99070089 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY —[• Q aO'7 O O E'S
CITY OF CUPERTINO BIIIhDING-ELECTRICAL 1 PF.RMI[NO.
x ,v1.DINC DIVISION APPLICATION/PERMIT PLUMBING-MF,CIIANICAL SOOO I
BUILDING PROJECT IDENI'IF'ICA'[ION
BUILDING ADDRIISS. D I 1 f ��N 't' iSANIIARYNio APPLICWHONSUBMITTALDATE
� 30-`�OWNER'S NAME: PHONE: _ COM'RACTOR:S NAM is O� �O NO: ��Or0111`` V C CONTARCHITI=IENGINEER: A/' .ICI NO,. ADD :SS:
'orrrnCr: JWw`Q� f L /_ , PHONE: _e.3 BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDGELECT PLUMB ME❑CH
t7 YJcscow. i I �
,
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FE'
I hereby affirm that I am ficenoal under provisions or chapter 9 hamonencing JOB DESCRIPTION
WOO with Sectio.10110)0(Division 3ofthe Businesxand Pmfessiams Co c,and my license is RESIDENTIAL
u10p i PERMIi'ISSUANCE
F .full bsrcc and eBcc(. ❑SFDWh Ll KITCHEN REMODEL
HQLicense Cinss e"� Lic.N Q kppuoArllpPPLIANCFS-RPSIDIiM1Al. ❑ADDITION [I PLUMBING RE-PIPE
�<a Date-Conwcmr
FDN ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
zco24 1anha minty plans shall he.sed as public records UPT021p AMPS MODIFICA'T'ION
OZ'^0 ❑INTERIOR SOCHIMNEY REPAIR
Hy•~•J Licensed Professional 201-100AMPS IMPROVEMENT E]SWIMMING POOLS
X� OWNERe,mirDERm CLAontrum OVER ISIOAMPS ❑BAI'II REMOL]I:IJREPAIR DUIiMOLI'1'I N
OOCC 1 hereby arfiw that 1 R-exempt from me RATIcmr's License Luw(or he �1
se.O d U following reason.(Senna 7031.5.Bomitess and Professions Code:Any city or comay SIGNS f:LECIHICAL �OTHf.R
1+13 O y which requires a permit m Consuun,ober,inquuve,demolish,or actinic say orwom, YI DO I(__. -�
C= 5 prior m its hansom,also requires the applicant for such p outdo file a signal emtemetn SPECIAL CIRCUIT/MISC. FIF
f�} that he is licensed purtt
suano the provisions of the Contractor's License Law(Chapter 9
Lail pSQ�O (commencing with Senion]fNq)Of DtvisionJ of the Rosiness and Professions Code?or TEMP.MEfERORPO :)NST. COMMERCIAL:
d y o y (list he is exempt therefrom and the hosts for he alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
1`X1 R Section]NLS by any applicant far apcwil subjects the applicmnoacivil peamy of POWER DEVICE TENANT ❑FOODSERVICE,
F, } t more than five hundred dollars($910). WOOTHLR�
❑ 1.as owner of the property,or my employees with wages as their sole compensation, SWIMMING OI.GLECTRI� will do the work,and the swcture is not intended or offered for sale(Sec.]6W,Business �'ItI
W m and Professions Code:The Contractor's License law does not apply to an owner of OIDL -SWITCHCS-IB63^ hghhis own employees,provided that such improvements ureoat intended m ollend for N RESIDENTIAL Fl.EC[R Qsale.lLhoucverythe Wilding or improvement is sold within one year ofcompletion,the ARS/SQ.wnfi,builder will have the burden of proving(hu(he did not buildmimproeforpar-poseol'snle.)Las owner of the propcny,am exclusively Contracting%:kb licensed csmlmcmrs to TOTAL:
nstmet the project(Sec.7044,Business and Professions Cod.;The Coms cense Luw does notapplym an owner ofpmpeny who builds or improver(hereon,and QTY. PLUMBINGPERMITd1Q
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
Limnsc I.W. PERMIT ISSUANCE
I am exempt under Sea ,B&P C for this reason
Owner Dam
ALTER-DRAIN&VENT-WATER EA) VALUATION
�O
WORKERSCOMP1iNSAT10N DECLARATION PACK):LOW PROI'[CT.DEVICE �s•
1 hereby ulRrmunder penahy Of perjury one of the following declarations:
I Ihavc and will msintaina Centficme of C.nmmto ulGinsure for Workers Compcm DRAINS-FLOOR,ROOF,AREA,GOND, STORMS TYPE CONSTRUCTION
\t
\ tion,as provided for by Section 37NI of me labor Code,for the performance Of the,work for which this permit is issued. FIXTURES-PER TRAP
I have send will maintain Worker's Compensation Insum me,us required by Section
`1100 of mclaMrCode.l.nlie pcdortnance of me work fur which thin permit is issued, GAS-EA.SYSTEM-I INCAOUTLE OCC.GROUP f"i�'N
My Workc);1Fm0pesmiyalnsnrangc nmier and Policy n,�tE e ,/ s
Cartier:��r(,_,,{{,,-- ---FF'LLs..66'' Policy No.:^tl'rc�! 7�`t'Y GASB-IiA.'SYSTIiM-OVER4(EAI
CF.RTIFICATEOFEXEMPION FROM WORKERS' (/(�ap0 GREASMNDU.WRLWAST]zI RCEPfOR 0
COMPENSATION INSURANCE BUILDING DIVISION FEES
(I Infix need not he comploed if the permit is for one hundred dollars is Ioff GREASETRAP
or IcssJ PLANCHECK FEE
I certify that in perfnwancc.f mework for which this Permit isissued,I shall SEWER-SANITARY- Y)RM EA.2(01 19'. '
III,(emos
ploy any in any mm...vr sn ox became subject to the Workers'COmpea- ENERGY Ffili
Z robe.Laws of California.Data WATER HEATER W tNTIELECf t
Q Applicant I GRADING FEE
NOTICE In APPLICANT:IL after making this C,,mficnte of Exemption,yon should WATER SYSTE CREATING
(~ become subject to the Worker's Compensation provisions of the labor Code,you must SOILS FEE
Wforthwith comply with such provisions or this permit shall be,deemed revoked. WATER SER CH
Q
O
CONS H
RUCONLENUINGAGENCY 'WRF DENTIALPLMB. SQ.FT PAID
1 hereby aRmt that there is a ronswcuon lending agency for the performance of Date ReaeiP tN
the work for which this permit is issued(Sec.3097,Ci,C.)
1+' U Loaders Name TOTAL:
WLenders Address TOTAL:
Q., 1 certify that I have mad this application and state mat Ne above information is BUILDING IEE
to correct.I agree to comply with all city and county ordinances and scute laws relating In QTY. MECHANICAL PERMIT FEE
UZ building construction.and hereby authorise u,nowmatives of this city m enter upon the SEISMIC PEE
ammo,mentionW pnspeny for inspection purposes. PERMIT ISSUANCE
(We)agree us se,indemnify and keep hmmless the City of Cupntiu,against ELECTRIC FEE
save,
habilitteajudgmcnts,costs and expenses which may in my way accrue against said City ALTERORADDTOMECH.
in consequence of the granting of this permit. PLUMBING ME
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Ig01k)CPM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIryOVER IQf1D1 CFM) CONPWRUCION'1'AX
Signature nr AppliamVC.nvacmc Dam EXHAUSTHOOD(W/DDC[) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant mom or handle hvardous material HEATING UNIT(in 101),000 BTU
ns defined by the Culonitm Municipal Cade,Chapter 9.12,ono the I Iealth.,,it Safety
Coda Section 25532m)° 1[RATING UNIT(OVER I00 BTU)
❑Yea VNo VENTILATION FANgK111.13,RESID) PAID -
Will the applicant or future building occupant use equipment or devices which Date Ruupt M
Alm mit ha mrd nus air comaminentsat definM by the Bay Arca Air Quality Management - 'BOILER-COM 111P OR ILD,000 BTU)
TOTAL:
isuta4 BOILER- MP(OVER 10(too U)
FJ Yea
ONO
AIR C DITIONER
I have read the h ode.Se mamd 55 5,11.memos under Cholnct om 0f the Calle �jISSUANCE UA
buildigdoes&Sufcty Cala Sections 25505,is my and ombali.1onotify th that ifthe N RF.SIDPNTIAI.MEGA. SQ.FT. `1" J ^v
buildingdosnot currentlyhaveu(o It
o ismyon.ructtlttytri notify the rccupam
.(the rrquim which moa be Frit missuance nfu CeniOcme fQc icy.
Owner nr umh .gem Date TOTAL: ISSUED BY:
OFFICE