that 1 am licensed under provisions or chap",9(commencing JOB DESCRIPTION
Z hSectlon 9000),4Uiltood 3ofthc Rusin...and Pro,1mr,Code.and my llccn�w is RF I
C
Z0 rt I'IikMIT ISSUANCE SF n fall forecast eBa /(1 G tel,•• ( D ElD El KITCHEN REMODEL
aVU License Claes Lica APPLIANCES-RESIDENT'IAL []ADDITION ❑PLUh1BING RE-PIPE
F Z WDam Gmtmaor
tn<y ❑MULTI-UNIT ❑STRUCTURAL
F7H ARCHITECTS DECLARATION PANELS MODIFICATION
Z 0?, I undemono my plans shrill be used a.public records lll•T02W AMPS
OZ—O C1 INTERIOR El CHIMNEY REPAIR
I Licensed Professional 201 ["AMPS IMPROVEMENT (3SWIMMINGPOOIS
CYC;
OWNER-BUILDER DECLARATION
OVER]"AMPS I ❑BATH REM DELMEPAIR [I DE hITION
3y:C C Q I hereby affirm that 1 um eaatnpt from the Comraaors License Law for the
xi L U following reason.(Section 91131.5.Business and Prol'esxinro Cade:Any city it ,army SIGNS ELECTRICAL ���
W LL N which requires a permit to constmek cher,improve,demolish,or repro,any atmcture Al G
1 LL'0 prior m its issuance,also requires the applicant for such permit to file a signed sm¢ment ' SPECIAL CIRCUITIMISC.
Ey�P thathcislicenecdpursuannothe provisions of the Commaur's Licenulaw(Cb.Pmr9
W a��O (commencing with Section 7000)or Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE[NST. COMMERCIAL'
d(y e that he Ix exempt the,bore and the basis for mm alleged esnothin i.Any viollcun ul ❑NEW BhDOIADUITION ❑DEMOLITION
x^J� Section 911315 by any applicant lota permit subjects the applicant rot u civil penahy of YUWER DEVICES []TENANT ❑FOOD SERVICE
not mom than five hundred dollars(5500). 4KIMPROVENUENT
SSG E] of the propcny.ar my onfloyee.with wages es their xde compcnsntion. SWIMMING FOOL ELECTRIC illip
%F, will do the work,and the soa
uure is not intended or olfmmd for sale(Sec.70at Business OTHER
3ocand Processions Cade:'The Contractor's License Law does nm apply m an owner nI OUTLETS-SWITCHES-FI%TURES
property who builds or Improves thereon,and who does such work himself or through
his own cmployces,fmvidell that such improvements art not armored or offeredfor NEW RESIDENTIAL ELECT R SO ET.
sale.lLhowect thebmidingorimprovement issold within onlyearofcompletionthe (� FLOOR AREA LSQ.FT.
owner-huilder will have the burden of proving that he did not build or improve for pur- ///) V
prem of vale.).
1,us owner of the property,am exclusively contracting with licensed eootmetnrx m TOTAL:
nstrvn the project(See 7014.Business and Professions Qsle:)'I ne Coneducmrn Li- DC`C f49 1
cD
ese ma
nLaw does t apply to an owner of pfopcnp
y who build,or implores thereon."it QTY. PLUMBING PERMIT AA
who commas for suith a '/999
ch prycco,w
,amarchadO licensed pursuant m that Conn.,.,', I
Lionne[,ata. PERMIT ISSUANCE R„
r7 1ant events under Sec. .H X1'CI fle,reason
ALTER-DRAIN&VENT-WATER(EA) ` VALUATI N
Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE _
have
met will or In
Inde(pemahy or pmrjory ro n, the followinane log Workers
s ..; H
❑ Urns and wief..b ineCcn 3700of Con cern"Cog,
Wnrkmance fEe DRNNS-PLOOk,ROOF,AIU3A ONUS S'TUkIPS l'YI'BCONSTNUCI'ION
cation,as provided for mi Section 3900 of the[rMr Ct-0e,for the performance of the
ws9k for which this perms is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insmmnex,as tortured by Section
)OoRhe Labor Civil,far the pndomamit nceofthe nark foo which thin peris issued GAS-EA.SYSTEhI-1 INCA OUTLETS OCC.GROUP APN
My Worker' npct sutiylt' ecvta folie, lieyewWtTt�rb7&3a7M (EA) A2
MyW Vi_ ourr olimyolicy Ci U V'1 GAS-LA.SYS'1£M-OVEk4J
CERTIFICATE OF EXEMPTION FROM WOR KERSGREASF/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This seen i need not he eomplemd if the permit ix nature hundred dollar,(S 100) GREASE TRAP'
nr Ices.) PW NCIIfiCK FEE
I cenifythm iothe ferfbmuncc ofthework l'nrwhlchthis permiton,tred.[,hall SEWER-SANITARY-STORM EA.20X1 IT.
not craft,Boy Terns.in any manes,so os to became subj,a m the worker:Conifer- ENERGY FEE
Z cation Laws of California.Date WATER HEATER WNEf LELECTR GRADING FEE
z O Affluent
z NOTICE"10 APPLICANT:IF a11cr making this Cenillcam of Exemption,you nhnuld WATER SYS"I EMn REA'TINC, SOILS FEE
heamtc subject m the Worker's Compensation provisions of the Lubar Coda you must
C'
UJ forthwith romply with such pmaa...ort his pemmilshell be deemed revoked WATER SERVICE
0
� zCONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.FT. PAID
V [)—am Remtpta
O Thereby n(erm ohm there ixncondmctiun lending agency for the performm�ee of
f-x the work for winch this 1'mrmn o"sued(Set.3097,Co.CJ
OU Lender's Name TOTAL:
} W Lenders Address TOTAL:
6. 1 sanity that I have read Nis application and arm that the above information is BUILDING FEE
F to
correct 1 agree to comply with all city and county od inances and state laws relating to QTY. MECHANICAL.PERMIT FEE
L) Z oteldingctvc
osnannon,and hembyeall irelac,namosr,at this city memup e, ithe SEISMIC FEE
aMwearnationed propmny for inspection purryucs. PERMIT ISSUANCE
ELECTRIC FEE
(We).,.,a.arc,indemnify and keep hnnnlcss the City of Cup ndin r against
habilit,c,.,udguncrus.costs and ex rise,which may in any way accmc again.uaid City ALTER OR ADD TO SUCH. PLUMBING FEE
to c ..equcnaoftbe,,emirso t ispermit.
APPLICANT UNDERSTAND. ND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(I()10.000)CFM) MECHANICAL FEE
SOUR :REGULATIONS.
" AIR HANDLING UNIT(OVER 10.0011 CFM) CONSTRUCTION TAX
arc of Applican,Cut v Dnm EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEB
IIA%✓sRI Y S MATERIALS DISCLOSURE
Will the applicant or f ore nlldingaeeupantsmreorhandlchazallomsnmterial HEATING UNIT(TO I(mBm BTU)
as closed by that Cancrum ani pap Code.Chapter 9.12,and the Health and Safety
Gyle.Section 255326x1' HEATING UNIT(OVER 100.000 BTU)
C3 Ycs VENTILATION FAN(SINGLE RESID) PAID
he Rmceiptx
Will the...than or furore hailding occupant use rqt iponem or devices which BOILER-COMP(311P OR I(q.(Xq BTU)
emit haamdous air contaminants as detinsd by the Ray Area Air Quality Management TOTAL:
District'I ./ BOILER-COMP(OVER 100.000 BTU)
❑yes N(Na
I have mad the hacomet s ncerrlalc is under Chapter 695 of the Cali- 1' AIR CONDI I'I ONES ISSUANCE D 7'I,
rc.2553 cis P
Etmia lbsulthore,&Safety b lint cations 25505.25533 and 25500.1 understand dead the NEW RFSIUI:N'TIAL MECH. SQ.FT.
building Jcec not<urmntly bare a¢tea ,thtt it is my rtsponzihiliry et notify dte twcupum
of the rt ti encots which must be me poor t is of a Cenificmc f Omt ancy. -
Owner rauto iced agent Date TOTAL: ISSUED RV'.
OFFICE