00010067 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY i�100/ (/(/6 /
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
IBUIXDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL SOOO1
BUILDING PROJECT IDE:NTIYICATION
• BUILDING ADDRESS: SANITARY NO. APPLICA'T'ION SUBMITTAL DATE
22 S rY
OWNER'S NAM HONE: COM"RACTOR'SN LIC NO:
itsQ n N/C CONTROL#
CHITEC/HNGINEE `LIC NO, ADDRESS: • . �`�iQ /M ❑
CONTACT: PHONE: ��� T O V �I 'BUILDING PERMIT INFO
/�..•O ���/ �j� JAI
- I ❑ ConsuItan bees PmJ by App lcun[ dtlal) NLDG ELECT' PI UMH MECH
LICENSHD CON]RACTORIS DFCIARA'I'ION QTY. ELECTRIC PERMIT I FEE
I hereby affirm that 1 am licensed under previsions of chapter 9(nonunenefng JOB DESCRIPTION
OCZ with Section 7")ofDivision 3 oflhe Business and Professions Code,and my license is RESIDENTIAL:
IIyy p O PERMIT ISSUANCE
,,W= In full three and effect. CSFDWI. CKITCHI?N REMODEL.
<VZU Lice Class-/' = APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
HQ L Date+]�' Conlrn����
Fly ARCHITECI"S DECLARATION PANELS L1MULTI-UNITCS'I'RUCI'URAL
m Z 1 understand my plans shall be used a%public records MODII9CATION
Oz 410 UPT0200AMILS CINTERIOR ❑CHIMNEY REPAIR
„F„Iy Licensed Prolbssl000l 201-10#IAMPS IMPROV17MENT CSW[MMING POOLS
a .-.I1 OWNT:R-BUILDER DECLARATION OVER 1fgq AMT'S ❑HATH REMODE1JREPAIR 0DEMOLITIO
C C 6 I herchy affirm that I um exempt Gore the Commeuta,License Law fur the
iq5 6 9i
6 V following reason.(Section]Ill I.S.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑DTHER
I+L 3 LL( which requires a permit m audience,ober,impmve,demolish,or upmr any swoon
Chan prior to it,ouance,Jnnrequimsdsoupplictnnlnrwdlpermiunfile aei,mod,ocamcn, SPECIAL CIRCUIT/MISC.
Shy that he is licensed moment to the provisions of the Commemes License Lim,(Chapter 9
W C) (commencing with Scerie.1000)af Division3nfdw Business and profession,Code) TGMI'.h1E1'IiR OR 1'OLF.IN. COMMERCIAL:
d y o er
that he is exempt Ihery ern and the basis for the alleged canapuon.Any viol Let of C NEW RLDO/ADDITION ❑DEMOLITION
LLXl LLy Section 7031.5 byany appliaant fora peardsahjects theapplicanun u civil penally ofIiVICFS El TENANT CPOOD SERVICE
Cabnot more thin five hundred dollars(35110). IMPROVEMENT
p1.its owner ofthe property.or my cntployces with wages to their sole an I MINGPOOLI/CIRIC
will do the work,mal the structure is not imendedorodemd for mde(Sec.ID1q nasi [10[MER
and Professioro Codn:The Conhactor's License Law does nm apply m an,. r nf. O LETS-SWI FIRS-FIXTURES
property who builds or improves thercen,and who does such work himself or Ihm h
his own empleyces provided that such improvements x nm intended ce offered f 'W RFSIDP TEAL ELECTR SQ]T.
sale.If,however.the building or improvement sold within one earifco p ion,0m SQ.IT FLOOR AREA $/SQ.I7.
ownenbuilder Will have the burden of proving that he did nor a ori rPur-
pose of sale.). t vc
❑h its owner of the property,am exclusively Contracting wit lice..n1 contract to TO'T'AL:
construct the project(Sec.7014,Business and Professions Cad )The 'on encmr's Lh
use Law does not apply to an owner ofprimany who builds or prove.thereon, nd QTY. PLUMBING P17RMIT FEE
who contracts for.such projects with a caotercue(s)Iicenwai arrna to the Imre o
License lsw. rx ERMIT ISSUANCE
C 1 ren exempt under Sec. .R& for this reason
ALTEk-DRAIN&VIiNT-WATER(EEA) VALUATION
Owner e its
WORKER'S COMPENSATION DECe following
PACK[LOW PROTGCf.DIiVICF. -SOD
I nanny affirm Linder penalty of perj on one m'me fnsum for din
-Iohave and will for bynection Scam of Ce LalsooCode.mrefor Wm res' toori of DRAINS-FLOOR,R(A)EARG,COND. STORIES 'IYPF.CDNSTRUCTION
Workits pmvlJhi for by Section 3]IN1 of IM1c Labor Coble,for the performance of c
work Ter Which this permit is issued FIXTURES-1'F.R TRAP
C I have and will maintain Workeds Compo s he w Insurance, h his pu d by S .ad
3]0l of the Labor de,f nthc re.nuance an
work for which this pe�mitr ssucd. GAS-PA.SYSTEM-t INC.40L3TLET5 OCC GROUP ANN
My Wnrk move an nd Policy n
Camuc Policy No.: GAS-PA.SYSTEM-OVER 4(EA) 3sVZ
CERI'IFl ATI:OF EXESIVI'[ON FROM WORKERS' L�
COMPENSATION INSURANCE GREASFANDUSTRI,WASTE INTERCEPTOR BUILDING DIVISION FEES
(ThiswetionneWnotberomplCLWifthcpetmitisfononchund dollars($100) GREASETRAP
or If,,.) PLANCHECK FEE
Icenilythat inthe paufnrmanceofthework Torwhichlhis pe it isissued.[,hall SEWER-SANITARY-STORM EA.2o0 FT.
not employ any person in any manner so as m become subject tot Workers'Compen- ENERGY FEE
O Z xution Laws of Calor.ia.Date WATER HEA)ER WNENVELECTR GRADING PEE
z O Applicant
NOTICE TO APPLICANT:If,after making this Certificate Exemption,you should WATER SYSTI?M/1'R BATING SOILS FEE
f~ lN" become subjwl m the Worker's Compensation provisions a he Labor Code,you mull
{a1.1 r� forthwith comply with such previsions of this permit shall deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING ENCY NEW RESIDENTIAL['LMR. SQ.IT. PAID
V 0 l hereby elBndfuLthereisamnstmminnlem gagencyfortheperfommnaof Date Receipt#
the work forwhiIt
h thix petmIQULenders Name TOTAL:LandedAddreT(YIAI_1 comfyhave oder tris ttpplicmio and stare that the ubova information is BUILDING FEE
comect.l agree ply with aR city and c ntymedinaoeeeandstumlawsrelatingTo QTY, MECHANICAL PERMIT FEEand hereby authoriu eprcxSEISMIC Fiiliabovcanentioneerty for inspection apoxes. PEkMI"f ISSUANCE(We)agave.indemnify: d keep hamdess the City of Canadian againstELECTRIC FliC
ostsandexpen s which may many way acemeagalnstsaid City ALTER OR ADD TO MECH. PLUMBING IiF.untsequencegmutingofth' permit.APPLICANT STANDS ND WILL COMPLY WI'TH ALL NON-POINT AIR HANDLING UNI'T(TO 1ff"CFM) MECI IANICAI.FEE
SOURCE REGONS. AIR HANDLING ON]T(OVER 10,0100 CFM) CONSTRUCT ION TAX
SignatmxafAp /Cmr actor Dom EXHAUST HOOD(W/DUCI) HOUSING MI I'IGATION FETT,
HAZARDOUS MATERIALS DISCLOSURE
Willlhe applicant an future building cecupant stMe m handle hazardous mammal HEAT]NO UNIT ITO 111(.00(1 BTU)
as defined by the Capenino Municipal Cade,Chapter 9.12,and the Health and Safety
Cade.Section 25532m)'! 1 UEA'HNG UNIT(OVVR 10)IN0 BTU)
C]Ye., CNo VENI'I LAJION FAN(SINGLE RES ID) PAID
Data Receipt M
Will the applicant or future building occupant use equipment in devices which
do mit naevNous air contaminants as defined by the Bay Area Air Quality Management B011.1111-COMILDHPOR IW,WBTU) TOCAL:
Dion,V? BOILER-COMP(OVER 100.000 HTU)
❑Yes No , —vo
1 have read the haruNous materials requirements under Chapter Nus of the Cali- AIR CONDITIONER ISSUANCE DATE
frena.Health&Safety Cade.Sections 25505,25533 and 255]4.1 understand thin if the NEW BESIDE NI'IAL MECH. SQ.ET.
building does not currently have a tenant,but it ix my resper sibility to ami ly the occupant
of the requirements which must he met prior to issuance of a Cenifarte of I]ccapvacy.
Owner m aamodced agent Data I OPAL: ISSUED BY:
OFFICE.