00020050 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLYeii)In PERMIT O
CITY OF CUPERTINO B W Llllh'1.-F.LECTRICAI, NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL C
BUILDING PROJECT IDENTIFICATION J
Allm-
LNERS
RHSS: / 1r SANI'T'ARY NO, APPLICATION SUING]-]At,DAPI?
:55 CV-Jf/PNIv/ PHONE: C RA O '5 AME: LICNO-
r - -5 NIC CONTROL#
ARCHEII JI'/ENGINhfl R: LI O'. p{l1) E:1CONTACT: PHONE: l[/ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PL�U.-Ml BB MECH
❑ ❑ la ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm thm I am licensed under gravis co,of Chapter 9(Commencing JOB DESCRIPTION
�d'Z with section 7000)of Division 3 of the Husiness and Pmfession.0 C.and my license is RESIDENTIAL:
W p O PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
TUU tmurnreeaWerreet. _ 1
Q,ZV License Cl Cnmmnar APPI.IANCES-RIiti1D1iN'f1AL []ADDITION ❑PI.UMBINGRE-PIPIT
yQi Da¢-�M CrS DECLARATION ❑MULTI-UNIT L1 STRUCTURAL
Fpr. PANELS MODIFICATION
Z 1 understand my plans shall be used as public me ds OZ-� UPi62(XIAMPS IMPRIOR El CHIMNEY REPAIR
W L¢cneWPmf sional 201-ItNSAMPS ROVIiMEVJ E]SWIMMING POOLS
CYC;
OWNER-BUILDER DECLAHA'DON OVER IWOAMPS BAT EURFPAIR (]DEMOLITION
C wl Q 1 hereby af0on that I am Camnpt from the Commercial License Lew for the
X2 V fill—in,seams.(Section 7031.5.Holiness and Professions Code:Any city.1..my SIGNS ELECTRICAL HER
W 3<L y which requires a Permit n)Construct,alter,improve,demolish,or repair any structure
'Hill III t '1 us'nicel the PPI' ,fm,mhP lu o file a,q chihmemem SPECIAL CIRCUITIMISC.
f' "y•]] matoused p tl the prov,u I he C 1 "Li I ("'Iacrif COMMERCIAL:
(commencing with Section 7000)of Dtvsiou 3 ofth B :' ssa dP f msCWe)or TE MIR'ER OR POLE INST.
a a e tY than he is exempt therefrom and the basis for the alleged Csemplion.My violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ad Section 7031.5 by Say applicant for apevNtsubject%the applicant a crvilpenaltyof POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than rive hundred dollars(3500), IMPROVEMENT
OQ ❑ I,mownerarf the se,cray,orm,enmloyees with wagelas their sole compensation. SWIMMING POOL ELECTRIC
F, will do the work.and the suucturein not intended or offered liar sale(See 9144.11usimas ❑OTHER
i 3 m and Professions Code:The COn.O11ra License Law dues not apply as an owner of OU'LLETS-SWITCHES-FIXTURES
progeny who builds or improves Ihemm,unit who dal such work himself or through
his own employees,provided than such improvements ore not intended or offered for NEW RESIDENTIAL ELECTS SQ Ff.
safe.lr,M1nwevcrJhc bnilJingor impnrvenmm is solJ within one Yearnfntmp....so,the $Q.F4.FLOOR AREA SISQ.FT.
owner-milder will have the burden of proving that he did not build or improve for Par-
fuse of salc.l TOTAL:
Fl I,as owner of the pmPeny.am exclusively contracting with licensed contractors un
construct the pmjem(Sec.]OW,Business and Professions CWe:)The Contractor's cens, dues not apply to an owner of property who builds orimpeoves thereon,and QTY. PLUMBING PERMIT FEE
who mnunuas for such projects with Cc i........(q)licensed Promm m tba Contractor's
License law. PERMIT ISSUANCE
1 of exempt under Sec. ,B&P C for Tho reason
ALTER-URAIN&VLNT-WATER(EA) VALUATION
net Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE 6-0000
I hereby uflimt under penally of perjury one of the following declarations
(have and will inainuina Ccnihcmunl Consent h+sdl-innum for WorAer's Compen- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCT ION
tion,as provided for by Section 37M of the labor Code,for the performance of the
ar which this Permit is issued FIXTURES-PER TRAP
If
and will
i nuinmin Workers Compensation Insurance,as required by Section
3700 of the Labor Code,fm the petlnnmmn:cofthe work for which lhlspcnntt rciseual, GAS-CA.SYSTEM-I INC.4 OUTLETS OCC GROUP APN
My WnrACFY�;n� eslfnnJnxuraneC nu runic Palmy nygM1aR3�t1 � 'I/ �Y/sf�
C,W..: ''}}�'o JY.C�//in I 'rmranpolicy No.: ��ff�Jyy l/fb[[•Y/l�f?�I OAS-ITA.SYSTEM-OVER4(CA) L•(r9w
' CERTIFICATE OF EXEMPTION FROM WORKERS' GREASERNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Ihlsseclion need nal becomplued iflhePennil lsl'0ronehundeeddollarx(5100) GRHASETRAP
or lees.) PLANCHECK FEE
Icenify that inthe P,Uoonar,calthe work for which this pcmtil Ll.aued.Ishnll SEWER-SANITARY-STORM BA.200 FT.
not employ any person in may manner so as to become subject lu be WorAcri Compcn- ENERGY PITC
Z satim laws of California.Dam / WATER HEATER W/VENT/ELEC R
z O Applicant
.�. GRADING PEE
NOTICE TO APPLICA N'T:If,after making this Certificate of Exemption,you should N'A'T I?R SYSTEMfT REATI NO
SOILS FF.F.
E~ bccomo subject y the Workers Coions or this puts hal of the Labor Code.you nmol
W � Emhwilh comply with wch provisions or pemtit shall be deemed revoked. WAI'13H SERVICE
6 0 PAID
CONSTRUCTION LENDING AGENCY NEW REM I'LMtl. SQ.FT. Date Rcae,gn N
L) O I hereby affirm that is a Construction lending agency for the performance of
W F the work for which faster...1 is issued(SCC.30,],Civ.C.) TOTAL:
Lenders Name
fJ] fender's Address TOTAL:
} W I ccnlfy that I have read this application and state that the above information is BUILDING PEE
H N correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC ItiE
U Z buildiagcommetion,unit hereby Cousin,mpremstalivesafthis city memerupon the
above-auniumed property for inopection purposes PliltMl'I'IS5UANC1? HLCCfRIC THE
(We)agree to save,indemnify and keep homeless the City of CUryman,against
Iiabililies,judgmenls,costs and expenses which may in troy wayaccmc against said City ALTER OR ADD TO MECH. PLUMBING IME
in coulcquence of the grunting of this Permit.
APPLICANT )CRSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IBM)CPM) MECHANICAL FEE
SOURCE REG A'1'IONS
AIR HANDLING UNI'I'(OVER I(1,IX)II CFM) CONSTRUC'T'ION TAX
Signature ofA t - m[nor ! Dae EXHAUST HOOD IW/DUCT') HOUSING MITIGATION FEE
7 ZUS MA'1'ERIAIS DISCLOSURE.
Will the applicant or future building occupant store or handle hazardous material HBA9l NO UNIT(TO 101.00(1 BTU)
as defined by the Cape,ti no Municipal Cotte,Chapter 9,12,tad the Health and Sellly
Code,Scaion 25532(1)1 DEAL INC,ON I '(OVER 100,00011TU1
E]YC' ""No VHVI'ILAT10N FAN(SINGLE REN ID) PAID Dane HecciPnx
W11 the applicant or future building occupant use equipment or devices which BOILER-COMP(3111'OR[00,1X10 BTU)
tit haaurdous air comatummus as deBncd by the Buy Area Air Quality Management TOTAL: J e
DiXhicfl BOILER-COMP(OVER (X1AL0111'1J)
C3Yca Po
I have xW the hmarome materials"mremcros under Chapter 6,95 of the Cali- AIH CONDITIONER ISSUANCE DATE
;4
Ilcu &Safcry CWe,Sections 255115.25533 and 25534.1 understand that if the NEW Bps[DENT]AL MECH. SQ.PT.
ing nal svrrcntly havoc¢a,on.thal it in aiy m,neibdlt, ,,mail,the onvpanl
of lit (Cuts whuhme,I hcntct prior R is.onceol a Crmit tc oIII ancy.
Owner gent Dare TOTAL: ISSUED BY:
OFFICE