S 0266 APPLICANTTD FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITYOF CUPERTINO BUILDING-ELECTRICAL. Pfigl I'I'NO.
-�- BUILDING DIVISION APPLICATIONXERMIT - PLUMBING-MECHANICAL. 0266
BUILDINOPROJF.CTIDENTIFICATION;1 -
BUILOINGAUURESS W I SANITARY NO. APPLICATION SUBMITTAL DAT(
O ER'S NAME: PHONE:" C NTH R'$NAME;: - LIC NOO.
1[V NIC CONTROL
ARCHH ,CT/ENGINEER: TIC NG ADDR S '
L ❑
coNTAC PHONE: • BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLD 91.F.0 P.0 e X1 � s 8-135.-' Soo
LICENSED CONTRACTORS DECLARATION QTy� ELECTRICYERMIT^ _ FEE .,
1 hereby affirm that l am licensed d v f Chapter 9 moromen ung , e,•,. ]OB DESCRIPTION
OaZ
wPERMIT ISSUANCE
RESIDENTIAL,OW p conal force and'Hect
❑SFDWL ❑KITCHEN REMODEL
�Uce
;are LCN Conl for APPLIANCES-RESIUEN'HAL ❑ADDITION ❑PLUMBING RF-PIPE
N zj{i1 Dele -
G AR CHIT ELT$DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL
FAN
z0'/+T4 IundemrnJ my plans shall he used as public records MODIFICATION
024 UP T02011AMPS
g'/+, l„,� Licensed Pmfeaional - El INTERIOR ❑ IMNEYRBP
4F' OWNER-BUILDER DECLARATION 201-I n00 AMPS IMPROVEMENT E]SWIMMING POOLS
1 hereby affirm that I am exempt from the Cmitic tdr's License Law for the OVER 1000 AMPS ElBATH REMODEL/REPAIR El DEMOLITION
d U fallowing reason.(Section 7031.5,Business and Professions Code:Any city or countyD OTHER
SIGNS ELECTRICAL
a W F whiaM1 require.'a permit to mmsl1N, alcor,imRum denemllsh,m repair any mormre
❑F❑,W.SOf�II prat he islts cenedprsaregoithe proveilicasnror Contractors
Licensolle e
oCmement SPECIAL CIRCUIT/MISC.
2, y matheasiicenod pursuant loth,pDisioneofthe Commemrsnd oselawlCroded9
Or ce (uthe is ixemwith Section or Diasisormine BusLtessandon.Ayvi Cade)or - TEMPMB'fBR OR POLE(NST. COMMERCIAL:
Or o N that he is exempt therefrom and the basis for the alleged exemption.Any violation of _ ❑ BLDG/ADDITION [D DEMOLITION
Section 7031.5 by Orly appllcanlfor upermit suhjecly the applicantmacivil penolty of POWER DEVICES ;NANT ❑FOOD SERVICE
i+ not more Nan five hundrWdell.rs(S500). I OVEMENT
�y
El SWIMMING owneraFlhe properly,or myempinyeeswiNwages.nhelrsolecompansadmn, SWIMMING POOL ELECTRIC
q will do the work,and themorctme mon ireendedorofficed for.cale(9ce.7044,Business OTHER
d a w and Profession Code:The Contractor's Lioeose Law docs not apply w.a owner of OUTLETS-SW 11 CH 9S-FIXTURES
pmmdry who hands or improve,ammor,and who does such work himself or Through
his own employees,provided Thal och improvements are not intended or offered far NEW RESIDENTIAL FLECTR SQ T,
pale.IL however,the building crimprovernam i„old wilhin one yearof completion,the SQ,Ff.FLOOR AREA S/SQ.FT.
per-boilder will have the burden of proving that he did not build or improve for pur-
pose of ole.). - _
[1I,as owner of the property,am exclusively contracting with licensed wnlmmrs
em - TOTALS. A ' D
.attract the project(Sec.7144,Business and Profesiooa Cade:)The Contractor's Li.
cense Law does nut apply m an owner ofproperty who hands or improve&thriven d QTY,('- ;PLUMBING PERMIT v ss FEE JUL 'whocounsel,f h project,with a oom '1 O licensed purmanu.the Connector, U �I nr.��
LicenseLime. PERMIT( Q a1!lIL.
❑ 1 am exempt under Seo. B&P C for this reason
Owner Dam ALTER-GRAIN&VENT-WAL ER(EA) L•t �HYy N
WORKER'S COMPENSATION DECLARATION BACK FE )pPorE o p an-Check cont iet-on
1 hereby affion under penalty of perjury one of the following declarations: II11YY
❑ Ihomeland wit]maintain.Certificate of Consent to self-insure for Worker's Compen- DRAINS wa roviner-acre TYPE CONSTRUCTION
.don,as provided for by Section 37M of the Labor Code,for the permanence of the - '
work for which this permit is issued. 1I.TURE."W400111tyfor Correcting adodiens.
❑ i have and will maintain Worker's Compensation Inurance,as required by Section .�t ! O
3700 of theelLadmrCode,to, perforenanceof the work fur which this permit is issued. GAS-EA. S IpeVIJI is on OCC.GROUP APN
My err///JJm •ora s� Ir on rr ut d P9Ucy nomhcram GAS-HA,CoMoftof�Ve Print s
/`� CERTIFICATEO,FXEMPTION OMWORKERS' 1
COMPENSATION INSURANCE GRFASF/1 �l I I v t�.” a s ••B1jiLD, UIVISIDN FEES r a
(This section most not be completed if the p.I,is future,hundred dollar,(SI 00) -
orlens) GREASC'I'RAP ,
PLANCHECK 17EE
I certify shot in the performance.fthe work for which this permit in inued.(shall SEWER- ��,/y��w��•
not employ any person In any rainstorm as to become.nhjea R,-the Workers'Quintana- " - _ 9N.RGYFI;H
Z s.lion Lawsof C.lifnni..Date
WATER HEATER WIVENT/ELEC
Q Applicant I - GRADING FEE
o-N+. NOTICE TO APPLICANT:IL after making thio Certificate of Exemption,you should WATERS)NIIIIIIIN?WIMP 4 a hecdme subject m the Worker's Cmmpensntiun provisions of the Labor Cade,you neon SOILS PEE
{1aforthwith comply with such provisions or this permit shall he formed revoked. WATERS IC
Q
p" CONSTRUCTION LENDING AGENCY NEW RF.SI I
V O - 1hereby.ffirm thanhereN scmnsimclion lerdiogagency Fmtheperformanceof Date Rmclptp
w !-r the work for which this permit is issued(See.3097,Civ.C.) -
Q .•``U�� Lender's Name TOTAL:
W Lender,Address TOTAL:
a I comity that I have mail hisapdiat n d 'Idle that the above mfor...l m is , BUILDING FE9
Z) coir.L I agree mcconN,with all city id e ty d" e:and suite laws relet g 1. QTY. MECHANICAL PERMIT,; -FEP.
V building conshuction,and hereby randomize representatives(if this cw city enter upon the SEISMIC HE
above-merlon and property for inspection purposes., PERMIT ISSUANCE
(We)agree to save,milmanify and keep homeless the Cary of CaNnano against ELECTRIC FEE
Iiabilities,judgmems,coslsladexpenses whachm.y in any way accrueagaanst said City ALTERORADDTOMECH,
in consequence of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-POINT AIR HANDLING UNIT(TO I Right CFM)
)URGER Is- S. I � �� MECHANICAL FEE
AIR HANDLING UNIT(OVER J 0,fN10 CPM) CONS9'HUCTION TAX
ui
I amre ofA A.
Dam EXHAUST HOOD -
pps.nl0 nRDO HOUSING MITIGATION FEF,
HAZARDOUS lmagneALSDISCLOSURE
Willthefuroreipal Cde.Chanlntme2r and
In,HeaMousmawdal HEATING UNIT(I'0100.(N10IiTU)
as defined io 0a Cupwwm Municipal Code,Chapter 9.12,.nJ Ihe'Hwllh and S.fery
Code,Section 25532(x)] HEATING UNIT(OVER 10[1(100 BTU)
❑Ves - ❑No VENTILATION FAN(SINGLE RESID) PAID -
Dole ReociptR
Will the applicant or Power building occup.nl use equipment or devices which BUFFER
pp
(JHP OR 100,000 BTU
emit hewrdous air coumminams as defined by the Bay Area Air Quality Manegemenl )
District^. TOTAL:
❑Yes ❑No BOILER-COME(OVER 100,000 BTU)
I have read the hicanlousmaterials requimment under Chapter 6.95 of the Cala- AIRCONDITIONP.R ISSUANCE DATE
roma.Health&Safety Cade,Section 25505,25533 and 25534.1 undrNand that if the NEW RESIDENTIAL MECH. SQ.PrE
building does not currently haver.tenant,met it ix my m,veraibillty n notify the occupant
of'he mqulmment which must be ma prion.assuunw of a Cert rite ofOccupuncy.
Owner or authorized agent Date TOq'AL: ISSUED BY:
OFFICE