B 0347 I' APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PE lyes NO 347
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. SOOOI , JJy'
BUILDING PROJECT IDFNTTI+ICA'I'ION
BUILDING ADDRESS' SANITARY NO. APPI.ICA'I'ION SUBMITTAL DAG
& 0 511[JV
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC /yr-
NO�y/,{. NIC CONTROL#
WITHITHGCUENGINBER: LIC NO: AUURPSS, ❑
CONTACC PHONE: BUILDING PIiRMI'F INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEEC'1H
El ❑ ❑ KZ
LICENSED CONTRACTOR'S DECLARAI HIN QTY ELECTRIC PERMIT FEE
I hereby affirm That I am fircr sed under provisions of Chapter 9(commencing JO DESCRIPTION
C k'LZ with Section7000)nf Division 3oflhe Bosincrainl Professions GMC,and my license is RF-SIDENTIAI:
P,(5 PERMIT ISSUANCE�.. um full liuca and clYyft.� --1� �, ❑SPDWI. ❑KI'TCHF:N REMWF.I.
1. correct Cl Lic.p�+ APPLIANCES-RESIDENTIAL ❑ADDITION E3 PLUMBING RE-PIPE
H,
G 4 Dart / 0'9 Cnnwmor
FOM ARCHITECTS DECLARATION PANELS ❑MULT-UNIT ❑STRUCTURAL
Z O tt2 Z 1 understand my plans shall he used a.public racmdv MODIFICATION
OZ—O UP70200AMPS [I INTERIOR ❑CHIMNEY REPAIR
(:.BCW Licensed Professional 201-I0(IOAMPS IMPROVEMENT L]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEI/REPAIR ❑DEMOLITION
K t I hereby offers That I am exempt tram The Contractors License Law for The
1 O W V fallowing reason.(Section 7031.5,Business and PrnfesNons Code:Any city or county SIGNS ELECfRICAI. ❑OTHER
W a R.F which re9uirea a permit to conslt et,site,improve,demolish,m repair any onemfe z
FSO prior to its issuance.also requires the appireartfor such Permit o fileasigned statement SPECIAL CIRCUITNISC.
} that he is licensed pursuant to she provisions of the Contractors License Law(Chapter9
(commencing with Section 7000)of Division 3 of the Business and Professions Coca)or THME MET I?R OR POIX INS I' COMMERCIAL:
M ly a¢O' that he is co mpt therefrom and the hoses fm the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
YXI 4M• Section 7031.5 by any applicant for a Permit subjects the opplicam my civil perallyof POWER DIIVIC'S ❑TENANT ❑FOODSERVICE
yy noo
t mm Than five hundred dollers(SSW), IMPROVEMENT
C]I.asnwnerof The property,or myemPluyeea wish wngn ea Theirsnle nmmpemrcaion. SWIMMING POOL ELECTRIC
will dothe work,and the structure is not intended maintained for sale(See7614.Bovines. []OTHER
unit Professions Cole:The Contractor's License Low docs not apply m an owner nT OVf1,BT5-SWITCIH'S-FIG
URES
prnpcny who builds or improves thmenn,and who dace such work himself or dvaugh
his own employees,provided That such unpretentious me mot intended os ofTercd far NEW RESIDENT1A1.IiLECflt SQ IT.
sale.If.huwetm the building or improvement is sold within one year ofcotnpletion, he SQ,IT.MOOR AREA ASQ.p
owneohudder will have the huNen of proving that he did not build or improve for pro,
psse of w1c). -
1,us owner of sM1e pmpeny,em exclusively romnucting with licensl canoselars To TOTAL:
mmaucl the project(Sec.7014,Bswiness and Imucc inns Code:),M.Contractor's Li-
sense Law does not apply it)an owner ofpmpcny who builds or improves thereon,ad QTY. PLUMBING PERMIT IEE
who contracts for such projects with a conTmmons)licensed pursuant to The Conamo rs
License Low, PERMIT ISSUANCE
Tom stamps under Sec. ,B&PC far this reason
ALITiR-DNAIN&VENT-WATER(FLA) MAY 1 �A IJVJ
Owner Dlnc
WORKER'S COMPENSATION D17CIARATION BACK PLOW PROTECT'.DEVICE.
pi
1 hereby aBinn under penalty of perjury one of The following decimations:
I have and will maintain a Ces ifimno ofConsenl to selflunare fon Worker's Coiner. DRAINS-FLOOR,ROOF,ARHA,COND.
station,as provided for by Section 3700 of He labor Code,for she perfur nonce of the
STORIES 'I'YI'E C NS'TRUCTION
work for which This permit is issued, FIXTURES-PER TRAP By
I have and will maintain Wnrkcr's CompcnOtinn Imumnce,as required by Scaian
3700 of the labor Code.for the performance of the work for which This permit is issued. GAS-EA.SYSTEM-I INC.401)'11EI:S OCC.GROUP APN
My WorkeesF Niandiomimua ea 'crand Policynumberare:
Cameo 11tlm C Policy No.:tJ O LL�/Itt"If 2jionts, GAS-EA.SYSTEM-OVER 4(f•.A)
CHR' FIATEC OPLI'TIONFROMWORKERS'
COMPENSATION INSURANCE GREASFANOUSTRI,WASTE INTERCEPTOR
BUILDING DIVISION RES
('This section need not heemopleted ifthopenat is for one hundred dollars($100) GREASETRAP
nr less.) PfANCHECK RF,
I cerify that in performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.2(1)FT.
not employ any person in any manner so as um become subject to the Workers'Compen- ENERGY ITE
zz Nation Laws of Culillunin.Date WA'I'IiR HEA'fERWIVENTNLECTR
Applicant 1 GRADING FEE
rN.
NOTICE TO APPLICANT.If,after making This Certificate of Exemption,yen should WATER SYSI'HMTRRA'1'ING
a become subject to the Worker's Connpenmtinn Provisions of the[.,,bar Colic,you in ntvI SOILS PGE
[[7 forthwith comply with such prome
visions or This permit shall bedeed revoked. WATER SERVICE
0. 0
rte. Z CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fn PAID Dace Re � Tb
V O Iherebyaffirmtha0here iso aommation lendingageocy(",the performance of
The work for which this permit is issued(Sec.3097,Co.C.)
0 UU. P Lenders Name TOTAL:
O V Lenders Address TOTAL:
I� d Icenify that l have most this application and state that the above information is BUILDING FII.: V/
correct l agree to comply with all city and county ordinances and state lows relaxing to QTY. MECHANICAL PERMIT IHiF-
UZ huilding construction,and hereby authorize representatives of Thorny to micrupon l he SEISMIC FEE
obove-mentioned property for inspection purposes. PERMIT ISSUANCE
I We)agree to save,indemnify and keep harmless the City of Cupeninn against ELECTRIC FF E,
Iiahilities.jadgmenu,costs and expenses which may in any way acerae against said City ALTER OR A DD TO M ITCH.
in consequence of the granting of this Permit. PLUMBING 1717EAPPLICANT UNDERSTANDS AND WILL. O, PLY WITH ALL NON-POINT AIR HANDLING UNIT'TO IQIKK)CFM) MECHANICAL FEE
SO ItF.GULnf1ONS.
_ C l �(♦ I r 11"/[x0 AIR HANDLING UNIT(OVER IO.(KK)CFM) CONSTRUCTION TAX
Sm at Applicant/Contmctar IIain1?%IIAIJST IIOOD(WIOUCI') HOUSING MI'T'IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicants or future building occupant store or handle hazsNnus momrml HEATING UNIT(TO 100,000 HTU) 0
vs defined by the Cupeninn Municipal Code,Coupler 9.12,and toe Branford Safety
Cattle,Seetinn 25532(07 BEAT ING UNIT(OVER IMAM ITT To
E]yes VENI'ILA'I'ION PANS I NGLE RENO) PAID
Dune Recclpa 4
Will she air comas or furore building by the H use equipment or Marta which BOILER-COMP CHP OR 100,100 BTU)
emir hazaNnus air contaminants as defined by The BajsArca Air Quality Management T AL: O
�DIs1ITC1'( Ycs tJ^ HOT 1.HR-COMP(OVER 1110,010 BTU)
I have real Ibe hazaNnus nmamriWs requimsncnts under Chapter hAIR CONDITIONER 95 n(the Cali- ISSUANCE DATE
fame.Hrulth&Safety Cade,Sections 25505,25533 and 25534,1 understand that if dm NEW RESIDENTIAL MHCH. SQ.FT.
Wildim does not cnrcn11,have. That it is my respunsibilil,To notify the..,at
of the 2me-its which must hs sect prior avuentt uta Cenificm 57
of Dycupancy.
w\e1�e Y 5 f Iy 1_99
�
Owner mauthoniacd agent )ate¢ �f ISSUED BV:�
OFFICE