B 0287 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
. IU NG-ELECTRICAL PERMIT Nq/
CITAAF CUPERTINO LMBMEHANICA10287 OL ^7
N BUILDING DIVISION APPLICATION/PERMIT BUILDING PROJECTIDVNI'IF[ A']ON SOOOI `1X
BUILDING ADDRESS: SANITARY NO. APPLICA'HON SUBMI'1.1'ALDA'I'P
�_09oo 34evems ve l< 31v)
OWNER'S NAME: PHONE': CONT BCfOR'S NAME LI NO: WC CON'FRGLR
A//ON duQch 29- �/v7F Xlftau�g S`jer li T., 95 yto
tCHITECDENGINEER: LIC NO: ADDRESS: C� 1A.
e/ t ❑
.l 6 s�i w T/`CJx SO.l'/ll le;; fJlyS
ysNTACT. PHONE: BUILDING PERMIT INFO
r�G 1V(yv�� 2YG 3 F 3 3 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMR MECH
Oavell f/re ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT F17F
1 hereby union that 1 am licensed under provisions of Chapter 9(cmnmencing JOB DFSCRIPTION
O%'iZ with Sectlrr9(IBB).fDlvisimm 3 rRhe Businc,,and Profession'Clasomdmylicemois RESIDENTIAL:
O O A 1117RMIT ISSUANCE
w ty F in full force and a wt T. / ! �b C SFDWL C KITCHEN REMODEL
<UU Laenu CWss. `1—Lic.p U
ZZW nae Commas APPLIANCRS—RESIDENTIAL ❑ADDI'1'I(IN ❑PhUMBWG RE-PIPH
'
of ARCH]I iC'FS DECLARATION PANIiIS CMULTLUNIT [I STRUCTURAL
ZOyZ Iundcrsmnd my plans sM1allMuscJ as public records MODIFICATION
oy_o UP TO 200 AM ❑INTERIOR ❑CHIMNEY REPAIR
F.N.�W I.icenud Professional 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVIiR IIXNIAMPS 11 BATH RISMODEIJRIiPA1R DEMOLITION
%C G I hereby all,.that I am exempt from the Contractor's License Law for the • _
dOLLU ❑OTHER // Y V�
X 6 following reason IScetion]031.5,Business and Professions Ctdv:Any city or county SIGNS ELECTRICAL ' Y V
kW LL y which it, ape also re consbue,alley,improve,demolish,or repair any amaure
FCFq OQ pollo,i, also Iformrimmethep..uPPliwmlor such pemtina fileaslgned smtement SPCCIAL CIRCUITIMISC. 2;
2 (co ce is ting xi pursuant 70th)provisions of the a Business License Luw(Cha Caste)
or '1
MCO (commencing with Section 1p(10)nfDivision Sof the Business and Professions Cude)or TEMP,METE OR PoLIiINST COMMS
`ty c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW NLUG/ADDITION ❑DEMOLITION
Station 703 L5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES CTENANIC1 1700D S17RVICE
,t mare than live hmmanal dollars($51X0.
IMPROVEMENT
=60Los at,of the far"ity,or my employees with wagesas theirsole campansatian, SWIMMING POOL ELECT RIC
TFC will do the work.and the someoneisnot intended or offered for sale(Sec.70aa.Business [_1 OTHER
and Professions Code:The Cnntmetrr's License law does not apply an sea owner of OUTLETS—SWITCHES—FIXTURES
property who builds or infoolo,ocivon,and who does such wok hlmsell'or tbmugh
his own employes,provided Nat such improvements me nm intendul or offered for NEW RESIDENTIAL FLEC'k SQ FL
sale.If.however the building or improvement is sold within nneyeof afennspleiam,the SQ.e?. O ADA $/SQ.IT.
mer-builder will have the burden of proving that he did no build or improve far pur-
po'e.f mlc,7. n
0 1,as owner,cf the propcny,am encloavely comma nogwith licensed conoan°n u, T°"'^'- JUL 0 8 ANinstruct the pnjcct(See.1UW.Business and Professions Cale:)The Crmmcmr's Li- -
se law docs not apply to an owner of property who build or improves thereon,and QTY PLUMBING PER. I' PEE
who contracts l or such projects with a cmnrucluds)licensed Pursuantto the Contractors CIIY Ur uuren I 11
License Law. PERMIT ISSUANCE,
O runt exempt under Sec. ,B&P C for this return
OwnerDote ALTER—DRAIN&VENT—WATER(EA) VALUATION
. N/�S �
WORKERS COM PIINSA'1'I(ON DECLARATION BACK FLOW PROTECT.DEVICE /
I hereby affirm undo penalty of perjurynnc of the following declarations: J
evvV/J
'have and will maintain a Certificate ofConsenuo self-insum for Workers Comped- DRAINS—FI. .ROOF AREA.COND.
m provided for by Section 3700 of the Labor Code,for the performance of the S'IYTRIF.S 'TYPE CONS'TRULTION
k for which this penao is issued, FIXTURES—PERT 1'
,t0 hare and will maintain Workers Comped+inion Insurance,as inquired by Section
.i]IXlofflRi�edr Lahr CCipTalyye,,Yforthe a)//resordaaccofthe weak far whicchhis permit is issued. GAS—EA.SYSTEM-1 C.4 OU'l LIiFS OCC.GROUP APN
ClYriem/isAt0.e_�Ilr nlel2anlicy Na.nd Y,�YG°��ov yvo GAS—EA.SYSTEMOVIi (EA)
CERTIFICATE OF MU( ION FROM WORKERS'
COMPENSATION INSURANCE CRGSL%INUUSTRL WASTE TIiRCITTOR
BUILDING DIVISION FEES
(This section need not becontplmediOhe permit is lar ane hundreddollan(bl(Xp GREASE TRAP
or Its,.) I'hANCHECK PEE
I cooly that in the performance ofthe work o,which Ilia perom,is i.vsmed,],Iran SEWER-SANITARY-STORM IiA. I
nm employ any perso eny manner so as to h)come subject m the Worker'
Camper- ENERGY ENERGY ITE
o z stand Laws California.Dae WATER HEATER WNENTIELECHI f:F.
7 O Applicant GRADING E
.7 NOTICE TO APPLICANT:If,alley nuking this Cerafirwia al'Exemptlnn,you shom WATER SYS I'EMRRENI'ING
(~ h become subject m the Worker's Compensation provisions of the labor Code yaa most SOILS PEE
forthwith comply with such provis mm or this permit shall be deemed revoked. WATER SERVICE
0
CONSere iso'IONLtion lending
NEW RESIDIiNT1A1.PLMN. SQ.PI', PAID
� � Iherchy affrn that iso construction lending agency for the performance of Date 12eceipttl
IL F-' the work for which this pemtit is issued(Sec.3097,Civ.C.)
OU Lender's Name TOTAU
U I.eaa1,,s Address I TOTAL: D
1 certify that I have read this upplicadon Imd.ate that the above information is BUILDING FEE
it y correct.l agree to comply with all city and county ordinances and state laws relating to QTy, - MECHANICAL PERMIT FEE
L) Z building construction,and hereby amhodze representatives of this city to enter upon the SEISMIC FEE
mhove-man cared property for inspection pugmses, I'HRMIT ISSUANCE
(We)agree 70 rasa indemnify and keep harmless the City of Cupanino ugainst HI,GCI'RIC 1117E
Iiabildies,judgmems,cosu andexpenus whidntay inanywuyaccme against said City ALTER OR ADD TO MECH.
in consequence of the grunting of this permit. PLUMBING PEE
APPLICANT UNDFRS'FANDS AND WILL COMPLY WITH ALL NON-POIN"1' A I R HANDLING UNII'('TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNI'1'(OVE IILIXN)CPM) CONSTRUCTION TAX
m
Silammrenf A,IwidlContmer Date EXHAUSTIIOOD ON/Ul1CO HOUSING M ITIGATION FEE
HA9ARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingorcupanl store ter handle hamNous material I IEATING UNIT G 0100,00)BTU)
m definal by the Cupediner Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532ND? HEATING UNIT(OVER HX),00013'1'U)
0 Yes 7Na .,
7 VI3NTILA'1'IUN PAN(91NGLE RES ID) PAID Ionic Receiptk
Win the applicant or fnum building occupant use equipment or devices which
it hazardous air contaminants as defined by the Bay Arca Air Quality Management BOILER—COMP(3HP OR 1 W.(M BTU) 'TOTAL:
moll MOILER—COMP(OVER I0IL0(t)11'1'11)
E]Yes NA)
I have read Ne lmNous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Tama.Health&Safety Cole,Sections 25505,25533 and 25534.1 understand that air, NEW RESIDENIFIAL MECH. SQ,1'L
building docs not currently have vteou 1.that in ismy moramihilay to nnti]y the occupant
of the requirmcnts which moat Fe don.isuonceofa Certificate. ce,inry.
Owner m authndi ed age )me TOTAL: ISSUED BY:
OFFICE