31356 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P`RMIT NO. 3
5 6
3 1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J J v
BUILDING PROJECT IDENTIFICATION
BUILDING ADDIiBSS: or - - SANITARY NO. APPLICATION SUBMITTAL DATE
OWN E: CO A 0 N & A
—C_ V
_ NIC CON'T'ROL#
\RCHITECT/ENGINEER: LIC NO: ADDNIIF ❑
I CONTACT. /rP,H2ONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB E
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT F'EE
1herchyoul' met IamflhaBu undernd Prordsof Chapter 9(commencing JOB DESCRIPTION
QaZ with Sodom Ifinte]Ikq)rf Division3afthe Business and Pro ssiuns Code,and my license is RESIDENTIAL:
Cp idfuil force and eff PERMIT ISSUANCE
to Q DSFDWL DKITCHENREMODEL
aV License Class Lic.g pPPL1ANCFS-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
u Date C mdracte
,::) A C111'1'EC'S DECLARATION PANELS 0MULTI-UNIT ❑STRUCTURAL
O91 l understand my plans and Fs used as puhlic Lor els MODIFICATION
0
J UP102WAMPS [I INTERIOR - ❑CHIMNEY REPAIR
QLicensed Profcssirnel 201-1000AMPS IMPROVEMENT
a• 2 OWNER-HUILDER DECLARATION
yy 1 hereby affirmShad 1 am escmpt form the Comracmea License Low for the OVER]"AMPS D BATH REMODEUREPAIR [I DEMOLITION
x36V fallowing......(Seed,h 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL []OTHER
ltis77
0 which requires o permit to conmmn,aIle,,improve
,demolish,or repair any structure A Ofd df�(fj� 1
u,40 prior 0 its issuance,also requires the split cant for such permit to file a signedstatement SP17CIAL CIRC01T/MISC.
y that he is licensed pursuant to the provisions ofthe Contarors License Law(Chapter9
� p0 (commencing with Section]000)of Division 3 of Ne Business and Professions Code)or TEMP.METEROR POLEINST. COMMERCIAL:
that he is exempt therefrom and the hasis for the alleged exemption.Any violation of D NEW BLDG/ADDITION D DEMOLITION
uX1 Y• Section 7031.5 by anyapplicantfar.Fermit subjects theapplicannoa civil penalty of POWER DEVICES []TENANT OFOODSF.RVICE
t„ y not more than five hundred that.($5N)). IMPROVEMENT
M El 1,as owner of the properly,or my employees with wages as their sole compensation. SWIMMING PORI.ELECTRIC
a will do the work,and the structure is not intended orefferul for sale(Sec,]IW4,Business []OTHER
S and Professions Cnak:The Carnouctors License Low does not apply to sea owner of OUTLETS-SWITCHES FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such Improvements are not intended or offered for NEW RES IDENTIA E SQ FT.
sale.If,however.the building or improvement is sold within one year ofcompletion,she — SQ.PT.FLOOR AREA s/SQ.
owneclarilder will have the burden of,proving that he did not build or improve for per-
p seofsale.).
D I,as owner of the properly,nm exclusively codtmcting with licensed contractors to TOTAL
tm ismm the project(Sec.7044,Bmxinms add Professions Code:)no Cnmr c ors Li-
cense law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMB MIT FEE
who contracts for such projects with a contractors)licensed pursuant to One Committers
License Law. PF:RMITISSUANCE Q
D lamexemptundm See.- ,B&PCfonhismason
Owner Date
ALTER-DRAIN&VENT-WATER(H VALUATION
- /Yn _,,�
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE a/�y)
I herchy union under penalty of perjury one of the following declarations: ..//((//�V�
I haveand will maintain a Cenifcate of Consent to self-insure for Worker's Camper- DRAINS-FLOOR,RODE AREA.COND. STORIES TYYF.CONSTRULTION
emion,as provided for by Section 3/110 of the Labor Code,far the perf smartie of the
w
for which this permit is issued. FIXTURES-PERT RAP
1 have and will maintain Workers Compensation Immature,as required by Section
37I0rfthe Landr de,fonbe perG,citwnce of the work l'or wM1ich this permit is issued. GAS-EA.SYSTI:M.IINC.40UT1.1!TS OCC.GROUP APN
My Wor nn nsnti cr and Policy,n
Comae Policy No.: GAS-EA.SYSTEM.OVER 4(EA)
CERTIFICATE OF vXEMPDON FROM WORKERS'
COMPENSATION INSURANCE , GREASERNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
section need not he completed ifthe permit is for one hundred dollars 1$l Off GREASETRAI'
or lees) PLANCHECK FEL
Loy anythrumthe pnymannrof the work for whichthis One Wokers'Com ,Idbm- SEWER-SANITARY-STORM EA.2(10 Ff.
not employ any person in any manner so s do become subject m the Workeri Compen- ENERGY FEE
0 z smion Laws of California.Data WATER HEATER W/VFNT/ELECTR
O Applicant GRADING FEE
y NOTICE,TO APPLICANT.11 after making this Cenificme of Exemption,you should WATER SYSTEM/TREATING
a �^ became subject m the Workers Compensot ion provisions of the Labor Cade,you must SOILS FEE
4iI ry fnMwith dandy wi@such provisions or this pennitshull be deemed revoked. WATER SERVICE
Q
CONSTRUCT em isa'IONLENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FL PAID
UThar by which thi that them iasued(Sao 3Dlctming.gcncy for the performance of Data Receipt
{]+ the work fur which this pcmdt is issued(Su.309],Civ.C.) '
Q ULanders Nome - TOTAL:
Lenders Address TOTAL:
1� d 1 cenify Shut I have read this opplicatinn and sem thm he abnve inhumdion is - BUILDING FEE
CA correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby audience representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned property for inspection pmposes. PERMIT ISSUANCE
(We).9.m save,indemnify and kap harmless the City of Cuperlino against ELECTRIC ME
liabilities.judgments,costs and expenses which may in any way accrue against said City ALTER ORADDTO MECH.
in asequence of the granting of this pemtiL PLUMBING FEE
APPLICANT 1 )ERSTANDS AND WILL COMPLY WITH ALL N-POINT AIR HANDLING UNIT(TO 10k000 CI'M)
SOURCE RF CATIONS. MECHANICAL FEE
Ia y� AIR HANDLING UNIT(OVER 110110,000,OCl
CONSTRUCTION TAX U
Sig*ro,OITAPiftaho0opprector me EXHAUST HOOD(W/DULT)
HAZARDOUS MATERIALS DISCLOSURE r HOUSING MITIGATION FEE
Will the applicant or furore building occupant sum,or handle faunal mmcrial HEATING UNIT(TO 101.000 BTU)
as defined by the Contain.Municipal Code,Chapter 9.12,tend the Health and Safety -
Code,Section 25532m)7 // HEATING UNIT(OVER 11M.000 BTU)❑Yes No VENTILATION PAN(SINGLE RES ID) PAID
Willthe applicant ter(umrc building oecupaseDate Receipt g
me, devices IIOILER-COMP(3HPOR 100,"BTLE
emit hazardnmminams
Institutions air caas defined by She Bay Arca Air Quality Management -
District' / BOILER-COMP(OVER I sLosio ITU) TOTAL
DYce �7N11
I have had the hau/Nous materialsuirements under Chester 6.95 of the Cali- AIRCONDHION17R
V P ISSUANCE DATE
fumia g=&St
cry Code,Senium 25505,25533 end 25314.1 to novnnd that if the NEW RESIDENTIAL MECH. SQ.FT.
building does curtendyhave.tenam,that it is my responsibility do no'ythes pant
ofth re t um edprmO.ssuunceafa Cm=
Ow o uadmJ eget Data TOTAL: � ISSUED BV:
OFFICE ,