30224 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL w^c PERMITNO. J{^ 0 22 q
BUILDING DIVISION APPLICATIONIPRRMIT PLUMBING-MECHANICAL Iv L L 4
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: �,,�., �ANITARY NO. APPLICATION SUBMITTAL DATE
d @fib 6 p��-o•t�r o \_ S`CR pp,�
NAE
'S ME'. PH�ONrE�: CONTRA O 'SNIC NO,
eN w1`Y' NIC CONTROL
4RCH /Ford INFER: LIC NO: ADDRESS: - SVS ❑
CO A . PHONE: rya,�s BUILDING PERMIT INFO
4Q/4�a! Consultant Fees Paid by Applicant(Initial) BLDG P CH
AC
CONTRACTORS DECLARATIONYi QTY F,LECTRIC PERMIT FEE
C C Z S.
I hereby affirm shat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Iyo thSminn7pg)ofDivisionlofthe Business and Professions Code.end mylianse it RESIDENTIAL'
F+ly O n full farce and effect. PERMIT ISSUANCE
�FUZ�j License Class Lica 'DWL ❑KITCH17N REMODEL
NQL Date Contractor APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING REPIM
1..7 tra ARCHITECTS DECLARATIONPANELS MULTI-UNIT El STRUCTURAL
Z O tt��� I understand my plans shall be used as public records MODIFICATION
0ZOilUI'T0200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F 4�j Licensed Professional
=dR•C2� OWNER-BUILDER DECLARATION 201.1000AMIMPROVEMENT
1 hreby affirmion I..exempt fromthe Commnors License Lew furthe OVER I"AMPS El BATH REMODFII
REPAIR ❑DEMOLITION
3IL U�' following reason(Section 7031.5,nosiness and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
H ekt,O which requires a prnnirto amshud,star,improve,demolish,or repair any swcture
m...777 pricrmitsissuancc,also requires lheapplicam forsuch perms to file.signed statement SPECIAL CIRCUIT/MISC.
D- that he is licensed puramntto the provisionsof the Contractors License Law(Chaptert)
p `eo (commencing........ion 70f(1)A'Division 3 ofshe Businessman Profession Code)or TI?MP.METER OR POLE INST COMMERCIAL:
6 G' that he is exempt Therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/AUDITION ❑DEMOLITION
-„y Section 7031.5 by any applicant fora pemits.hjects the applicant to a civil penalty of POWER DEVICES'
not more Nan five hundred dollns(1100). []TENANT ❑FOODSERVICE
�'al ❑L.s.wndafthe Property.nrmyemPloycex wird wagesas their solecompensation. SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the shucmre is not intended or offered tarsale(Sec.7044,Business ❑OTHER
and Professions Calc:The Contractors License law docs not apply m an owner,f OUTLETS-SWITCHES-FIXTURES
property who builds or improves them..,said whe dues such work himself m through
his awn employees,provided that such improvements art not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however.she building or improvement is sold within one year of completion.the SQ.FT.�R.00RAR S/SQ.FT.
r-builder will have the burden of proving that he did no build or improve for par,poanaea rade.). -
❑1,ms,theerof the Property,mB B.exclusivelyrand cannoning wish:)The
Contractor's
m
omse Lo the es not (Sec.7Dn wnerosx.nd ity who
Cale:)The C,mmcmre W- ���
%hecawdocsnotaPplyban with
.,.deny whosedpds 000nt to the flicamnContra,and QTY. PI,UM11BING PERMIT FEE
wha nmwats 6nnneh projects wilt a mmmmor(s'71icemW pnou.nt m the Convnctm's�
License Low, IPERMH ISSUANCE z
❑ 1 am exempt under Sea. ,B&P C for this reason
AI:TF.N-DRAIN&VENT -MA (IA)
Owner Date VALUATION
Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DE
I any,affirm utitle,penalry,fperjury one of We following declarations:
I have and will maintain a Certificate ofConsenno self-imum for Worker's Compen. DRAINS-FLOOR.R00, RFA,ARD, - STORIES TYPE CONSTRUCTION
satimy as provided for by Section 37M of the lade,Cale,far the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
SEP1 have and will amatory Worker's Compensation Insurance,as require)by Section ,y ^A 1 ( h
37W of the Lahr Cale,for the pcdermance of the work for whichthis Permit is issued. GAS-EA.S YSTEM.I INC.40 'T OCC.GROUP -- APN
My Workers CamPcnsation Insurance canner and Policy number we:
Carrier: Policy No.; GAS-EA.SYSTEM-OVER 4(EA) (1 t Vs- flit i 'III
CERTI FICATF.017 EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE GREASEANDUSTRI,WASTE INTERCE BUILDING DIVISION FEES
(Itis section need nosh completed if the permit is firtome hundred dollars(S IOTA GREASE TRAP
or less.) PLANCIIHCK PER C'
Ice the in the performance of the% for which this'he W..keradl,Ishut SAWIiN-SANI'T'ARY-STORMEA.20017
not entpiny n ran In any mtpm+«se� .Moon Fi hjuctmthe Warkrrs'C.mpen- ENERGY PEE lyiA
Q Z cation Law M Calif. 'a.Da WATER HEATER WNENT/L'LECIR �lV
Q Applicant GRADING FEE
V) NOTIC13 A :If,after making this Ceni a of Exemption,you should WATER SYSTEM(TREATING
become subj i es the Worker's Compensation Provis ns,f Ore Iabof Code,you nnnt SOILS PEC
forthwith comply with such provision orchis peormtsh.11 he deemed revoked WAI ER SERVICE
n
7z CONSTRUCTION LENDING AGENCY NEW RGSIDENTIALPLMB. SQ.FT PAID
V l for which thi Chet there issued(S ,i0lenJing agency ratite perfnrtnance of Date RcceiplN
In work for which this permit is tetrad(Soc.3097,Civ.Cd
t E'' Lender's Name
TOTAL:
I, 0s Lender's Address
y 1 certify that 1 have real this application and state that the above information is BUILDING FEE g ass—
V)
U) comet.I agree to comply with all city and county nNinawca and state laws relating to OTY, MECHANICAL PERMIT FEE
U G7building commetion.and hereby authorize representatives of city to enter upon the 0 SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
We)agree to save,indemnify and keep hi miles the City of Calamine against ELECTRIC FEE
liabilities,judgme.w,costs and expenses which may in any way items,against said City ALTER OR ADDTO MUCH.
in mnscqucnce of the grading,f this permit. PLUMBING FEE
APPLICANT UNDERSTANDS ANDg AND PI Y WITH ALL NON-POINT AIR HANDLING UNIT AIR HANDLING UNIT(OOVE ROIOtX)11 CPMI
SOt EGIJLA MECHANICTIONT
>/ CONSTRUCTION TAX
I-
Sigt&uamy6fAppr7ma1Cyadmzmr Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building output stow or handle hazardous material HEATING UNIT(TO IO0,fKK1 BTU)
as defined by the Culmina Municipal Cale,Chapter 9,12,and the Health and Safety
Cale,Section 25532(u)? 1IFAt ING UNIT(OVER 100.000 BTU)
Fl Yet Fl No VENTILATION PAN(SINGLE RESID) PAID
Data Receipt#
Will the applicant or foram huilding uecupam uu cquipmem or Jeviccs which BOILER (JHP OR IW,WO BTU)
mit hazardous air contaminants to defined by the Bay Arco Air Quality Management - TOTAL:
Lion,,?
El ❑Nn BOILER-COME(OVER 100,(1011 BTU)
'
91hawthehazardous materialsreuirementsunder Chater 6.9.5,fthe Cali- AIR CONDITIONER -
q P ISSUANCE,DATE
fdy Code,Scetinns 25505,25333 nail 25534.I unJetxumd tat ifthe NEW RESIDENTIAL MF.CH. SQ.FT.mn0y have Honk shat iii nywa tesihilitymn.tifytheoccurew emd si / ora Ceniftcamof Occupancy.
nmthotizcd. Dec Al- ISSUED BY.
OFFICE