S 1455 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUIL)ING-ELECT RICA. PEt IT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-AIECDANICAL J 1455
BUILDING PROJIECC IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPI.ICATION SUBMI'FEAL DATE
Q / e i /` s
OWNEIf,'NAMI:: PHONE: CONI RAC TORTS NAM : LIC NO:
Q V' WC 'ONTROLp
. ARCIIIJ'1?Cf1ENG NHHR: I.IC NO: AD)RE.'S. ❑
CONTACT: PHONE: BUILDING P[iRMTf INTO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
OZZ1 herehy alum the 1 am licensed order proli,i er,of chapter 9(commencing JOB DESCRIPTION
wo, with Section 700(h lDivincer 3ofNe Btniousaal Pmfesaion,Crde.and my license is RESIDENTIAL:
Fw= full forcc;mid ef`gf�(�q� t/�6k PHItMIi'ISSUANCE
�W-' 'a �r��L ✓7 DSPDWL ❑KITCHEN REMODEL.
UZU Liccnse Clues Lic.M APPLIANCES-RESIDIiNT1AL []ADDITION C1 PLUMBING RI PIPIT
t-Q W Dale Gontmclnl
HDrn ARCHI'IEC'I"S DECLARATION PANELS ❑MULTI-UNIT El STRUCTURAL
z p to z I understand my plans shall be used as public records MODIFICATION
pZ=Q
11Y'r021X)nMl'S ❑IN'HRIOR ❑CHLMNHY REPAIR
Licensed Professional 2111-IIM )AMPS IMPROVEh1ENT []SWIMMING POOLS
7 J OWNER-BUILDER DECLARATION OVER NX)AMPS
❑RATA REMODELd2EPAIR ❑DEMOLITION
W, I hereby onium tial 1 oat exempt from the Ca.it... 's Linrae Law lot Lha
W 3 0 6 U fallowing tutor.(Section 7071 S,Business and Professions Code:Any cityacoumy SIGNS ELECTRICAL ❑OTHER
LL N which requires a permit to construct.alter,improve,demolish,or repair any dominate
prior to its issuance,also requires the applicant forsuch p maniran flea.signed statement SPECIAL CIRCUITIMISC.
F, that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
W COO (,nnmoticing with Section 7(XNBuf Di, ion 3of'Ihe 13 co and Pot ..ion Code)or TI?MP.MI?'fER OR POLI;INST. COMMERCIAL,
6 4x0 t' that he is exempt therefrom and the nasis for the alleged exemption.Any violation of El NEW BLDG/ADDITION El DEMOLITION
W-.m Section 7031.5 by any applicant fora permit subject,the applicant ton civil penalty of POWER DEVICES ❑1HNANT ❑FOOD SERVICE
~ 0mousse then five hundred dollars($50().
❑ Lu,miner of the property,or my employees wiN wages as their sole compensnion, SWIMMING POOL ELECTRIC OTHER EMI:
^ will do the work,and lhesauctum is not imendehooffncd hostile(Sri.9164,11nsinesx OTHER
L3 and Professions Cale:The Contractor's License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES y� f{J
pI who builds ar .improved thereon,and who dao such work himself or through A � (J
his own anployecs,provided that such arprovuutenl arc nal insured or oacred for NBW "1 TIAL F.L.ISCTR SQ ITL'.
soft.If,however the building or improvement n odd wide.mrs yearofcompletion.the SQ. R AREA 9SQ.FT.
cr-huilder will have the huNan of proving that he did not build or improve far par- (� 11 pNr
pose of Salo.). {7 /�flWl
El 1,as owner of the progeny,am exclusively contracting with licensed comtmcnrs m TOTAL: C/
cOnrud the project(Sec 7044,liuxiness and Profosioro Code:)The Contractors Li. Ut Lui-
censeLaw diva nor apply to on owner of property who lmildaorimproves therven.and QTY. LUM PERMIT FEE n/QIV
who contract'for such pngce s wall a c ntmctngs)I cerved pursuant to On Contractor 91
License Law. PERMIT Ut A 'E
❑ 1 am exempt anter Sec. ,B Ne P C for this reason
Owner Doe ALTER-DRAT "IIiiWATER(EA) VALUATION
WORnd,,pCOM PENSATIOne DECLARATION BACK Fl.OW PROI'F.C'
vemad will maintain
under penaRyaf ofC.anoae eelf-iolhwing n-Workmtimm -
❑or,a,and dvlForby S,Oium f370 of Comemmself-imsamhe Workersiot h- DRAINS-FLOOR,ROOF AREA.COND. STORIES TYPE CONSTIU=1ON
salon, r p ith bi far by Swoon 3]W of the Lnhur Corfu,for the rlurmunce of the
work lie which this permit is issued. FIXTURES-PEN TRAP
❑1 have and will malnoin Worker's Croce ofthe w rk or alu h required by Section
37000 the Lahur G+de,tiro the performance of the work lir which thi,permit is issued. GAS-RA.SYS'fHM-I INC.4OUTLET S t]C0.GROUP APN
My N'orkcr'Co t satin) nwtance cartitt anJ l'oliny n berg :
Carrier Policy Nu.: GAS-BA SYSTEM OVER 4 fl?A1
CIiRTIFICATE P EXEMPTION FROM WORKERS'
COMPIlNSA)'ION INSURANCE GRP.ASEIINDUS'IRI.WASTE INI'F.RCH"OR
('Thisunin faced not bo contpRcd if'dtelnna it is from,hundred dollars($I BO) BUILDING DIVISION FEES
GREASETRAP or Intl PhANCIII?CK 19iL
I certify that in the performance ofoe 'ork G+r al icher permitisis ed.I stall SEWIFR-SANITARY-STORM EA.200179
not employ any person' any moot Sas u j ( the c G+mpen- ENERGY FEE
IT
O Z anion I.awa a if n .Date n WATER H17ATEII WNEN'I'/EL[CTR
Q Applicant GRADING FEE
NOTICE T6 APPLICANT:If,ager m ng tt
this Cdficn o Eaemton
p ,you should WATER SYSTEM)TREAFING
h'
because subject to the Workers Canteens. Tun pmvisiand n in ubra Code,yon must SOILS PEI?
� s forthwith comply with such provisions canis permit sM1nll be eattW revoked WATER SERVICE
Q
GDNSTRUG1?ON ENDlNGAGENCY NIiW RESIIJF,N'1'IAf.PLMI3. SQ.IeL PAID
LJ 0 Thereby alarm that there isaconstruction lending agency for the performance of Date RecciptM
the work for which This gerund is i..acd(Sec.309],Civ.C.) II
OF't Lenders Name T TAL:
GLenders Address TOTAL:
1 certify shut I have read this application and irate diet the uMwe int maOon is BUILDING FEE
Vas) correct.l agree to comply with all city and county ordinances and state laws reladngo QTY. MECHANICAL PERMIT FEE
V ,� building construction,and hereby aphorize representatives ofthis city to enter nprm the SEISMIC VF.r
chose mentioned pn,vny lir inspection purposes. PERMIT ISSUANCE
(We)agree o save,indemnity and keep harmlesso the City of Crandi ogynt ELECTRIC FF.F,
luddidev,pshorco.costand expenas which may in any way accrue III said City ALT ER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING HE
APPLICANT UNDHRSTA NDS AND WILL COMPLY WI'1'If ALL NON-1101 NT AIR HANDLING UNIT TO I(This)CPM)
SOURCE.REOULA'I'IONS. MIiCHANICALL
AIR I IANDIANG UNIT(OVER 111,000 CIM) CONS'fRUCT10N TAX
Signature of Applicara Comractar Date EXHAUST HOOD(WMUCD HOUSING MITIGATION FE
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant nr linme buildin,we.,antmore or handle hrturdimantmenal HEAPING UNIT TO IW,(XN)BTU)
as defined by the Criticism,Municipal Code,Chapmr 9.12,..,,he Health and Safety
Code Sectio 25532(u)? HEAPING IINIT(OVER 1009( X)BTU)
❑Yee [:1 No VENTILATION PAN(SINGLE RIEND) PAID
Doo kwcipt p
Will the applicant or future building occupant use equipmentor devices which ROIL ER-COMP(3HPOR 1 W,IMO BTU)
emit hazardous air nmtaminant as defineA by the Bay Arca AiritQuality Management TOTAL:
Dlstrlml
❑Yes ❑Nn BOILER-COMP(OVER 100,000 BTU)
I
I have rend the h oarlorsocutriall requirnsulaunder Chapter 095'or the Cali- AIR CONDIT ONHR ISSUANCE DATE
fomia Health R said,Cr ma 25505,2553)and 255]4. ted and that if the NEW RE,SIDEM'IN.MHCH. SQ.FT.
building docs no Cu y no as W.I. mit is my rcsryntsiti ty nl fy th t on ....-
c quires s nab u be d o r m issue c To ni s f( vas v.
O n authorizer ngem )at TOTAL ISSUED BY:
OFFICE