30901 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ;t.
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. O 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT
IDENTIFICATION-
ILDING ADDRESS: - SANITARYNO.' APPLICATION SUBMITTAL DATE
-Z-11"k 1 ( 12,a� r]FS.a,-eI L�tZ
ER'SNAME: - PHONF:r Z$3 CONTRACTOR'S NAME LIC NO: List
M2 t�tE02+.JCONTROL#
iRCHITELT/ENGINEER: ' LIC NO: DRESS:
lc�0 �C-'9�Y L"LT� .OV�T. SAND
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELS F,CT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑ `�`l/`''-
I hereby affirm that I am licensed ower previsions of Chapter 9(eommanang JOB DESCRIPTION
❑az with Section 7000)of Division 3 or the Business ad Pmfcs.vzms code.add my license is -
EraOOforce y PERMIT ISSUANCE RESIDENTIAL'
4 U U Licenfullse Classfid effect. Lc# ❑SFDWL ❑KITCHEN REMODEL
yah Date Contractor APPLIANCES-RESIDENTIAL. []ADDITION [I PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS
p,Dw ❑MUI,T6UNTT ❑STRUCTURAL
ypy ^.I understand my plans shall be used us public records � MODIFICATION
OZ^ UPT0200AMP5
Licensed Professional' ,. ❑INTERIOR ,OGHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-IOWAMPS IMPROVEMENT
6 I hereby affirm that 1 am exempt horrific Cmrddwd,a,License Law for the OVER 1000 AMPS - ❑BATH REMODEIIREPAIR"El DEMOLITION
iCS�O d O following reason.(Section 7031.5,Business and Professions Cade:Any city m county SIGNS ELECTRICAL ❑OTHER
wr a W F' which inquires a permit to construct,ulcer,improve,demolish,m repair imy union.
�0 pd.,wits issuance,also requires lheapplieant dasher permitm file.signed statement SPECIAL CIRCUITIMISC.
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
(courmering with secomor 70f10)of Division 3 of the Business and Professions Gtde)or v TEM P.METER OR POLE INET. COMMERCIAL-
that he is exempt therefrom and the basis rer me alleged exemption.Any violon,m of ❑NEW BIAG/ADDITION ❑DEMOLITION
y Section 7031.5 by any vppiicem for a permit sonic##the upplicvnt to a civil penalty of POWER DEVICES E:1 TENANT FOOD SERVICE'
Zc y not more then five hundred dollars($500). IMPROVEMENT ,
.it
❑ 1,us owner of the pmpeny,fir my employees with wages as their sole c.mpensmioq SWIMMING OI,ELECfRIC
F will do the work,and the structure is not intended creffered particle(Sec.7(00,Business ❑OTHER
Irl m and Professions Coro:The Contractor's License Law does not apply to an owner of OUTLF TCHER-FIXTURES
.a
Tragedy who builds or improves thereon,and who does such work himself or through
his own empinyee,<,provided mot such Improvements ore not intended or offered for NEW RESIDENT FLECTR - SQ F-r
sale.If,however the building or improvement is sold within one year of coripletion.the SQ.FT FLOOR AREA $/SQ,FT.
owner-builder will have the burden of proving that he did nal build or improve for put-
poseofcdc). I Ns- I� -
❑L.asownerofthepropeny,am exclusively contort,with licensedcoat.cm,to TOTAL: P Ail
nnmetthe project(Sec,7044,Buaineat and Professions Code)The Contractors Li- ���
cense Law does not apply m an owner of property who builds or improves thereogend QTY PLUM INIT FEE
whocontmets forach pmjeca with a contractor(s)livenicaliasuanl lothe ContractC or's -License Law, PERMITISSUANCE
A/nnI%%ww.nn
E]Iameoainptoader Sec. ,B&PCfmIhisroason
ALTER-DRAIN&VENT-WATER(EA) V Y V�Ic$1ATION
Owner Date - Ch 'V -
WORKER'SCOMPENSATIONDECLARATION BACK FLOW PROTECT'.DEVICE I
10 1 hereby affirm under penally of perjury one of the following declarations:
I have and will maintain.Certificate of Consent o self-insore for Worker's Camper- DRAINS-FLOOR,ROOF,AREA,CONK STORIES.
- TYPE CONSTRUCTION
nation,as provided for by Seclion 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
3700.f the Labor Code,for the perfonnantnof the work far which lhispermit is issued, GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP
MyWor pens Insurance wrier and Policy gyngpyr t�,,
Cartier: Policy No.:`7`I (2A>(4i* OAS-EA.SYSTEM-OVER 4(BA)
/
CERTIFICATE O EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASF./INDUSTRL WASTE INTERCEPTOR sBUILDING DIYISLDN(BES
('this sermon need not becdmpleted ifthe pennil is fnrone hundmd roll.rs($10Hl) '
or less.) GREASE TRAP
PLANCHECK FEE
Icenify theninthe number so
t work for subject
the WrkwGed,lshab SEWER-SANITARY-STORM EA,200 FT.,,
nut employ any peccnn in any manner m as to became subject m the Workers Cnmpen- ENERGY FEE
Q 7. aalian L.ws of California.Date WATER HEATER WNENT/ELECTR _
Q Applicant - GRADING FEE
Uj NOTICE TO APPLICANT.If,after making this Certificate of Corruption,you should WATERSYSTEM/TREATING
F� 5: bee ome subject to the Wmker'e Compensation a vkiars of the LvMn Code,you must SOILS FEE
L>a
Q Podhwltb comply with.,tich provision.,in this Nornitshall be deemWrevoked WATER SERVICE
57. CONSTRUCTIONLtion lending agency
NEW RESIDENTIAL PLMB, SQ.FT PAID '
U Thereby affirm thenhrre isewnssmmian lending agency for the perfarmvnce n( Date Receipt#
L^r the work for which this permit is Issued(Sec 3097,Civ.CJ - r
Fit Lender's Name -
Ler'#AJdev TOTAL:W
TOTAL
a 1 cenify that 1 have read this application and state that 0)r above information is BUILDING FEE
Z) correct.l agree to comply with all city and county ordinances and slate laws relating to QTY. MECHANICAL PERMIT FEE
U ,771. building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEB
#hove-mentioned property for inspection purposes. PGRMI'T ISSUANCP.
(We)agree to save,Indemnify end keep nature.the City of Capedio.ngdinst ELECTRIC FEE
list)ities,judgment costs and expertw1which may funny waytesm ioninnsom City ALTER OR ADD TO MECH.
in nmseyuence ft qR- 1AN1'1.1A.Pd ing of this rmit. PLUMBING FEE
APPLI E N D ILL.COMPLY WITH AL�NON-POINT AIR HANDLING UNIT(TO l0,000CFM)
SOURCE RE 1I MECHANICAL FEE
l 1 ` 6E. a� AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
/ Signature ofd
JZA
Jture
ma K1Dam EXHAUST HOOD(W/DUC'19HOUSING MITIGATION FEEGUS MATERIALS DISCLOSURE -
building occupam finer#or hendlo hazardus mvtarinl' HEATING UNIT(fO IW,(IhO BTU)
as it, W by the Cuunicipal Code,Chapter 9.12,and the Health and SafetyCade,Seclion 25532HEATING UNIT(OVER 100,000 BTU)
❑Yes 7 N . .
VENTILATION PAN(SINGLE RESID) PAID Dale Receipt#
Will the applicant or fits a building occupant use ea Air Qu lilyor Maces which 'HOILER-COMP(3HP OR 100,000 BTU)
mit hazardous air contaminants ns definW by the Bay Area Air Quality Management TOTAL:
District? � BOILER-COMP 100,000 BTU)
❑Yes -
.. -
Il rve dtheh.zallousmateriaLvrequirementonnder Chapter G95oftho Cali- AIR CONDITIONER ISSUANCE DATE
/// forma H th vfmy Cade,Be ions 25505,25533 and 25534.I understand that if the NEW kIS1DENTIAI.MECH. SQ.FT. ^
building currently
hav ,lenat'rm,mis mwpur.ccldfito notify c occupant
/ of mere n lbe met pdormissuanee eta Cedifieam{d �Cprey
.
Owner. gear AT' Dam TOTAL: ISSUED BY:
OFFICE