29530 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMI'Y NO. O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
DJ
BUILDING PRECT IDENTIF'ICAT'ION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
iqy 12- Ro,L,,RJ6Li5S 4V 3-ZQ-t16
OWN 'SNAMR: T PISI�F —���/ CONI'RAC-FORS NAME: LIC NO:
77 N/C , CO///Nyyy'1'R/Ohp
RCHIT� ?:NGINEER: LICyNO% Zj v ADDRESS: D ❑ �[JLJI
CONTACT: PHONE: BUILDING PP—I121MITlIINI17
Swi YT/1 7 7 O p / ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLDMB MECH
LIC, vENSSEED CONTRACT'OR'S DECLARATION 0 QTY ELECTRIC PERMIT FEC
I hereby affnn that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
W4Z with Section T000)of Division JAf the Business mrd Professions Cade.anJ my license is RESIDENTIAL:
[-0 0 PERMIT ISSUANCE
m full force and effect. a
[�,1 U LicenFOWL 0 KITCHEN REMODEL
se Class Lic.M �DI)TION El PLUMBING RE-PIPE PE
TAW Conlmcmr APPLIANCIiS-RF.SiDIiM'IAL
F Dsn ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
O[OO.. 1 underatanA my plans xM1all be use]m ublic rtnads ., MODIFICATION
Z-q p UP'10200AMPS - El INTERIOR ❑CHLMNEYREPAIR
�r3 t�i Licenses)Professional 201-1000AMPS - IMPROVEMENT
GWNIiR-BUILDER DECLARATION OVER 10(NIAh1P3
ag ') ❑RATH REMODEUREPAIR CI DEMOLITION
tX 6 1 hereby affirm that 1 em exempt from the Conlmnor's License Law for the
O U following reason.(Section 1Ul1.5,Business and Pmfexsiona Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
F Rj O F which reclaims u permit to cam ns",Aller.improve,danadieh,or repair any someone .., r.
prior)nitsissmusc,olsorequimxlheapplicnat farsuchperminotileu signed statement SPECIALCIRCU1T/MISE. .k' 4h tl !6Y
} that he is licensed pursuant m the provisions of the Contranors License Law(Chapter')
X00 (commencing with Section7")of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:-
4 that he is exempt therefrom and the basis fnr the alleged exemption.Any violation of ❑NF.W BLDG/ADu1$'M [��Mp ION
ry Section 9031.5 by any applicant far a pennitsubjects the applicant u civil penalty of POWER DEVICES vV1I( J ly)�
tmore than five hundreddollars($50(). ❑TENANT LIFO i S, ICC
zQ ❑I ownernf the Iumperty,Armyemployee,with wagesas,1Ai,ama compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
_ will do the work.Aad droona oi isnot intended,offend fmsale(Sm.1644,Bminess ❑OTHER L I I Y 1))• 1:111`1- t
and Professions Code:The Coruna ar's License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
propcny who huilds nr improves thereon,and who dre,such work hinuml l'or through
his own employees,provided that,such improvements arc not intended or offered for NEW RESIDENTIAL CLEC'I R SQ Fp
sale.If,hOwaver.be building or improvement is sold within one year of completion.the 055 ^f SQ.FT.FLOOR AREA $/SQ.Int
ownecolmilder will have the burden of poising that he did not build Ar improve for par- L.
Nestorian.). -
I,as owner of the Property,um exclusively comractiny with licemed am ramors I
consumer me project(Sm.1014.Business and Professions Code:)The Carucc rx Li-
cense law docs no,apply to An ownerof property x he builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts I'orsuch projects with a commarans)licensed purmantto the Contractor's
License law. PERMIT ISSUANCE -
1 am exempt under S . B&I' for this mason
Owner Is -I's- 1 ,._ z ALTER-DRAIN&VENT-WATER(HAI VALUATION
dwWORKER:SCOMPENSAIION DECLARATION RACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations.
I have and will maintain a CertiEcale of Consent to self-insure for Workers Compton- DRAINS-FLOOR,ROOF,AREA,GOND' STORIES TYPE CONSTRUCTION
Action,as provided for by Section 3900 of the labor Coca.for NPerformance e Perfoance of the
work far which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Conilensation Insnnmce,as required by Section
3100 of the Labor Code,far the perfmmunceof the work for which this Permit is issue, GAS-EA.SYSTEM-I INC.40UTLE IS DEC.GROUP APN
My Workers Compensation Immosam carrier and Policy number au;
Cartier. Policy so: GAS-EA.SYSTEM OVER 4 EFA)
CERTIFICA'T'E OP EXEMPHON FROM WORKERS'
COMPENSATION INSURANCE GREASBIINDUSTRI,WASTE INTERCEPTOR
111111..DINO DIVISION PL+k;S
(This section nerd not hecompleteJ ifthe permit is fnnme hundred dollars($I W) GREASE'IRAP
or less.) PLANCHECK FEE
-certify thatin the any manner ofrhe work fur whichthis permitisismmk I shall t
mnentpluy Aar Person in any manner as to rite Workers'Cnm en- SEWER-SANITARY-STORM EA.2(X]f!T. -
Y t^ 1 P .ENERGY FEE
OZ Applicant
Laws ol'Culifnrnia.Dam WATER HHAI ER W/VENTE-LECTR ,,
z Applicata GRADING FEC
NOTICE somesubject
O APPLICANT the Worker's
IL Compensation
pr Certificate of of Exemptio ca,you
WATER SYSTEM?RELATING 1
(~ , became su ompm the Worker's Wars,or this provisions of the Inbar Code,you matt SOILS FEE 1 y
sr forthwith comply with such pnrvisinnsonhls permit shall he deemnl revoked. Wq'TCR SI?RVICE
0 •
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PL.MB. SQ.ET. PAID
LJ Ihereby affimt bar them is a construction lending agency for the performance of
U Dme a e�tp
the work for which this penNr is issued(Sec.3091,Civ,C.) -
p U Lenders Name _ TOTAL:
W Lenders Address g
Ly I certify that 1 have read Nis epplismi.a d state that the ehave infornmiao is -75 BUILDI FEC i+
Tri corect.I agree to comply with all city and county ordinances and mane laws relining to QTY, MECHANICAL PERMIT FEE
V 1Z building coconstruction,and hereby authorize representatives Ardis city renter upon Ilio SEISM `��
abode-mentioned property fnr inspection purprnes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep hamtlam the City of Capron^against ELECT I
Iiabilidies,judgtnents,costs and expenses which may in any way Areme Against said City ALTER OR ADD TO MECH.
in consequence of the grunting of this permit. PLUMBING FE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ALR HANDLING UNIT(TU 10,000 CVM)
SOURCE REGULATIONS. MECHANICAL F'E
AIR HANDLING UNIT(OVER IR"CFM) CONSTRUCTION VX
Signature ofgpplicannConuuctor Date EXHAUSTHOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGA NFP,C
- by
Cuparror futunibuilding sec hantr9.12,handle Heals and Safety
BEATING UNIT(TO I(NI,IN)O BTU)
C Defined by the 321.)?no Municipal CrNe.Chapter 9.12,and the))earth and Sufcry
Coda,Section 25532(a)1 HEATING UNIT(OVER 100.IX0 BTU)
Yes ❑No VENTILATION FANS INGLE R USE)) PAID
Dam R ipt M
Willd¢applimanrorfawre building by theBcupant useuAir unt urdeviceswhich HOLLER-COMP(3HP OR 100,000 BTU)
Tit hazallom air contaminants us defined by the Bay Arta Air Quality Managemcm
DimrinY TOTAL:
❑Ya - E]No BOILER-COM P(OVER 100,000 BI'U) ,
I have mod the hararchars mamdalx requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
fomin Health n clime CAde,c aligns 25505.25533 and 255]4.I undersand tam lithe NEW RESIDENTIAL MC:CH. SQ.FT.
building does not c which have a tenet).shut it is ua responsibility m notify thepancy.nl
of the requircmenti which must be tan prianoissuance nl'u Cerifcote of Occupancy.
Owner or authnnud agent Dam A J ISSUED BY:
OFFICE