30289 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJEC F IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE.
95 7 -- �10-9h
O RS NAME: PHO7,M1_CJ3� C b}]' C'PDR S, 1 -. / � 2 y5;
(/[� AM O SIC
CONTROLp
�ARCHITECI'lIiNGINEIiR; LIC NO: AD�HIi• /7 S. LC.NAZS.. A ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB
MECH
1:1 E:1 LJ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed ander provisions of chapter 9(commencing JOB DESCRIPTION
w0.'Zwith Section 9000)of Division 3 ofthe Business and Professions Code.and my liceneis RESIDENTIAL:T)WL CJ KITCHEN REMODEL
F�-�� in full force,and effect. PERMIT ISSUANCE.
aUl' ❑SI
I-U F- License Class Lim.q
ZU APPLIANCES-RESIDENTIAL ❑ADDITION [.}PF.UNd({,ING RE-PIPE
tiQL Dine Llmmemr
ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑MODIFICATION
Z p 14 Z 1 understand my plans shall he used as public raards PANEIS MODIFICATION
QZ Q UPT020DAMPS ❑INTERIOR L1 CHIMNEY REPAIR
F�.F.,W Lieaued Professional 201-I00OAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
C C Q 1 hereby affirm dull I am eaanpt reunite Contractor's License Law Barone
x6�aa..V following rcamn.(Section 703 L5.Business and Profession Cade:Any city orcountySIGNS ELECTRICAL ❑OTHER
IT7 3
wt; which requires a permit In contact.alter,improve,demolish,or repair any s in'ture
`W Oe prior to its issuance,also requires the applicant for such lmmotno file a signed statement SPECIAL CIRCUIDMISC.
S }•.1 that he is licensed pursuant m the provisions of the Contvcmrs License Low(Chapter 9
C> (commencing wiNSection]000)of Division 3nfthe 9usincssorWPmfessimns Codi TEMP.MITTER OR POLE INST. COMMERCIAL:
dqx m n that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NBW BLDG/ADDfDON ❑DEMOLITION
W ern Section 9031.5 by any applicant for u permit sohjccts the applicant o a civil nerallyol POWER DEVICES ❑TENANT ❑FOOD SERVICE.
F_
not more than rive hundred dollars D5W). OTHER IMPROVEMENT
Q � Las owner of the pmpeny.or my employees wiN xnges nstMir sole compenwtinn, SWIMMING POOL ELECTRIC
will do the work.and the structure is not intended orotfered for sale(Sec.]64e,Business []OTHER
63 unit Professions Code:'"a Contractor's License Law dues not apply nt an owner nl OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such impvvancnts arc not intended or offcmd for NEW RESIDENTIAL ELECfR SQ FT. -
lale.IL however the building or improvement isxold within one year ufinmplxdmn,the SQ.F FLOOR AREA $/SQ.FT.
owma-builder will have the burden of proving that he did not build or lntprove for put-
'we fsale.).
Fl I,as owner of the pmpeny,am emlusively contracting with licensed conuactors to TOTAL
emetu d the project(Sec.7044.Holiness and Profession Code:)The Commerce s LI-
leaseLaw deal nmapplynomustier ol'property who huildsorimproves thereun.tmd QTY. PLUMBING PERMIT FEE JUL 30
who contracts for such projects with a contrecmr(s)licensed pursuam pollution the Contractor's 199
License low. PERMIT ISSUANCE /t� s
❑I am esempt under Sec. .B&P C fur this remon
ALTER-DRAIN&VENT-WATER(EA) VVI-LYALUATI N
Owner [)ate
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 herehy affirm under penalty of perjury one of toe,following declarations:
❑(have unit will maintain uCenillr tcnfCnnenuu sell=insnrcfor Worker's Cma,cn- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONST RUCTION
cation,as proviJM for by Section 3)10)of the labor Code,for Ore performance of the _
work for which this norm,is issued. FIXTURES-PER TRAP
I]1 have and will maintain Workers Compensation Insurance,as required by Section
1700 ofthe Labor Code,.for the performance,of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Works s ' ti m EJ'��ge ' old Policy aomhcr
Carries —e�Policy No.: GAS-G.SYSTEM-OVER d(IA)
CERTIFICA OTE P 03
EXEMPTION FROM W t KERS' GREASPONDUSTRL WASTE IM'ERCEPfOR
COMPENSATION INSURANCEBVILDING DIVISION FEES
(This section need not be completed if the omni is for one hundred dollars(11 GREASETRAP
nr les.) PLANCIIECK PEP.
I ccnify that imthe vilmmarra of the walk for whichmis permit is issued.Ithan SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner sol as to become subject to the Workers Clarence- ENERGY FEE
OZ nation Fai of California Date WATER HEATER W/VENT/ELECTR GRADING FEE
z Applicant
NOTICE TO APPLICANT':If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING a SOILS FEE ti become subject to the Worker's Correlational previsions of the Labor Code,you must
funhwith comply with such Iuo,kiononhis permit shall be deemed revoked, WATERSERVICE
l 0
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
Vp (hereby affirm that there is a construction lending agency for the Performance of Date RcceiptN
t-+ the work for which this permit is issued(Sac.3017,Civ.C.)
{1r 17" Lenders Name TO"1'AL:
0 W Le,nders Address TOTAL BUILDINGF E
3m 1 certify that 1 have read this application and state that the above information is
0..t In cerect.l agree to comply win all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE -
V SEISMIC FEE
Z building construction.and hereby authonre representatives ofthiu city mo enter upon the
above-metnioned prepeny for inspection on,usea, PERMIT ISSUANCE
(We)ngrce to save,indemnify and keep humJess the City of Cupin
erto again ELECTRIC FEE
Iabilities,judgments.crisis and expenses which may in any way acture against said City ALT ER OR ADD TO MECH,
in PLUMBING FEE.consequence of the granting of this
APPLICANT U ER TANDS D LL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO I0.000CFM)
MECHANICAL FEE
SOURCER A I
O'£ AIR HANDLING UNI'P[OVER 10.000CFM) CONSTRUCTION TAX
Signet Appf nYC7m m Dam EXHAUST HOOD OVIDUCT) HOUSING MITIGATION ME
HAZARDOUS MATERIALS DISCLOSURE
Willtha applic�ntm fmure building occnnantstorc m'handle numduusmamriol HEA'L'ING UNIT G 0100,0X)H'fU)
as defined by the Cuftemirm Municipal Code,Chapter 9.12,and the(Health and Safety
Cole,Section 25532(x)' HEATING UNIT(OVER 100,000 BTU)
❑Yes [-1 No VENTILATION PAN(SINGLE RESID) PAID
Dom Hettipt p
Will the applicam m future building occupant me equipment er devices which
emit herardous air contaminants m defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR 100.000BTU) TOTAI,
Dismien. BOILER-COMP(OVER London)BTU)
❑Yes EJ No
I have most the hmaNnus materials requirements under Chaper 695 of NAIR CONDITIONERe Cali- ISSUANCE DATE
to nnia Health&Safety Cede.Sections 25505.25533 and 25534.1 understand tom if on NEW RESIDENTIAL MECH. SQ.Pn
handing docs not emmody have o meant,tam it is my rexpmsibility in entity the reetpant
of he aNdremem which must be met prior to Isuance afn Carol of Ortiq uncy.
Owner m otionimd agent Dam TOTAL: ISSUED BY:
OFFICE