30074 APPLICANTTO FILL,IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL; PERMTTNO, OO
BUILDING DIVISION APPLICATIOWPERMIT PLUMBING-NIECHANICAI.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - . 'SANITARY NO. APPLICATION SUBMITTAL DAT
at 8j ' Kv,'e-w' 4a&1e-
OW ERS NAME://'' PHONE: COM'RACTOR:S NAME: LICNO:
14am h '2-SS-813 D NIC CONTROL.
�RCHIT /ENGINEER: LIC NO:r ADDRESS: ❑
CONTACT: - •PHONE: - BUILDING PERMIT INFO
❑ Consultant Foes Paid by Applicant(Initial)' - RID ELECT/ PLUM n1ECll
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I bercny up..a mm 1 am licensed ander proxi,ionx of Cb,im,0(commencing JOB DESCRIPTION
W0z with Section]1N0)of Dmisiva Sof Ne Businexsardl Profesiorm Crir.aoJ my hremels
Fw= and�� in full force d effect.' ' PERMIT ISSUANCE
•aLianas Class Lir. _ � SFDWL G KITCHEN REMODEL
6 U r APPLIANCES—RESIDENTIAL
w Date Commucun ❑ADDITION [-I PLUMBING RUPIPIi
G _ _
PANELS
[—.pN
ARCHITECTS DECLARATION - 0MULTI-UNIT OSTRUCTURAL
, -
z O y rrme at,Ama
Z 1 undenr shall be uxd as public records MODIFICATION
UPTO 100 AMPS
Qz�O - [I INTERIOR ❑CHLMYEY REPAIR
Licensed Professional 201-II00AMPS .IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH RF.M DF.I/REPAIR ❑DHMQI'FHON
Q 1 hereby ammi on 1 em exempt from the Conuacm of Licence Taw for the
XO6U following remoa(Seaion]lIJ1.5,9u.iness and Protessinnx C,NC Any city or rountySIGNS ELECTRICAL []OTHER
Y131a, which squires a permit to concord.alter,improve,demolish,or repair any structure - t
f�LL•OQ, poor to its issuance.also requires the applicant for such Permian file a signed statement SPECIAL CIRCUIT/MISC.
ttyyyyy that he is licensed pursuant to the provisions ofthe Contractor's License Low(Chapter 9
COp fcommencingwith Section V(NNprf Divisinn3 of the Businessvnd PmmWun.s CmR)or TEMP.METER OR POLE INST i COMP' ��
d 6 c C that he is exempt thertfmm aaJ rhe at for the alleged exemption.Any violaion of •9 9TNEW ❑DEMOLITION
x5d 4'
Section 7031.5 by any applicant for a perme appm
it subjects the a civil penalty of POWER DEVICES
u]�y - []TENANT ' ❑FOOD SERVICE
t more Nan Eve hundmd dollars($51X16
FZY V IMPROVEMENT
_< n Lax owner of Nepropeny,or my employees wird wages mthcir(Sri,
cumpcmmtion. SWIMMING POOL ELECTRIC
WL2 will do thework,nnJ No-sirvcuuc is nm intenJul nndlercA for.v1 apply to an Business ❑OTHER
13 and Professions Code The Contractor',License Law does not apply n,an owner of OUTLL"IS—SWITCIIIiS—FIXTURES
property who builds or improves thereon,and who does such work himself or through -his own employres,provided tbn such improvements arc not intended or offered for NEW RESIDENTIAL ELECPR SEPT.
sale If however.the building or impoo,scumant isId within one year cdcompletion.the SQ.Fri. O S/SQ.FL
crb Id willhave Ne burden of proving th in he,1J not build p f par- /1
pose of 1 - - TOTAL: '
1,a. f thepapery,am exclusively contracting' with licensed scontractors,to - _
construct the project(Sec,70,14,Bus nos and Professions Code.)The Contractors Li-
ceme Law dtesnotapply tom,owncrot property who bunds or improves thcmou,and QTY. PLUMBING PERMIT FEIi
who contracts fur such projects with o contmclodspicenuJ punuitto the Convector's
wL,. anne
License Law.mpt u
Ip
l v exender Sce. ,1{&P C far dots reason PERMIT ISSUANCE 6 V
1
Owner
n . ALTER—DRAIN&VENT—WATER(EA) - VALUATION
2
WORKCOMI'E SAI'10N DIiCLARAI'IONT^ BACK FLOW PROTIUL DEVICE 2710?�5�
1 hereby aRrm under penalty of perjury ane of the following Jttlamtions: _
I have and will maintain u Certificate ofCcownuo self-insure for Worker'%Camper- DRAINS_—FLUOR.ROOF,AREA,COND. - STORIES TYPE CONSTRUCTION
aahon,as provided for by Section 3]W of the hahor Code,fon the pcdornianca of the ,
work for whichthis Permit is iss.ad. FIXTURES—PER TRAP $Ep 25 996
❑ 1 have:rad will nmintain Worker's Compensation Insurance,m required by Section
3700 ofthe Lavr Code,for the perl'onwnce of the work for which this Permit is issued. GAS—HA.SYSTEM.1 INC.4 OUTLETS , OCC.GROUT' APN
My Worker's Compensation Insurance carrier and Policy mother are:.
Carrier Policy Na: GAS—EA.SYSTEM-OVER 4(F.A) VII t Vf UW L fl11\./
CERT1171CATI:OF EXEMP'T'ION FROM WORKERS'
COMPENSATION INSURANCE - GREASEIINDUSTRL WASTE.INTERCEPTOR
BUILDING DIVISION FEES
(This section aced nm he<ompldW it du, is fm moa hundmlJallurr(81(NI) _ ,
or[card � GREASE TRAP � I'LANCHECK FEE G
Loy any Natinihe peafformance any
work for which this die W ekes'Counter. SEWF,R—SANITARY—STORM EA. FT.
not employ any Peron in tray manner en us m breams nohjeei n,the Workers'Compen. ENERGY FEE?
O ,Z sanon Laws of California.Date WATER HEATER wNENTE-LECTR GRADING FEE �aT
z 0 Applicata v •✓4
=
N01 ICF TO APPLICANT.IL after making Nis Cerll cam of Exemption,you should WATER SYS'I UNFTREAT1NG
F , become subject to Nc Worker's Cooperation f the Tabor Code,you mus SOILS FEE ..
C 1 psora provisions o
� w•, forthwith comply with such provisions or this permit shellbudeemed revoked. - WATER SERVICE -
.� Q ^ „ -
CONSTRUCTIONLENDINGAGENCY NEW RESIDE- AI.PLMB. SQ,FT. PAID
2-916
U X - Date Raciple
V Q work
which
his Permits at iso issued
lending agency for the performance of s
the work for which Nis permit is issued(Sec.J1ri7,Civ.C.1
Lender's Nanta TOTAL:
(U Lender',Address - - TOTAL: A13,10
1 ceniry that 1 have read Nis application and state Nat the above information is BUILDING FEE
Ncorrect.l agree to comply withal[city and county ordinances and state laws raising to QTY. MECHANICAL PERMIT FEE
U Z buildmgconsmction.and herebyawhoozerepresenmtivesy( citymenmruponthe SEISM IC FEE a
abuse-memimmal groped,farimpectionph,poes. q
(We)agree m save,indemnify and kap harmless Nim
e City of Chahar.agat PERMIT ISSUANCE 3� EL[CTRIC ItiE G
Iiabll ities,judgmenm,costs and expenses which may in any way occom,against said City ALMRORADDTOMECFL �
in cunsequemce of the granting of this permit aPLUMBING FEE
'. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO'1O,WCFM) MECHANICAL ME a�
SOURCE RT:f,UI.ATIONS. ti _
ATR HANDLING UNI]'(OVER 10.00)CFM) - CONS'TRUCI-ION TAX
w e ak q
Sig-a ore of Plicam/Conldcrar ...Date EXHAUST HOOD(W/DUCT) - �4�Is1/ HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant some or handle harardous material HEATING UNIT(TO 100.000 RTU)
as Jeri tied by the Cuyenino Municipal Code,Chapter 9.12,and the Ilcahh and Safety
Code,Section 25531(x)9 ' HEATING UNIT(OVER 100.100 BTU) . .
❑Yes r ❑Nn G� O PAID
VENTILATION FAN SINGLERESIfII Dan Rr rips R
will Ne applicant m future building(ccupit use cyuipmem or devices which
t hazardous air contaminants as defined by the Boy Area Air Quality Management BOILER—COMP(JIfP OR IIXhfIW RTU)
rd
�Disrict9 - s i TOTAL:
❑Yes ' ❑No ' s BOILlils—COMP(OVER 100000BTU)
I have read the harual motermle m mrarreux under Chapter 695 of the Coli AIR CONDI HONER ISSUANCE DATE
fomia HraIN&Safety Cale,Smions 25505.25SJJ iJ 255X.1 utiderttand Wt if the NEW RISIDENT1AL MECH. SQ.FT.
hoilding di.s nut currently have a mint,that it is my rexpureihll lty to notify Ne occupam
of Ne requirements which most he met prinnn isrmoment it Cerifcam of Occupancy.
Owner or authorized agent Dam "TOTAL: ISSUED BY:
OFFICE