S 1811 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull"ING-ELECTRICAL Pe rl'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMIIING-MECHANICAL 1811
BUILDING PROJECT IDENT IEICATION
BUILDINGADDRISS: 1 a � / SANI'T'ARY NO, APPIACA'I ION SUBMITTAL DXIE
OWNS 'S NAME: P�N�^ g'D CON t OR. A ': LIC NO'
// NIC CONTROL#
Alt I ECT/ENGINEER: LIC NO. ADD i ❑
CONTA PHONE, BUILDING PERMIT INTO
6 '9 33U ❑ Consultant Fees Paid by Applicant(Initial) BLDG Inc PI.Uh1R MECD
LICENSED CONTRACTOR'S DI:CIARAI'ION QTY ELECTRIC PERMIT FEE
1 thereby aRmt dtm I alta Bcellsed order pros6ml:s of Chapter 9(commencing JOB DESCRIPTION
WOO with Sedicn91g0)off"I'm -off csusinesnnd Prnf.,,ionac d license is RF.SIOP.NTIAL:
WOO ''9 I'13RMII'ISSUANCE
FWWll In full force andeRect. Cff 0/ ❑SIDWI. ❑KITCHEN REMODEL
aUV ClL¢ense I Lic.# APPLIANCES-RE.SIDENHAL []ADDITION ❑PLUMBINGRE-PIPE
�ZQWW Dn o Cnnlrecmr
Fy ARCIII'I'ECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O1 understand at,plans shall be used is public records MODIFICATION
OZ-q UP TO 200 AMPS [I INTERIOR ❑CHIMNEY REPAIR
��pW IJmnsW Professional 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
�Sd OWNER-BUILDER DECLARATION - OVIiR 11NN)AMPS ❑BATH REMODEVItEPAIH El DEMOLITION
CC a I herehy arm+thin 1 um cxen+pt from the Contractors License Law for the
x 3 W El OTHER
�� whichfollown,kine,a. rourstuI Z...no5.er,Ooui r,poli Nofoan C or sp n an orcountySIGNS ELECTRICAL
y whichraryiresnpermit n+ions the applicant
for such permit
ore a liranyswarm
Ems}7 didlieshets oecdprsuntto the thcapplicunlfne Comeon,Lito ease aw(Chruld mmem SI'F,CIAI.CIRCUITIMISC. Y
Inco he is Ecenned pursuant to prnvi<iam of tM1e Contmclad License Law(Chi
(commencing with Section 7010)of Division 3 floor Business and Professions Cade7or THNIRMEIT1RORPOLHINS'1'. COMMERCIAL
W
Qo O thus he is uxentpt narufmm and the basis for the alleged exemption.Any violation of
[I NEW BLDG/ADDITION ❑DF:M01.1TION
,MWSection]101.5 by any applicant for upe.I,wbl llteapplicamm a civil penalty of POWER DEVTCTS
not more than live hundred dollms($5IX). ❑TENANT ❑TODD SERVICEFSC ❑Las owner nfthe pmpeny.army employees with wngcs as lhcirsnlenmtpens;cion, SWIMMING POOL.ELECTRIC IMPROVEMENT
rill nmhe wnrk,and the dominate is not intended ornRered tarsals(See.FM4,13minl, OTHER
a 3op
.^ and Noteseinne Cale:no Contm en's Liceasu Law Jens not Apply ,,un owner of OIJTLETS-SW I'1'CHPS-FIXTURES
pmpemy who builds or improves therein,and who Anes ouch work himself or through
his own employees,provided put such intervention;are not imendN or offered lar NEW RESIDENT AL ELECT R SQ FT'.
sale.if,[lowlier,he heilihm,or imprnvemmat is sold within one year ofcompletion.the SQ.FT.FLOOR AREA 5lSp.Fr.
owner-builder will hove the burden of moving that he did not build or improve for pur-
poac of side.).
F71,as owner of the pmpeny,am exclusisely contracting with licensed comm n m to •rorAL:
construct the project(Sec.90,14.Business and Pofensinn.s Colo The Connector's Li-
cense,Law does and apply toanowner ofproperty whobuilds orimproves thereon,and QTY, PLUMBING PERMIT FEE
whoeonweu forsueh projects with a cnmmctur(s)licensed pursuant mthe Cuntmcmr's
License Low, PERMIT ISSUANCE
1 am exempt order Soc. .li Ar P C for this reason
ALDER-DRAIN%VEND-WATER D!A) VALUATION
Owner UIO
• Wfn under PCOMET?Nqua,on DECLARATION BnCK FLOW PItOTECr.Il1iVICl?
hereby nlflnn under penalty of perjury one of the fallowing d arkeir in or
❑Ihuve andwied fo F, eCcnilicmc of Cnmcnor Code,
for Wmkds Gtmpen- DRAINS-FLOOR.ROOF.AREA,COND. STORIES 'IPPR CONSTRUCTION
,mi.n.I as Inch bd for by Section 7710 of the Labor Code,for the pcHamMnce of the
work fn Inch Nis pemtit is lssned. FIXTURES-I'ER'IRAI'
c and will maimmir Workers Compensation Neurone,its rcyuired by Section
3700 mOleLoom Calc,for the performance of the work for which this permit is issued MS-[A.SY$T'1iM 11NQ 40U'rLETS OCC.GROUP APN
My Worker 'ompen I nonce carrier
IPoli:.y nun:M1e a^�
Carrier:-(3�f - - Pol icy Na.: AA a'� GAS-EA.SYSTEM OVER 4(IiA)
;EItTIFIi` t CAT T 10N IRDM WORKERS' GRHASEANDUSTRL WAS TE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
flhisuetian need not he completed ifthe pound is for one hundred dollars 05100) GREASE-TRAP
or IasaJ PLANCHECK fli6
I ready that in the performance of the work[or which this permit is issued,l shell S17WER-SANITARY-STORM EA.20X1 Ff.
not employ any person in any manner was to hewer,suyiem o the Workers'Cooper- ENERGY RIF-
Z amino Lows o1 California.Dare WATER HEATER WNENTIELECUR
�1 Applicant GRADING 1FI3 S
� y NOTICETO APPLICANT:If,after malinglnie Cemifemeuf Exmnption,you should ' WAT'ER SYSTEMITHMA'I INE
a ; become subject to the Workers Compensntinn pinemar s of the Labor Code,you muss SOILS :F.
forthwith comply w a lionehpnrviman—,thispermil,inel be deemedo,oked. WATER SERVICH
a Q
CONSIBUC'1'ION LENDING AGENCY NEWRESIDT:NTIAI.I•hMB. SQErr.
.
U O PAD Date J r s attempt x
I herehy nflirm thauhere iso construction lending agency for the perfomtanm of -r\ J
the work R,r which this permit is issued(Sec.30197,Civ.C.)
1'L' F Lenders Name TOTAL:
Lenders AJdrexs r ll AL BUILDING PER
I certify that I hove read this application and state that the aMrve information is
LFi fA correct.1agroeIt,comply with All city Ann county ardinanee..and,nate News relining to QTY. MECHANICAL PERMIT FEE
U a building candructinn.and herehyunionize representatives of this city to enter upon the SEISMIC FEE
iNwo-memianel pn+perty for impection purposes. PERMIT'ISSUANCE
(We)ago.to save,indemnify and keep homdess the City of Cupenion against ELECTRIC FEC
bdolhics,judgnrems,costs and expenses which may inany way uccrueagainst said City ALTER OR AD?)IO MECH.
Isap:ence of the gronting of this Permit. PLUMBING FEE
APPLICANTUNDERSTANDS AND WILE.COMPLY WITH ALL NON-POINT Alit IIANDLING UNIT(TO 10/0NI CI'hH
MECHANICAL FEE
SOURCE RCGULAI'IONS.
AIR HANDLING UNI'T(OVER 10.010 CPAP) CONSTRUCTION TAX
Signature of ApideantlContramnr Date EXHAUST HOOD OW/DUCT) HOUSING MITIGATION FEE
I IA9ARDOUS MATERIALS DISCLOSURE
Will the npplicam or future huildir,is,uisca,mrcorhande haaiodomminenal HEATING UNIT(TO 10.00 BTU)
;is defmN topic Cupatlno Manumia l Cale.Chapter 9.12,and the health and Safety
Code,Section 23532(107 HEATING UNIT(OVER IOPOC)BTIH
E3 Yes E3 No VENTI NATION FAN(SINGLE RBSID) PAID -
Dam Receipt x
Will the applicant or future bailiffs,occupant use equipmem or devices which BOILER PIT OR 100.1)(1)BTU)
snit h:rmNous Air contaminants as doffed By the Bay Arca Air Quality ManagementH: s
District? BOILER-COMP(OVER liability)BTU)
❑Pus El No
I hae mad the hamNnus mamriaH tq
euirta mm� under Chapter 695 of the Cali- AIR CONUI'HONER ISSUANCE DATF. Q
forma Ileallh%Su&ty Cale.Sections^3505.3533 add 25534.1 nldemand that'I tha NEW RES IDENTIAI-hlliclL SQ.IT.
builAingAa• rid scorch lyhav ,ham it is myrtxpnnsihilityto tifylhen upam
of Cher est met pnnnoirmyr,ofaCeIt I -of dbo y.
t,, ( qq
Owner tar amhonrcJ agent
Dink TOTAL: ISSUP.DBY: Tr--
OFFICE