30846 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY /w1 1/•��
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. 30846
] O H T V
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT'1DEN'TIFICA]'ION
BUILDINGADDNESS: SANITARY NO. APPLICATION SUBMITIAL DATE
22 LaT l PENIN u A 'Z vr' `7
OWNER'S NAME: PHONE: CONTRACTOR'S NAME. LC NO:
N 11r.� 215 �/12� NIC CONTROL#
ARCHITECTIENGINEER: -f v+ .IC NO:
J �1J ADDRESS: r ❑
I o 5 S'v1eLe Rl�Io I
CONTACCTp PHONEG ,f BUILDING PERMIT INFO
Set 'T�K r Aa7a-a`�''SAcJ 2•�r7-T ❑ Consultant Few Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
MC�— LE ❑ ❑ ❑
LICENSE.)CONTRACTOR'S DECLARATIO QTY ELECTRIC PERMIT FEE
1 hereby eflirm then I am lirensed under provision..of (mm mdng JOB DESCRIPTION
wo,Ma'Z w{th Scaion]OW)of DivisionJtuf the Business and PmPossin: and my cox RESIDENTIAL:
II- - full force and effect. PERMIT ISSUANCE
WP '". ❑SFDWL ❑KITCHEN REMODEL.
aUU Lmcnsc_Clas% � La.k APPLIANCES-RESIDENTIAL ❑ADDIl1UN ❑PLUMBING RE-PIPE
Q 1 Dam 1 Conwnnr
ARCHITECTSDECE.AR f [I MULTI-UNIT ❑STRUCTURAL
f-NZ l understand my plans shall be used as public c PANELS MODIFICATION
O" a UP T0201AMP5 ❑INTERIOR ❑CHIMNEY REPAIR
F,'�.EE:;W Licenwd Professional 201-1000AMPS IMPROVEMENT
COWNER-BUILDER DEC ON OVER]But)AMPS ❑ ATHREMODEIJREPAIR ❑DE�MOLITION
S:00<U 1 hcrchy,farm that I am exempt from the Contractor',License Law for the OTHER P RE GA51" Mr—
ad 3 LL F following reason.(Section 7031.5.Business and Pfofes%iom Code:My city or county SIGNS ELECTRICAL.
y which matdms a permit to eon Tact,ahcr.improve,danullsn,of repair any unamro (RIIOu.. I}1:>�IP#GE1Xr
j prior,%its issuance,also requires the applicant for such Permit to file a signednmemem SPECIAL Cl RCUITb11SC. C41M1✓I p/ f(� �n
f } that he is limedantI
pur,un the provisions of the Contractor's License law(Chapter 9 E -
W (commencing with Section 7000)of Division J of the Business and Professions Code)or TEMP.MITER OR POLE INST COMMERCIAL:
A.qx c C eha he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
Se,ion]031.S by any applicant forapennil subjects the applicant(uncivil penullyof POWER DEVICES [:]TENANT ❑FOOD SERVICE
I-Z
not mom than five hundred dollars(5500).} IMPROVEMENT
Sa ❑Las otha .rofthek...d property.ors Out moyeeswi.hwages asd fill nti, sole compenv6on, SWIMMING POOL ELECTRIC
yW(..,0 will doth work...nde: sa C....m taimende'a Lawe osa,,,apply to in,owner o's
❑OTHER
Tal and any whion,Oode:The Cunwetreo License Law doe,not apply s if owner mf OUTLE'I'9-SWITCHI35-PIXTt1HP.5
#roomy who builds or improve thereon,and who ntte%such work himself or through
sal own employees.e provided That such improvements
entise sold within
art not ione ntended meoraf&red for NEW RESIDENTIAL ELECTS SQ FT. _ e
salalLaaldcr will
bur improvement it at he
malbycorimprpletian,the SO,R EL6 HARIA ESQ.FT.
wncr-builder will have the burden of proving that M1e JiJ nm build orimprove Por ,pur-
0 1,as,1ofane FEB 4 REC l
❑I,as owner of the#mossy,am exclusively contracting with licensed mnwmar%(u TOTAL:
construct project(Sec.70G1.Business and Professions Code:)The Cour actoex Li-
nse Law does not apply to an owner of property who builds or improve%thereon,and QTY. PLUMPING PERMIT FEE
who canvas for such projects with a cunlnwmr(.v)licensed pursppnl ht the Contractors CITY Ur uurEHIIIVU
License Law. PERMIT IS. CF
❑1 am exempt under Sec. .B k P C for this reason
ALTER- AIN -WATER(EA) VALUATION
Owner Dam a{��.�
WORKERStmi] COMPENSAr10N DECLARATION1heBACK FLOW 1'ECT. li 60c>
I hucby af0mt under PnmRy of deperjury one of enc iii,am followingW-kerdevistraiunr. LR•a
(nave anal will for byneCion 371)of Ce Labor Coach,to. for Wndeh Compcn- DRAINS-El .R .AREA. 'D. STORIES TY PE CONSTRUCTION
Minn,as h,11idcd for by Section 3]W of enc labor Code,for the Performance of ehc
an
for which this permit is ismcd. FIXTURES-PER TRA
CI
1 have and will oda.fon he affo,arm.filition Insurance,h respired,i Section
J]W tut Ne laMrCode.fonhe pcAomancc of the work for which this pemtit is issued. GAS-FA.SYSTEM.)INCA 0 TS (>(l!C.GROUY APN
My Work el t pry and Policy& be w.r...,.t
Cama: �l HE t \/A1O Te Policy No.:'�STI tO�IhMJi� GAS-IiA.SYSTEM-OVER4(F.A)
CERTIFICAT'lS OF EXEMI'1'ION FRf]M W ORKliK.S
COMPENSATION INSURANCE GREASMNDUSTRL WASTE IN'1'ERCEPTOIt
BUILDING DIVISION FEES
(This section need not be completed ifthe permit is fortune hundrcddollars(SIM)
nr less) GREASE.TRAP PLANCHF.CK FEE t
I certifythat intheperRomaecoldiction,forwhich thispenna is ismad,lshall SEWER-SANITARY-STORM EA.2W PI'.
sol employ any person in any manner sit us to bee.me suhjca to the Workers'Contpcn. ENERGY FEE
zalit..law,.f Calif.mia.Data WATER HEATER WNENTAiLECTR
O Affliction GRADINGFEE
h NORCE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEM/IRGATING
a become smbjca to the Worker',Compansmlon prevision, W
of the Luber Ce,you nmst SOILS FEE
forthwith comply with such provisions or this permit shall od deemed revoked. WATER SERVICE
jz CONS'T'RUCTION LENDING AGENCY NEW RGSIDENTIALPLMB. SQ,14. PAID Date Receipt#
L) Iherchy affirm lea.here iso c.nstmetinn lending agency for performance of
the work for whi h�en�''s�'��'�s''py;��..{{31��II`�rf u=CCit ISce.309] Civ.C.i) Q-
01-•' Lender's Nemo�xVC.3.2=LkL�.i NICR�6.1fOL DNY.- TOTAL:
V Lender's Addrea• TOTAL:
y1 ccnify that I have mad this apflica.ion and vac tea...... ry inform........is BUILDING FEE
iHi h cmrcct.l agree nt comply with all cityand county ordioanae%and seam m v,mlatl"g to QTY. MECHANICAL PERMIT FEE
U z buildingctun9me.ion.and hereh amhminrmpm,mhoivev m daiscily memerulam the SEISMIC FIJI 'Zp
ohove-mO. ERSTANDS
mope ion purposes. PERMU'ISSUANCE
ndemnif and harmle%s the Cie fCu Cupertino . ELECTRIC FEE
( )an p Y" pc gains
liabilhicnJ expect ev'wInch may In any way,scree,gains.said City ALTER OR ADD'10 MECH.
ons_ .,m an parol:( PLUMµ1NG PEE
LIC .D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'TITO 10."CFM)URCMECHANICAL FEE
2 I-rAIR HANDLING UNIT(OVER If.IIf10 CFM) CONSTRUCTION TAX
Si re Afp'canUCunlmedia Data EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
u AZARDOUS MATERIALS DISCLOSURE
W lmrrtp icantorfuwrebtilding.ccnpmtvom or handle havndtuus mammal HEATING UNIT TO 100.000 BTU)
define by the .upenino Municipal CWe,Chapter 9.12,and the Health and Safety
de., vu 32(a)? HEATING UNIT(OVER RXiBlf1 BTU) '
sNo VENTILATION PAN(SINGLE RESID) PAID
Dole Receipt#
Will the applicant or future huilding%x'cupint use equipment or device.,which
niI hazardous air contaminants ex delincd by the Bay Area Air Quality Management BOILER-COMP(3HP OR 101,0!10 BTU)
Daanct?ehh
"TOTAL❑ BOILER-COM11P(OVER IW.UM)NTU)
1aAIR CONDITIONER ISSUANCE DATEImieHon.2550A2553]and 25534.1 understand that it the NEW RESIDENTIAL.MECOSQ.PI'.nuilding ,. t That,.ismym%p nsibilitytonmifythemcupamt.f.heme.prim m issuance of a Certificate m0ceufamcy.
2/4/7
r
ners, res assn ores roT'nl.: IssocD BY:
OFFICE