99090126 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PER
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BU1LDINGA61PRESS: SANITARYNO. APPLICATIONSUBMI .DATE
OWNER'SNAME: �� �e N A ORSNA ' A /I LICNO:
Y.A N/C CONTROL#
CIi1TF.C1'l1iNGINEGR: LIC NO: AD RESS ❑
7lab � ✓k at,
CONTACT: P S'Q PHONE: BUILDING PERMIT INFO
S l0 O ' ` ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
1:11:1 ❑
LICINSED CONTRACTOR S DECLARATIONQTY I?LECTRIC PENN II' tl FEEr�
1 hereby affirm that I licensed under provisions or Chapter 9(commencing JOB DESCRIPTION
C0z with Section laq)of M 3,a the Basi dP rasion,Cods,and by 1,cit ei RESIDENTIAL:
O FERMI F ISSUANCE
CSF In full force and eRedj)�a�` 7 (a ❑SIDWL ❑KITCHEN REMODEL
FazU Licen Cly llLiep AppL1ANCCS-RESIDIiN LAI. El ADDITION El PLUMBING RE-PIPE
X44 Dam /— Commcmr
L-Dy ARCHITECT'S DECLAR / PANI31l ❑MULTI-UNIT ❑STRUCTURAL
z e�a z I understand my pons sha11 be used ds public records MODIFICATION
C z-J C UPTO 200 AMPS
❑INTERIOR ❑CHIMNEY REPAIR
j Limnsed Profna.lnnnl 201-1000AMPS LMPROVI:MENT SWIMMING POOLS
a CC¢ 1 hereby afErm OW 1 ant OWNER- pt BUILDER in Contractors license Law for the OVER 11X10 AMPS CI BATH RE MODEUREPAIR DEMOLITION
tz+LLdU fallowing reason.(Section 7031.5,Business and Pinlessions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
O N which requires a permit no cornuate,alter,improve,demolish,or repair any swcare
prior to its issuance,also requires the applicant for such pernluo file a signed statement SPECIAL CIRCUIT/MISC.
W,? but he is licensed pursuant lo benrovosio.softhc ConOucoes Uensc Law(Ch,b,9
BI�0C) (commmitem,with Sectie.90M)of Divisinn3n1fthe Busibs,im Pndesslons Code)nr TEMP.METER OR POLII INST. MAL
d L e y
that he is exempt therefrom anti the basis for the alleged exemption.Any violation el -BLDG/ADDITION ❑DEMOLITION
y LL, Section 7031.5 by any applicant for u pennii suhjnl,the upplicatn to e civil rymulty of POWER DEVICES
y ❑ITNANT FOODS;RVICC
not mom than five hundred
mircry.or n(4500). IMPROVEMENT
F=Q ❑I,us ownendthe propeay,or my employees with wags as their sole compensmion, SWIMMING POOL F.LIiCfRIC
f F,O will do the wark,and the structure is not intended or offered for sale(Sec.9044,Business �OTHa
L3 and Professions Cede:The Contractees License Law does not apply to an owner or OUTLETS-SWITCHIiS-FI%TURES
property who builds or improves thereon,and who class such work himself or though A 1
his own employees,pnwldW thin ouch inmmvtmm�ls am not intended or nlTrred far NEW HESIDEN'CIAL Ii1.BCTR SQ sale.If.however the building or improvement is sold within one year of completion, he I--.SQ.1?FPoS.O Q,4T.
0et builder will have the burden of proving that he did not build or improve for par-
past f le), z-'-Z1
E]1 of be p ops.entun exclusively contracting with hcenrce contractors to TOTAL:
emnsocion n project(S9044 Business dPr r..too,Code)Mae Cmrarrai Li - - - -- - ® ����
c I d not apply to an owner orproperty n Wild:or improvesren
theod QTY. PLUMBING PERMIT. FEE
wnocommbs for such prolectsw Bn acontrecterev
ts)licensed parnnt to the Contractors �I SEP
License Law. PERMIT ISSUANCE
1 ant exempt under Sec. .B&P C for this reason t1
Owner Dare ALTER-DRAIN&VENT-WATER TPA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE _j
I h,m1,,.ffirm under peaai,y.f Perim,mo of the following deelarmano:041 o
(have and%ill maintain a Certificate of Consent td self-insure for workers Coburn DRAINS-FLOOR,ROOF,AREA,CONE). ST IES 'TYPE CONSTRUCTION
sation,as provided for by Section 39W ol'the Labor Code,for the performance of the
work far which this permit is issued. 3 FIXTURES-PER TRAP'
❑1 have and will maintain W'moces Compensation Insurance,as required by Section
37M of the Labor Cale,for the performance of the work for which this permit is issu GAS-F.A.SYSTEM-1 INC.4 OUTLETS OCC.GROUPMy ASN Q
C�WmkefntMensai Incur ncecartie Pol ytNoYnnnte GAS-E.SYSTEM OVER 4(EA)
hh CERTIFICATE OF EXEM17ION FROM WORKERS' LEA
COMI'ENSA'I'IONINSURANCEGRBAST? NDUSTRLWASTEINTF.RCEI'1DR 111LD1X'G 131VISION
(This section need not becompleted a me permit is forone huredreddnllars(SIM) GREASETRAP
or less) PLANCHECK FEE
I ermly Nat i.the performance of the work for whichthis is,mnit is issued,Ishull SEWER-SANITARY-STORM EA.20017.
nm employ any person in any manner vt as to become subject m the Workers'Comped- ENIiRGY PEE
,Z, s pion Lews of Calif ern., Date WATER BEAT 17R W/VENT/ELECfR
0 Applicant GRADINGV —It
h NOTICE.TO APPLICANT:IL after making this Certificate of Exemption•you should WAITR SYS'IEh1/IRHATING xl3P
a beemne subject to the Workees Comnerasmion provisions of the Labor Code,you mast SO 'R FEEL
forthwith comply withsuch provisionsnr this permit shall be deemed revoked. WAHiR SERVICE
.7z CONSTRUCTION LENDING AGENCY NEW RESNENTIALI'LMB. SQI'1'.
. 113
CA LE i•)
C..1 p Ihe¢hy affirm diol them iso cnnswetinn lcrii.gagcncy fmthepeifnmmnu:of I'P ^tDete sax ecel�tb
U. F the work for which This permit is issued(Site 309),Civ.C.) LL� {
U.U Lenders Name —IYITAL:
0 W Ltndnra Address TOTAL:
1 certily that 1 have read This application and same That be above information is 6tL1'DINGIte`
E' rjcorrect,1 agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
U a building xbonnction,and hereby emhorire representatives of this city menta upon me I ISEISMIC FEE
abnvcbeminncd property for inspection purposes. PERMIT ISSUANCE
(We)agree m save•indemnify and keep harmlexs the City of Contain,against ELECTRIC FEE
Tabilides,judgmonts,costs and epertcs" Itm yin any way aecmengai net said City ALTER OR A DD TO M I3CH PLUMBING FEE
in comax, ence of The granting This permit.
APPLICANT UNDERSTAN S AND W COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(To to,"CFM)
SOURCEwREGULAT I MECHANICALFEE
�7�/'t AIH HANDLING UNIT(OVER 10,0(X1 CFM) CONSTRUCTION TAX
Signumr'c o^-Applicuni/Commmor Date EXHAUST HOLD(W/DUC`G HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will The applicant or future Wilding mention store or handle hazardous material HEATING UNIT(TO IM.00)BTU)
as defined by the Cupati.a Municipal Cotle,Chapter 9.12,and The llealth and Safety
Code,Section 25532(u)'I HEA'T'ING UNIT(OVER 100,000 BTU)
❑Yes [:J No VENTI LATION FANS INGLE RESID) PAID '-
Date Rece' p
Will the applicant or nos a building by the B use a Air enl or Management
which m haearaous ab contaminants as Defined by The Bay Arca Air Quality Managemem BOILf:R-GDMP(BHP OR I W,IXq BTU)
i,trlc't} ,
F7 YO, F-1NoBOILIiR-COMP(OVER I00,000 BTU)
1 have read the hazardous mmenuls reyuircmems under Chapter 6.95 of The Cnli- AIR CONDITIONER ISSUANCE DATE
Ban 1{ce1Th&Safuy CWoo:
25505.25533 and 25534.1 understand that if the NEW RESID17N'1'IAL MECH. SQ.Fr..
building dreunoT nt,that it is my responsibility to notify Ne occupanttop, swhic r once odaCcmrca•��o� paDate TOTAL: ISSUED BY:
1, OFFICE