S 1806 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINTPEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE ITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 1806
BUILDING PROJECT IDENI'IP'ICA'I'ION
BUILDINGADDRESS: SANITAHYNO. APPLICATION SUBMI ITAL DATE
o compo% tjo
OWN17R'S NAME: PHONE, CONTRACTOR'S NAME: LIC NO:
NIC CON'IAOLN
�,11tC111'1'PC'NUNGINFER Yl LIC No ADDRESS ❑
CONTAC'L PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUME MECH
3r vy ❑
LICENSED CONTRACIOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Thal I am Iicenwrl under provisions of Chapter 9 ocommencing JOB DESCRIPTION
�ceZ with Seclion]IXq)ofDi,i,ic.3oF,ba Busivossvnd Professions Code,and mylicenxeis J
a10p PERMIT ISSUANCE
F W� n full farce and effect. 1 • )WI. ElKKITCHENIREMODEL�VU [.it.-Class I.it.# APPLIANCES-RESIDENTIAL A'DDITION ❑PLUMBING R -PlIFF
W Dom Court r
CCARCIII'I'ECI"S DECLARATION ❑MI11.9'I-UNIT ❑S'IRUC'I'URAI.
ZO'�z Iundcrswnd mypl.mehal heuaud
duepuhhenc ,r. PANELS MODIFICATION
OZ4, UP'TO 200 AMPS El INTERIOR El CHIMNEY REPAIR
Licensed Professional 20I-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION
C Q1 hereby a1Bmm that 1 am exempt from the Contractor's License law for the OVER DMO AMPS ❑RATH REMODEURF.PAIR El DEMOLITION
3 a V following Mrs .(SWom 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W a h which requires a permit to construct,eller,improve,demolish,or repair any structure
�.W.W�
prior o its ismance,alsorequires lheapplicam farsuch permit o file asignedna¢meul SPECIAL CIRCUI'FIMISC.
That he is licensed pursuant o the provisions of the Commctor's Lirens,law(Chapter 9
�p0 (csnontenc ing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.M I:I HR OR POLE INST COMMERCIAL
d q o eL that he is exempt Ihereliam and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DF:M01,1'PION
W-,m Section]11315 by any applicant lot a letmil,mhjects the applicant nia civil penally of POWER DEVICE' ❑'TENANT ❑FOODSERVICE
F=Qn u more Won rive hundred dollen($510). IMPROVEMENT
❑ 1,cowne,iddnepmpeny.onny employees all wages.,theirsole..mpensation, SWIMMING POOL ELECTRIC s
F will do the work and the structure is not intended or oB'erod for sale(Sm.]M1 Business OTHER
3 ..,IProfessions Code:The Comranor'x License law does not apply to an owner ofISOF
OF rLFTS-SWITCHES-FIXTURES
OL property who builds or improves mcrean,and who does such work himself or through
his own employees,provided Ill.,such impmvcmenn are not intended ns offered for NEW RCSIDEN'I'1At,ELEMR SQ FT,
sale.IL however,the building or improvement is sold within one year of completion,the SQ.FC FLUOR AREA LSQ.IT.
ow.crbuilder will have the burden of proving that he did not build or improve for pur- p�a
pose of sale). JUL 1 0 MIW D
NL nn owner of the properly,am exclusively and
P ofi,,wlag with Items C cmtramorx m TOTAL:
gIDxemm the prjecl(Seo.](431 Be....I anA Prnfeno lots Codd—ir 'uIbe Cantrualar�x and
dseiloso,La.docs Oil oameliplyloun ownendlm,pmny whosedpornato ,, inConold.o, QTY. PLUMBING PERM IF PP,B CITY OF IiUI'Chi{IVU
woo eammelx u,r xacn pnjedx wan.m conlmelonv licensed narxoam to tea cammelat�x
License Law. PERM1'I'ISSUANCE
,1 ❑ I am exempt under Seo. B&PCrrlhisreoonn
91 .TER-DRAIN&VENT-WATE ) VALUATION r)
Own Dam �/
WORKER)`CI BA FLOW PROTECT DEVICE O
I herebyill maintain
ai under penalty oeperjuryoneo(the followingW ker''s Cor
❑lame ad Will far by Section acme of ConservmCore,fur for Wnorina Ce if the EG.REASIVINDUS1
Pf.fN)R,ROOHAREA,COND. STORIES TYPECONSTRUCTION
w.i.Is as provided for ni Section 3]1X1 of the labor Code,for the p:donnance aI the
work lin which this permit is issued oker' - 'EH TRAP
I have Lawill mountain Wofker's Cnma lit the w Insurance,nx required by Section
3]I1B of the Luhur Codc,for lwrlivmmam nllho work fnrwllkh this p`nnil is issued. SYS'I ' -I INCA OUTLIiTS OCC.CROUP AI'N
My Worker's Compensation Insurance comet and Policy number me,
Cmric,: Pithily No.: SYSI'17M� ER 4(EA)
CERTIFICA'T'E OF EXEMPTION FROM WORKERS'
COMPENSA1lON INSURANCE. 'al.WA 1N'1'ERCF.PTOR BUILDING DIVISION FEES
1This section need not lc completed if the Permit is for one hundred dollars l$IWl RAP
nr Icr W) PLANCHECK PEfi
I¢rtify that in the perferrnanceofdhe work far which this permit is issued,l shall SEWER-SANITARY-STORM I:A.'(Yd Fr,
01
nnIendplay any Personin any msanctions mhes esubjec oIhcU WmAcrF Comoen- GRADINGY FEIi
Applicant of California.Date �J��„- r It'ree, WA'ITR HEATH W'NENOMLECTR
Applicant
/ �-T� GRADING hili
be...tic TA7RCRJ[RIaT.'GIT r . end cam of Exemption,you should WATER SYSTEM?REA'I'ING SOILS 7',H lwamo
{� , fnrlhwiliiconranpl lyto With
ith Wsuocrkh.pmrvCinumnnpxmlrxmIhiinxn Pconal Taos of Inc lahnr code,yon mm�t
shell rte dannd revoked, WAfHIt RIiNVICN
n
CONSI'RUC'1'If)NI,l?NDINGAGENCY NEW RESIDIINI'IAL PLM9. SQ.1'C PAID Dam Receipt#
UO
1 hereby affirm that here is a construction lending agency for the perlimmmnce of
LI6p+ the work for which this permit is issued(Sea.3097,Co,C.)
F' Lender's Name TOTAL:
WddI<nx Address TOTAL:
6. 1 certify that I have read dais application and state that the above information is BUILDING FEE
I) correct.l agree to comply with all city and county ordinances and state laws relatingla QTY. MECIIANICAL PERMIT FEE
V $ building eomwction,and hereby uumoriro representatives of this city it)enter upon the SEISMIC FEE
above-meminned progeny for inspection purposes PERMIT ISSUANCE
(We)agree weave,indemnify told keep harmless the City of Cuperri.o agvinsl • ELIiCIRIC PER
I'nlhilitios.judgnmms,costs nnA expense which nmy in vny wiry ncmru ago bel nuiA City I ALTERORADD'IOMECI{.
aroryuence o[the grating of dmie perulit PLUMBING PER
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10.1101 CFM)
MECHANICAL PIBi
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCTION TAX
Signature of ApplicanVConwctor Date EXHAUST HOOD(WIDUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or huedle haumrdons material HEArING ON]FfF0 I W,00 BTIO
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Ih ahli and Safety
CMB Section 25532(a)? I` HEATING ON IT(OVER 1101,1100 DTH)
❑Yes \0 No VCN'I ILATI DN PAN(SINGLE RES D) PAID
Dole Rcreipl#
Will rho uapllc to or future building by he Bl use equipndQu nt devices which
mil hamnous air contaminants ux ACOnW by the Oey Arra Air Quality Munngemmat BOILER-COMI'(3HP OR I(O,f00 UTUl TO AI.
District!
❑Yes �n BOILER-COMI'IOVER IW0 BT11)
.00
r
I have mad the havNau.0 materials requirements under Chapter 6.95 of the Cali- AIH CONDI'1ON[N I:SU NCE DATE
fram Ilcallh&Safety Cade,Sadinnx 25505,15533 and 8531.1 mWentatW dna,if the NEW RP_S 1DENTIAL MECH. SQ.FR
building does not currently have a tenant,Lha it ix my responsibility to notify the occupant
of the"timemems which mono Mand prin�nissuance of a Certif I of(kcupmcy.
Owner or eulhnrized
age.(i rss� TOTAL: • ISSUED BY,
� q' OFFICE