99110083 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO F777HUILDINO ELHC'1'RICAh PERMIT
BUILDING DIVISION APPLICATION/PERMIT PLWI ROJECTIDENTIFIC
IfUtLU1N1:1'ROJI!CT ILEN'I'IFIC'ATIOT qq
I'D
ILDING ADDRESS: SANITARY NO. APPLICATION SUBMI ITAL DAT'
1 D Na—W,4AU A, , Z
V;*.M'AC'I
F PHONE� C NI C OR�NA (� � ,/rV1R1• /
N❑IC
Q)MNOLM
CUE view 04
PHONE: BUILDING PERMIT INFO
/IdA ❑ Consullant Fees Paid by Applicant(Initial) In. E21PLU❑MH SUCH
LICCE}NSEDDCCON FRACORR SS DDECLARRXI'ION(, _W QrY ELECTRIC PERMIT FEE lrLrll
I hereby, m food 1 an licensed wade,pn,,i,inns of Chimer 9 oa nunenemg I JOB DESCRIPTION
1=z so At Section'IOW)nl Uis talon 3ofmv Bu,fm.,,mu Profess m ode/ndmylicenseis RESIDENTIAL;
100 PERMIT ISSUANCE
in full force and effect. ❑SFDWL ❑KITCHEN REMODEL.
tUZE,SI
Licemc Lic.M APPLIANCES []ADDITION ❑PLUMBING RE-PIPE
Z u: Uam Cantme
fQa ❑MULTI-UNIT, ❑$TRUCTUItAL
ARCHITECTS DECLA (N
O y PANELS MODIFICATION
t,n z 1 undermmd my Plans shall he used aN public recorI N
UP1'0210AMPS ❑HE17RIOR ❑CHIMNEY REPAIR
F'1a01 Licensed Professional 201-1000AMPS IMPROVEMENT 0SWIMMING POLIS
F.�W OWNER-BUILDER DECLARATION OVER 10fX1AMPS ❑BATH REMODEIIREPAIR ❑DEMOLITION Q 1 hereby aPrm that I am exempt from the Commcmr'x License haw for the
❑OTHER
a V lidlowing reason.ISeaion 7031.5.Hnoness and Professiore Code Any city or county SIGNS ELECTRICAL
O ' which requites a permit m construct.alter,improve,demolish,a repair any tomato
Q, priorto its issuance,also requires the applicant former permit to file a signed stamment SPECIAL CIRCUIT/M is
3ythat he is licensed famuam In the provisions of the Contrn,mr's License Law(Chapter 9
4 Qp�O (commencing with Section 700d)at Division 3 of the Business and Promsoes CWc)or TEMP.MEI'ER RI'OLIi INST. COMMERCIAL•
C^_� that he is exanpt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑OF
Section 9031.5 by any applicant for a permit subjects the applicant nn a civil Penalty of POWER DEV CES 'NANT TOO[)SERVICE
1 m not name than live hundred dollars(55(00.
CSp (] Las owner of tile property.or my empinyccs with wages us their sntoo on.pen nam. SWIMMING )1,ELECTRIC IMPROVfiM
(.. will do the work.and the structure is not intended material for sale(Sec.90,14.Business ❑OTHLR
3 m and Profunians Code The Cnmrumnrs'Liurnse L a,des nm apply m nn owner of OUThIffS—SWI'fC 9— IXTU 'S 12--14 104401tl
property who builds or imprmes thereon,and who docs such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL EL' SQ Ef.
sale.If.however the building orimprnvenent issold sithlnone ycandamnpIxli.n,the SQ.FT.FLOOR AREA E/SQ.pT.
owner,builder will have the burden of proving that he did not build or improve for pur-
Pwco1"snlc),
1,as owner of the proptnY•am exclusively contracting with Iicsnsed emtmaors 10 TOTAL:
onaruct the prnjcn(Sce.7044,Bouire,N and Profr,s"ions Coda)The Convucmr's Li-
nse Use does not apply in an owner of property who builds or improves thereon.and QTY" PLU B ,PERMIT FEE
who contrails for such projects with o comrecloax)licensed pursuant no the Commaors
License law. PERMITISSN
0 1 am exempt under Sce. .B&P C for Nis..,an
Owner Dam
ALTER—DRAIN&VENT ER(I? ) OVALUATION
�5 /
WORKER'S COMPENSATION DECLARATION HACK FLOW PR(YfF.CT. VICE �0(}J( (,1{,.•
1 and
W a0irm under Certificate
of perjury ane of the itutim for W rms'Cor
Ir.as and will maintainSee, IIOcamf the Lab...
kart for Workers Comped- DRAINS—I LOOR,R .GOND. STORIES TYPE CONSTRUCT
roman, r provided for by Sermon 39IX1 of the labor Cndq lin the per(nmwncr of the
farwhidoilthis pantain imucd. FI%'TURES—PEN TRAIT I V•N�.
w bout and will maintain he poria Carne or son Insurance, h required ny Section v 'Y
7 lot the lrbnr Code,for the perfo,mance afthe work for which this permit is issued, GAS—EA.SVSTEM-I INCA(IIJI'hli9'S OCC CROUP
APN
My W'orA yQynl ysmnce came Po yNo'PolicY rykf GAS—EA.SYSTEb1-OVER4(EA) T� 31G'lq•o�e(
Carrier. '{a� 33r�iJ11AA(
CI:RHFICATE O'EXEMPTION FROM WC Rh IRS' GREASUINHUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE: BUILDING DIVISION FEES
(This vctionnecJ nal be eumplaediOM pcnnit ismonehundrWdollars(SI10) GREASETRAP
or less) PLANCHECK FII?
locality Ina(mine pahmnamool thework for shall this permiO,issued,l shall SEWER—SANITARY—SORM F.A.210.0 PI'.
not employ any person in any manner so as to become subject to the Workers Compen- ENERGY FEB
Z cation l,awsof Cnliumi a.Dmu WA'I'IiR BEATER W/VEN"HELECIR GRADING ITE
Z APPlicam
NOUCE*10 APPLICANT:If,after making this Comm cape of Exemption,you should WATER SYSTEMITREArING
F 'N" SOUS FEE
become subject 1.the Worker's Compensmiopr
n provisions at st the"IN Code.You mu
w ti fonhwahcamply with such provisions.,this pnmitsholl he deemed invoked WATER SERVICE
�\ 1
n' CONSTRUCTION LENDING AGENCY NEW'RESIUENTIAL PLMH. SQ.FT. Date Receipt»
U O hombyutiimu atmerelsannn.gme,inn lending agency for the performance of 1,
the work lo,which this permit is issued(Sce.3097,Civ.C.) 1
U Linda's Nome
TOTAL:
U Lenders Address
'�' Pr I cenify dna 1 have mad this application and state that the above information is BUILDIN
lin c rat.I,greetumonply withall city endcounty ordinances and state laws relating to QTY. MECFIANICALPERMIT FEE
U Z building construction.and hereby authoriserepresentatives of this city to order upon the SPJ>.M1C FEE
aMwamentioned property for inspection p ulloca PERMIT ISSUANCE -
(We)agree to save.indemnify and keep harndcss the City of CuNnian again, s
1
Iiahilitics,judgmen¢,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBINGFEE
.......mace of me gcapia,otmi,permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO to."CFM) MECHANICAL.FEE
SO4RtFlUIJq�DONS
I�/�//�/ AIR HANDLING ON[['(OVER I),0dICFM) CONSTRUCTIONTAX
SigI Appli vnVC artm I I 'Dan, EXHAUST 11001)(W/DUCT) HOUSING MITIGATION HE
HAZARDOUS MATERIALS DISCLOSURE
Wflihe app0ca,d a timebtiklingaeenpamsorvia handle hmardaus material HEATING UNIT(TO 100.0010 BTL)
as defined by the Caper .im Municipal Code,Chapter 9.12,and the Health and Safety
Code, II m 25532(a)P HEATING UNIT(OVER 100.000 BTU)
Fl No V ENTILA'IION PAN(S I NGLI:RESID) PAID Date Receipt of
Will me upphoon, ,,Inure building nceupunt use equipment or Javier,which BOILER—COMP(31111 OR 100,000 BTU)
it hmuu
ards air contaminants as defined by Ne day Area Air Quality Management TOTAL:
nr'kts/( ❑No"/i a BOILER—COM P(OVER 100,00 BTU)
AIR CONDITIONER
Ihave mail the harsnlons nwmriuNnahirenanrc same,Chapter 695 of the Cali ISSUANCE.DATE /7
fnmia Bcalth&Safety Crude,Section,255(15.25533 mad 255}1.1 understand that if the NEW RESIDENTIAL MECH. SQ.Firy'
building Jo's nut eon my hnvri cont.mm 0,my m, r, mortify thm�ccuprm / /� /
ofthr reyu c s w ort prior to i'mnce of u Cep lfi o`e i )c nme, (/
Owner na hori¢d,gem ` I Dam TOTAL: ISSUED BY:
OFFICE