B 0305APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECfR
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECII'A
v9e 1 -� /t _ �� ❑ CO.Itanl Fees Paid by APPllwnl (Initial)
LICENSED CONRAMOR'S DECIARAI'[ON QT.
1 hmby aRrm That ] am Ikcnad ulda M)v LLas of Chnptu 9 (enmmeming
W8Z with S.cli.'1000)Mpivisi. Jtlf lk Busillty and Pmfessiom Codc.W my liccmcis
F,wO in full force
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ac
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O� ARCIIIICL
ARATION
zZI urdaoued my plans Jwll c urN Eunlic recros
CIZ—o
F 4 F' W Licensed Pmfeui«ul
C ca G 1 hereby affirIhet I OWNER-BUILDER
he CContractees License Lew for Oa
am U following rwwm. (Section 10313, Bmorce..1 R11fassice, Cuda: A, city or county
which rcyuimn a permit In coeslmcl. aper, impnrvc, dcnwlish, or repair any smtctum
prior to in issuwet, also raluitec thea applicantfir such permit In fila a sieced atetement
f�> that he is licenses lnnasent to th, prceisws of the Cmllru'mr's Liceme Law (ChWer9
w�0�0(.I.& with Seelien 700O.Fpitied. J ofthe Business turd Pmfebsion Code)nr i
6 a e K On be is exempt thacfmm turd I W suis for the alleged c"an,titm. Any violation of
mSection 7031.5 by wy uptlicant I'or a panni(sedj co; Ih: epplicaln In a citil penally of
~��no, mmc Ihw 'no hundred doll,
pLna twvnernr Jepnlpertr.mmy emgoyeet wile wngal as thelutla ealtpen.Wlilrb
win D,the wart, eat de be Co t is n«intended «Lades r«.ale LSec.II . Bu.itlw
3 ud iaty wh to COtle: TM Caumcmrs License Law soca Itot 4Ifi to lf wxr gof
h
poP n who Wilde Or impcd that
th.hn, and ve ohs alrh wort dledl ofu through
his own employ., provides Ihw such impt,, sol within thin mt imeNW «oRered fm
Bele.ILhtwev w i Jtesei theln«in of of int Toads,done yournrcanve f(w Inc
cr W iNkr will Wvc IM1c hlNcn n1' pmvin6 that W sir Ila W ilA or improve Ix par-
, pscd.akJ.
Fl 1, as owner of the Pre,rtY, and exclusively c.nnoa til with licensed..taa m
mnnma the prycet (S«. TULf, Ross u and Prost s mn Codex The, Contreator's (i.
me w tn«w
ePoly to an owner of property h « o buildsno,,bevet thereon, and QTY.
wDow
ho umtratls f« ,Meati pmjecht with a cumrntlon,) Ikemed pvsuam to the Conlru'mr'a
IAccrt¢1aw.
p 1 ant eaclnpl under Sec. . If h V C roe this mut.
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby Nmt order patdly of perjury one of the following; JerfUll irem:
❑IM1vvu oldwilllf by
nection 37M of Cb, Lab mux-imure f«Wrvkcr'�Grnpthe
.tion, ea pnwided for by Section 37M of IW (aha Gide, for IM1c Icrlirtmamc of IM1c
wort for which thio Ix^^il I. iAmcJ.
1 have and will maintain Worter's Cantpmw'wn Imams, u tv,nodi by Scmiow
l I)0 of dtc Mur Coh, f« the Lerf«ouocc of de war f«which lou permit is iuued.
MyW (r'. Cnn coati Inwrarcec Intl
Canicc idicy Nu: vin
CF,RTiMCNIT Op EXBMPHON I'NOM W ONKENS'
COMPENSATION INSURANCE
(Thi. rection need lu he aynplelal irthe lentdt is f«.c hualrN dOlbve (SI WI
Leroy Out in IM pMorneux,< Ofllc we" f« which this parent is ismed.I shall
not cmpley any parwl in any bunter sO u In becone, mbjMl In IM1e WaltersCcroNn-
O %. tylion Laws of Califnmin. Dam
O A,hconl 1
N NOTICE TO APPLICANT: If, after mating This Cadificage of Esenrlion, yw should
bamc wbjat to the Wm4<rs Cmlytcret Ponsisions of the W« Cade. yaw OW
forthwith comply with such pnoutiwu ac this lerrldl aluB be deemed (evoked.
Q
U O CONSTRUCTION LENDING AGENCY
I hereby vllirm lhtll Ibure in v eonvmainn larding agency for the pcdomtvmc or
F the wort far which this permit is iuunl(Sec. 3(,92. Civ, C.)
O U Ietud:6 Nis.
D] 1211d[rI Address
1 ccnify that 1 have lead thirty and! l,.. els owe that Inc above eslifiion is
r0.A tvrldin,opleetnco.ply," with
b,a.lhn1 a,m nmiwccodliboric6Dhd sly Otnterehllnem QTY,
U 1Nildingcni...of o,atd terchy aulhorirc repro%'111011Vev of thiol only In cmcrupn the
ahovo- (We) Sed parycny far In enity tend!
ha
(Wel agr¢ m save, Ia c.,crre and hi cp eamllca the
City Of Culcalim aP1 v
i. ciceia.ience anu, you and expenses which Ivy N yr way acme egviltu rid City
A APPLICANT
a(Jc RSTA6 SAnisPrci
DWI
APPLICANT UNDERSTANDS AND WILT. COMPLY WRIT X11 NON -POINT
SOURCE REGULATIONS.
HAZARDOUS MATERIALS DISCLOSURE
Will the ll'Ineam «finale Wilding oecerhaM o4Ore «haralle M1vrnAoto rllal"
definetl by the Cupenint Munkilul Cade. (Thapter 9.13, amt the Ileahh aryl Safely
dc, S.cllon 2553200!
[:J Vic, pNe
W II Ile vppliclon or future Wilding occupant use aryipinew uc e m which
of ha,cinh,ux an covmlHnmls as ckfirlal by toe Bay Arta Air wality Muugenelll
to%1) L/
p Yes
have los Joe hvaNt""jj Ire1enlJs tce no,r cnu Moder (.Nagler 6.95 of IW Cdi-
been Hmlth & Satay Cork, !ti'J.t 25505, 25533 tend 23311. I urd[leland ttil if the
ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANI I S
UP TO 2p AMPS
OVER 1000AMPS
SIGNS ITI.CfRICAI.
SPECIAL CIRCUITMISC.
TFbIP. MEIFR OR IOIF. INS ..
POWER DEVICES
SWIMMING IOOI, ELECTRIC
O V DYf S- SWITCHES - FIXTURES
NE RESIDENTIAL ELEC N, SO
00305 O 3 O
5000
SANITARY NO. ' APPI.IC 'ION SUBMITTAL DP
7 AS
NC CONTROL
BUILDING PERMIT INFO
BLDG ELECT PfL�U�.yIP \TECH
❑ ❑ A ❑
JOB DESCRIPTION
RESI� Dy FNTIAL-
❑SFDWL ❑KTfCHENRFb10DEL
❑ADDITION El PLUMBING RE -PIPIT
❑MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT ElSWIMMING POOLS
❑ BATH REMODELNEPAIR 0DEMOLITION
COMMERCIAL:
0 NEW BLDGIADDITON
❑ TENANT
IMPROVEMENT
❑ OTHER
❑ DEMOLITION
❑ FOOD SERVICE
PLUMBING PERMIT I FF
PERMIT' ISSUANCE
ALTER - DRAIN & VENT- WATER (East
VALUATION
BACK FLOW PROTECT. DEVICE
DRAINS- 11,00R. R(OIT,AREA, COND'
STORIIVISI���I///���V///
FIXTURES - PER TRAP
GAS - EA. SYST.1-1 INC. J OU
&TLETS
OCC GROUT'
I
GAS - EA. SYSTE),1-GVHR 4 EA)
GRES IJI NDUSfRL WASTE INTERCEPIDR
BUILDING DIVISION IT
GREASE TRAP
PIANCHECK FEB
SEWER -SANITARY -STORM EA. 200 IT.
FIJERGY FEE
W'AIHR IIHATER WNBbrrnil t:TP
GRADING ITE
WATER SYSTEM FATING
SOILS FEE
WATER SERVICE
PAID
NEW RESIDENTIAL PLNIIL SO. IT
Dwc Rcccipl N
TOTAL:
TOTAL:
BUILDING FEE
MECHANICAL PERMIT bT.E
SEISMIC HER
PERMH ISSUANCE
ELECTRIC PEE _
PLUMBING FEE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT TO III." CFM)
MECHANICAL FTIi
AIR HANDLING UNIT(OVER 10.0)()0:10)
CONSI'RUCHO&'IAX
EXHAUST HOOD OXMUCT)
HOUSING MITIGATION IEE
HEATING UNIT(TO 100.000 BTU)
IIIATING UNH' OVER 100,000 BTU)
)
Racip tl
TOL'
VINfIIA IO.N FAN (SINGLE RESID)
BOILER -COMP DHP OR 100.000 BTU)
BOILER -COMP OVER 100.000 BTU)
I
I E
AIR CONDITIONER
NEWRISIDENHALMECIL SQ, FT
I A
TOTAL: �ISSU JiHI�
OFFICE
twsQ. PT.