30413 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. ^
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 30413
BUILDING PROJECT IDRNDFICATION
BUILDINGADDRESS: SANITARYNO. APPLICATION SUHMI'ITAL DAL
22 v �-2bct,6
OWNER:S NAME: PHONE CONTRACTOR'S NAME: LIC NO:
NIC CONTR(11.N
J Cfl f- s \
�\RCHITI:CT/ENGINEER: LIC NO: ADDRESS ❑
luso STcao A-5( L>c 4-lo l
CONTACT: PHONE: BUILDING PERMIT INFO
255�'43�1� ❑ Consultant Fees Paid by Applicant(Initial) BLDG CLEC' PLUMB MECH
r( D�IfJ t� ❑ 'Cjt ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9 <a tan ing JOB DESCRIPTION
"Z Woo th Sc'non 711fN8 of It in and Professions Code Been is RESIDENTIAL:
wf - PERM] ISSUANCE.
F W n full fierce an fleet ❑SFDWL ❑KITCHEN REMODEL
<U�w Licc aCku...._ Lien APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
vFiai Dam K�/.�A!/ comeaanr
g_Dm ARCHITECTS DECLARATION PANELS 0MUI71-UNIT ❑STRUCTURAL
NZ I understand my plum shall be used ns public rcmN. MOLLIFICATION
Y'O 0 PTO 200 AMPS
OZ—, ❑INTERIOR ❑CHIMNEY REPAIR
F�.~.,W Licensed Prnlrssional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLAR ' ON
C Y'� OVER 1IXNlAMPS C3 BATH REM��/N.PAIR MOLITION
K < 1 hereby affirm that 1 am exempt tram the Cu mu o ce Low
for the
x60iU following rcu.n.lSeetinn 7031.5.easiness and Pmfes. mfrs :Any city ar countY SIGNS ELECTRICAL ❑OTHER rte,
1+13 W y which requires a permit err consumer,altar,improve,demo n or repair any structure
�.�Oa prior frits issuance.also rcgnims the applinnt fmsuch Pennitao file osigral,atemenr SPECIALCIRCUIVMISC.
that he is licensed Ismicomm the pmvi,tom of he Commerce,License Law(Chapter 9
W--pO (commencing with Section of Division 3 of the Business and Professions Code) TEMP.METER OR POLE INST. COMMERCIAL
C.S c Y nor he is exempt themfmm and the basis for the alleged exemption.Any vinlati.n of ❑NEW BLDG/ADDITION ❑DEMOLITION
Wim Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
�=0 not more than Five hundred dollar,(8500). IMPROVEMENT
❑ Ln,owner of the prnpeny,or my employees with wngcn as their sole annpcnsati.n, SWIMMING POOL ELECT RIC
will do the work,and thescture is net intended or offered for sale VBG),Business []OTHER
u1 and farmerin.,Calc The Contmemes License Law does not apply to on owner of OUTLETS-SWITCHES-FIXTURES
s
a 3 property who builds or improves them n.and who docs such wort:himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL CLEM SQ ET.
SQ
sale,l4M1nwrver,the hulldingorimprovcfncm is wlJ within ono yerrafarmplmioq the .FT.FLOOR AREA E/SQ.FT.
owner-milder will have the bunle r of proving that he did not build or improve for poo
w cfsalc).
EI 1,vs owner ufthe property,am exclusively canmeting with licensed contractors 1. TOTAL: -
construct the project(Sec.IIXN.Business and Professions Cade:)The Contractors Li.
nseLaw does not apply it)an owner of propcny who builds or improves Barren. ad QTY, PLUMBING PERMIT FEE
wboconaids forsueh Entices with a cnmmcrm(s)licensed pursuant o the Contractors AUG 2 0 199
License Law. PERMIT'ISSUANCE.
❑ I am exempt under Sec. .B A,P C for this mason
Owner Dam ALTER-BRAIN&VENT-WATER(G) r .VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penaltyaiperjury one al't he following declamei arc
❑ I have and will mainmin.Cenificamof Consent re self-insurefor Worker's Compeer- DRAINS-FLOOR,ROOF AREA,COND. STORIES TYPE CONSTRUCTION
seation,as provided for by Section 3701 of the Labra Cute,for the performance of the
I for which this Forane is issual. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
3700of the Iuhnr Cade,lir the pril a..nnne,of the work for which this permit is lm
sed. GAS-EA.SYSTEM-I INC.G OUTLF' OCC.GROUP APN
My WorkcCC 'ria Insurance cuoicr and Policy number arc
Cartier. �1^'f'� Policy No.: GAS-EA.SYSTEM-OVER CEPA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEBNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
IThis.vecrion need not he complctcdethe permit is krone hundred dollars($10H GREASIi TRAP
or lms.I PLANCHEOK 17EE
I cemy that imine perfo..acrid the work(..which this permit isissued,lshall SEWER-SANITARY-STORM EA.2lX1fT.
not employ any person in any manner so as it)r become subjecto the Workers'Compton- ENERGY FEC
O Z sultan laws of California.Date WATER HEATER W/VENT/ELECTR
Z Q Applicata GRADING PER
1—I
fn TO APPLICANT:11,are,making chis CenlBcam.f Exemption,you should Wgl'ER SYSTEM?RIiA'1'ING
F-' Sbecome vubjecr m thc W.rkcr's Compcnsalion provisions of the] r Code,you muse SOILS FEE
forthwith comply with such provisions or this Permit shall he deemed revoked. WATER SERVICE
Q
�z CONSTRUCTION LENDING AGENCY NEW RESIDFYIIAL PCMB. SQ.FT. PAID
I hereby,affirm that them is a constructionan
lending agency for the performce of Dam Remiprn
UO mewmklarwhi th'aCiti,i.n'a
T
e�llSec.3U ] Civ.C.1
Lendcr'.s Name fV �,.l.� TI tAnfL Zll" TOTAL.
U :
r ULender's Address TOTAL:
ae 1 um
unify that I have ad this application and Stam thnat the above information BUILDING EEE
F W correct.l agree to comply with all city and county ordinance,and state laws miming to QTY. MECHANICAL PERMIT FEE
UZ building constriction.and hereby aulhonic representatives ofthis city carrier upon the SEISMIC FEE
ahove-mentioned property for par ,purposes, PERMITISSUANCC
(We)up m
ndenify rid keep harmless the City of Cupcnino against ELECTRIC FEIi
liabilities.ju ors erW exPen cs which may inany way accrve against aid Ciry ALTER OR ADD TO MECH. PLUMBING FEE
incmnseq a rs gmnringoft permir.
APPLE C ERSTAND NO WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CPM) MECHANICAL FEE
SOUR(E CATIONS. NPf� ?QDoc,\taw)
E AIR I IANDLING UNIT(OVER 10.000 CPM) CONSTRUCTION TAX iii
s re.11 AP iiam/Contractor Date EXHAUST HGOD(W/DUCD HOUSING MITIGATION FEE
ARDOUS MATERIALS DISCLOSURE
Mures, liemit..furore buildmgoccupant,wren,handle hazatdous ma¢nul HEATING UNIT TO 100,00LO BTU)
as deli( 'd by the upertino Municipal Code,Chapter 9.12,and the HeaM1;tad Safety
C S 32(a)? HEATING UNIT(OVER 100.000 BTU)
Yes XNn VENTILATION FAN(SINGLE RESIDE PAID
Data Rceeipta
Will the applicant or form building narrators use equipment..devices which BOILER-COMP(]HE'OR 100als BTU)
emit narrators.us nit contaminants ,defined by hY the the Bay Amge
Arco Ai.Quality Mxnamenr TOTAL:
Domwi'I ROILER-COMP(OVER 100,0X)BTU)
❑Yes
I have thematerial. cquirementsualcr Chapmrh9e Cali-5ofd; AIR CONDITIONER ISSUANCE DATE
(.rain Health Safe ,e,Sections o-05,25533 and 25531.1 understand flat if the NEW RESIDENTIAL MECH. SQ.FT.
building does r flyhavento f.that it is my responsibility in cattily the rxeupanr
efthemquire sial no tell It mix an 1rj'ny�cafttd Acupancy.
40 rye NTN ✓lOW\1a t10S
Owner., dr, z t Dae TGTnL, ISSUED BY:
OFFICE