99110103 APPLICANTTO FILL IN INFORMATION WITHIN RED .ONES-USE BALL POINT PEN ONLY l O�
CITY OF CUPERTINO BUILDING-ELECTRICAL P
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
�IhDING ADDRfiSS:
BUILDING PROJECT IDF.NTIFIL'ATION
SANITARY NO. APPLICATION SUBMIoTI'Ah DATIi
O NER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO'.
4411
• ARCIIITEC'1'/IiNGI .iR: , r&jxrak NIC
CONTROL»
❑CC7
f 1A S
COMPACT. PHONE: dU1LUING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MF.CH
❑ ❑ )z ❑
LICENSED CONTRACTORS DECLARATION Q'Ty ELECTRIC PERMIT FEE
I herehy afrrn that 1 atm,licensed under prosishmns of Chapter 9(commencing JOB DESCRIPTION
O Division Sof he BusirwaimiJ Prolis,ions nWe.and my Iwcn.a is RESIDENTIAL:
�Z with Scnion]OOB u[
WOO PERMIT ISSUANCE
cFc�W. in full W,anJ OSFDWL O KITCHEN REMODEL
10U Luchs��t sl l� I Lin. AIIPLIANC17S-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
NQ6Date
2�on ARCHITECTS DECLARATION El MULTI ❑STRUCTURAL
Z O y q I understand my plans shall be,used as public mord PANELS MODIFICATION
O Z--a UI"10201 AMPS 0INTERIOR 0C14IMNEY REPAIR
F LQLW Licensed PremIannal 20I-1000AMPS IMPROVEMENT (]SWIMMING POOLS
OWNER BUILDER DIiC1,ARAPION OVER❑NXIAMPS ❑BATH REMODEL,REPAIR ❑DEMDLITIGN
C C Q I hereby affirm that lam exempt from Inc CDnmamrs"License Law fur the y , ,`
X 1 U following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL. HER 7�pM��1/�Tf_.uR,
u1'3 6.y which requires a pumiI um wnstmc,talar.improve,dnnoltsh,or repair any.wmcure ���(�
O� prior toils issuance.also requites the applicant for such Perini[ u fact a signed looment SPECIAL CIRCUIT/MISC.
f'�} that he is licensed Pursuant to the provisions ofthe Contractors License Law(Chapmr9
W�a0 (comuneocing with Section]OOOof Division 3 ofthcBminessand Professions Com0or TE MP.METER OR POLE INST. COMMERCIAL:
C d e C that he is exempt thercfmm and the hast,for the alleged axcmption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^m Section]031.5 by any applicant fora parmit,object the ap,licantma civil penalty of POWER DEVICES OTENANT 0FOOD SERVICE
not nave than I ivu hundred dollars($500) IMPROVEMENT
F-1 1,as owner of the property,or my employees with wages as their sole compensation, SWI MMI NO POOL ELECTR
F. will dome work,andthesumetme isna imcndedoraRered farsule(Sa.70M Business ❑OTHER
W3. trod 1'n,tescions Code 'rhe Contrueor's License Law does not apply u,nn owner of OUTLETS-SWI I'CHES-FI
propc,who builds or improves thereon,and war does such work himself or through
his own employees,provided that such improvements um not intended or offered for NEW RESIDENTIAL ELECrR
*41 sale.H:however,the haiddingor iprom
vocnt lasold within one yad
nemndetion,the SQ.FIT FLUOR AREA 5/SQ.FT.
m
owner Wilder will have the burden of proving Oat he did not build or improve for put-
gave of sale).
ur-
gaaofsale).
F7 as owner of the propeny,am exclusively contracting with licensed commemu to TOTAL:
consumer the police,(Sec.70,W.Business and I'ndemions Code:)The Commmm a cease thereon,and QTY. PLUMBING PERMIT FEE
Dorset,forsuch projects with seminarians)licensed porxumn to the Coduacma's -
em Law. PERMIT ISSUANCE
1 um exempt under Sec. .B&P C for this reason
•
Owtrcr Date ALM R-DRAIN&VENT-WATER(EA) � VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE (P a Qso
hereby attire,under penalty of perjury one of the following declarations,
❑ I have and will maintain a Centigrade ofConent to calf-insure for Worker's Campeau- DRAINS-BOOR.ROOF,ARE A.GOND. STORIES TYPE CONSTRUCTION
.cation,as provided for by Section 37W of the Labor Code,for the performance of the
wn k fm which this peon Lc issued. MYTH R HS-PER TRAP
1 have and will maintain Workers Compensation Insurance,as requireec
d by Stion
Sat I of the Labor 9Cpeale,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Camerlk�`^t1t yYyt Aityyn`4 etRrl cY No. 1� GAS-EA.SYSTEM-OVER 4(IiA)
l C,EERRII'IIFIICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES(This secgon need not he completed if the pmid eris for one hundreddellan(5100)
or fe".) GREASE TRAP PLANCHECK FEE
1¢rify that in the perrannmceofthe work for wblch this Permit is issued.I shall SI2WER-SAN]TARY-S'PORM FA.200 FE
not employ any person in any manner m as to become subjat to the Workers Compen- ENERGY FEE
O Z satiun Luws of Caligmmin.Dam
O WATER HEATER WNENTMLF.CfR GRADING FEE
NOTICE
z am
OTICE TO APPLICANT:IL afar making this provisions
o of Exemption.you should WATER St'STFh1/TREATING
1^ ; fmcnmr subject y the Worker's Compensation p,.it hal ab the Labor Cale,you mum SOILS FEE
� forthwith conmply with such pnwisinnx or this permit shall be Jecmed revoked. WATER SERVICE
PAID
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.Er Dole Recejyp�
UO I hereby affnnthat them is a cor,iumion lending agea_for the Performance of _I -1
W F No work for which this permit is isme l(See 3007.Civ.C.) s
OUI<nder's Name �
>- D.1 �� TOTPL:
Lenders AJdms, TOTAL: �
y 1 certify thus 1 have reml this application and state than the above information is BUILD '.PEE
�y correct.l agree to comply with all city and county ordinances and sure laws relating in QTY. MECHANICAL PERMIT FEE1
U buitiingcnmtcion.and hereby authorim repm%cdtatives ofthiscity nm enter upon the SEISFII FEa
m
above namin had pmpeny fur inspection porPtme. PERMIT ISSUANCE
(We)agree to save,Indemnify and keep harmless the City ofCupenjna against ELLGTRI: E
liabil'nies.juJgnmms.Via expenscwb,c1Omayma,way nurser against said City ALTER ORADDTOMFCH.
PIAMBIN'o 'E
APPonequcnce of g g o Nis pe 1.
LICAN-r U N AND LLC 1PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CF10) MECHANI CRHI-
SOUR
il AIR HANDLING UNIT(OVER 10d"CFM) CONSTRUCT OON TAX
$igi urs ApplicanrCon cur I we 17XHAUS'I'HOOD M'/DUCr) HOUSING MIT'IGA'TION hili
HAZARDOUS MATERIALS DISCLOSURE
Wil l the split icunt or future building occupant store or handle havordous material HEATING UNIT(TO 100,000 BTU)
JeGned by the Cuperrom Municipal Code.Chapter 9.12,and the Health and Safety
ede,Section 25532(a)? IIEATING UNIT(OVER 100,000 BTU)
❑Yes VENTI LATION FANS INGLE R ESI Of PAID pureT-c' 18
• P91 the applicant or.future building occupant use equipment or devices which BOILER-COMP(3HP OR 100,010 BTU)
ou
enmit haaarde air contaminant as defined by the Be,Area Air Quality Management TO
Dru'a? BOILER-COMP(OVER 100.001 BTU)
E]ys,
I have¢, heh
,da materials requirements under Chapter 6,95 of the Cali- AIR CONDITIONER i ISSUANCE DATE
panda Health .of Cede, Ia;iun525/a�(t5.25533 and 25534.1 understand Nm if the NEW RESIDENTIAL MECH. SQ.FT. �/JJ
Inilt' .mlyh., n°�a'y'`�tit'.t c(,onsihility mnmify thcacupunt /� %U - 9
of which abvne ti,,We ofa Cenifam of Occnpnne,r
t uulM1onmJ xgenl Dwc TOTAL: ISSUED BY:
OFFICE