31280 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. XJ oO O
[BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICAI ION
BUILDINGADDRESS: SAN]TARY NO. APPLICATION SUBMITTAL DATE
a3 Flo RaimoUllspisxwo le o Q L
OWNERS NAME: ['HONE CO fNACTON;SNAMB: LIC NO'.
CU til u Seo c—i NLtiA..t�CCK lq Eon( 41". S NIC conraoE.a
ARCHITE [ENG NEER: 0 LICNO: QBE ADDRESS: ` ❑
—Fil N 41r K Z e 2 NEa
CONTACT, PHONE: eLgJ�a 9�T bq BUILDING PERMIT INFO
949-8(,q—s»� ❑ Consultant Pecs Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
c C40 1 - 66-1 ZEZE L Y 'rf "te
LICENSED COM FACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby amort that l am firemee ander pmvisionx of Chapter 9(commencing - JOB DESCRIPTION
O0Z with Section 7000)of Division 3 ofthe Busi.essand Profession,Cale,and my liccnscis RESIDENTIAL:
❑
a�0� in fal l force and effuse. PERMIT ISSUANCIi
U Littnsc Clas: Lic.p 63S SFDWI, C KITCHEN REMODEL.
FZYi1 Dam Cnmmr- �� APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Fly ARCHITECTS DECLALATION� ❑MULTI-UNIT []STRUCTURAL
ZOy-., Ypanas a public 1. - PANC:IS
N Z 1 on emmnJ m h 111 be used as blas reroMs MODIFICATION
OZ- 3{a09fa UP FO 100 AMPS ❑IN'I'IiN10R El CHIMNEY REPAIR
t-t3 f-W Licensed Professional 201-IIXq AMPS IMPROVEMENT
< X OWNER-BUILDER DECLARATION
C� -) OVER 11XOAMPS ❑BATH REMODEUREPAIR [I DEMOLITION
y �Q I hereby affirm that 1 a-exempt form the Contractor's License Law for the
x 3 d U following m-on.(Section 7131.&Buxair,,and Pn ft,,,O ns Calc:Any city nr count, SIGNS ELECTRICAL C OTHER
W 40.� which tequires a permit to commiel,alma,improve,demolish,or cetera,any strvcmre
t'-OQ priormi&issuance.else requires the applicmtfor such pemtino filersigneJ smmmrnt SPECIAL CIRCUIT/MISC.
}'U that he is licensed pursuant to the provisions offs,Contractors License Law(Chapter 9
rp0 (commencing with Section 710X11 of Divi,ion 3 ofthe Badness and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for Nc alleged exemption.Any violmion of
40 NEW BLDG/ADDI'U(lN C DEMO],['[[ON
_ob Scom.7031.5 by any applicant fora permit subjed,,,he epplicanno a civil pemIt,of POWER DEVICES
m of more than five hundred dollars ISSUE), .PANT FOOD SERVICE
H Z i IMPROVEMENT
Q ❑ Lo.ownernl the propcny,remyotortmees wilhwages rsaleintde co-pensiness SWIMMING POOL ELECTRIC STweT.J Jo as.o
C will dothe work.and
r:ThcCimarrsnminmnuse Lo i do forutaplyn an Rosiness ❑OTHfiR
W m and Professions CMe:The Contrrcmr's Licenu Law Jtas not apply m an owner of OUTLETS-SWITCHES-FIXTURES
progeny who builds or improves thereon,and who does such work himself in through T
his own employees,provided that such improvements art not intended or offered for NEW RESIDENTIAL ELECfR SO FT.
side.If.however'he building-improvement is sold within one yearo(completion.the SQ.IT.FLOOR AREA VSQ.FT.
owner-builder will have the burden cf proving that he did not build or improve lin pur-
'a,ofsalc.).
O 1,as owner of the progeny,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.TWJ,Business and Professions Code:)The Contractor's Li-
rinse Law docs not apply u)un owner of po my whit bui Ids or i-proves Furman.and QTY. PL LNG PERMIT FEE
who contracts for such projects with a contmmorts)beensrd pursuant to the Contractors I
License law. PERMIT ISSUANCE
lam exempt under Sec. .B&P C for this reason
ALTER-DRAIN& NT- (EA)
Owner Mir ��� VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW P E 3o Doo
1 hereby afirm under penalty of perjury one of the following declarations: h
0 (have and will maintain a Cenificam of Consent to self-insure for Worker's Compen- DRAINS-FLOG ARF ,C ND. IlI)ry STORIES TYPE CONSTRUCTION
r fiun,as provided for by Section 371X1 OI m�
the Lis.,Codc,far the pe,umec of tb, V
whicM1Nis permit is issued. FIXTURES-PER'I'RA SNE - I
[I}P(have and will maintain Worker's Compensation Insurance,as required by Section -I�1
3701 ofthe Labor Code,far th, rfmmence ofthc workfor which this it is ism 1, GAS-EA.SYSTEM-I INCA S
a perm OCC.GROUP APN
My W-ker pcnsainn Insurance armor and Policy numb r me
Car rie, UnIpE�T �I�'—Policy
Nn.: ISG 31_5T3 GAS-IiA.SYSTEM-OVER4(IiA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thisscetion need not be completed lRhepcmtit is foronehundaddnllars(Stool GREASETRAP
or less.) PLANCIIECK FF.F.
Immy that in the tecommarom nfine work for which this Immut is issued,I shall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any mannerso as to btt
ccome.wbjeco the Wmkets'Compen- ENERGY FEE
zZ sstion Laws of Cmifomi..Date WATER HEATER WNENr/ELECfR
0 Applicant GRADING FEE
H NOTTCE'DO APPLICANT.If.ofmr making this Ccnificme of Exemption,you should WATER SYSTEM/1'RCATING
? become subjeel to the Worker's Compensation provisions of the Labor Code.you must SOILS FEE
UJ forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
7 Z CONS'1'RUC'1'ION hFNDING AGENCY NiiW RESIDENT IAL 1'LMB. SQ.FT. PAID
UQ l hereby affiren that is a construction lending agency for the performance of Da Receiptp
the work for which this permit is issued(Sec.3097,Civ.C.)
lenders Name TOTAL:
Lenders Address TOTAL:
1 certify that have, it this application and sone that the above information is HUI,) 'F
IjO correct.)agreemc! ply withau city and county ordinances and state lams miming to QTY. MECHANICAL PERMIT FEE
U Z building corrouctit .and here"authntiee mprtsemmives of this city to enter upon the SEISMI'1 -E
t--I above-mentioned �e��r fm inspection pumous.
(Wet agtc osuvgi idnnoify andkcepharmlessth'City of Cu,wrlmo against PERMIT ISSUANCE. ELECTRIC FEE
liabilities.judgme ts,conxaodexpenses wbichmey in any wayn,nue against said City ALTER OR ADD I'D MECH.
nuquenceo he granting of this P< it. PLUMBING FEE
AI'YLICANTU DFRSTAN )WILL COMPhY WITH ALL NON-POINT AIR HANDLING UNIT G70 10.000 CFM) MECHANICAL FEE
SOURCE tOL A t
1O 101,t AIR HANDLING UNIT(OVER QdW CFM) CONSTRUCTION TAX
Sign reIthm
ndCmanacor flute EXHAUST HOOD OVMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wimmo or Entire building acap.ntemre or handle hazmdousnimerlal HEATING UNIT(TO I Eli BTU)
m definedpenino M al Code.Chapter 9.12,and the Health and Safety
Codc,Sec (a)7 HEATING UNIT'EOVER 100,000 BTU)
El VENTILATION[AN(SINGLE RFSID) PAID
Will thea Beam or famre building t use a mem or devices which Dore Heccip k
pp gbytheD quip BOILER-COMPTHPOR 100.0001OLF,
40,emit haraNnus air contaminajarmad by Ne Pay Arta Air Quality ManagementDistrictT TOTAL:
Ycs HOILI?R-COMP(OVER IW,1XX18TU)
1havereadthehvaNlz AIR CONDITIONER
r quiremena under Chagcr ti.95 of the Cali ISSUANCE UATF:forma Health&Safety Cak, 5505.25533 and 25534.1 understand that Bthe NEW RESIDENTIAL MECH. SQ.E..
1addm,dtusnmcumcmlyhaof the requirenmnts which murior toi.mine- mins-ate .
d0 y
to Io9l'�r.
Owner or authorized age- am TOTAL T ISSUED BY:
OFFICE