30635 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO, �O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING•MF:CIIANICAL
TNI LDING PROJECT IDENT'IF'ICATION
635
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
,2,r63�7f �oad�+. Oiz`w C� ,Avo CA. 9smiy 0 7
OWNER'!af 1"4 CS &'F PHONIi:_�_ Y� CONTRACTOR'S NAME: LIC NO:
L /r7V�� N/C CONTROLxa?
�ARCHITECUT?NGINSHR: LIC NO: ADDRESS: ❑
CONTACT:/ PHONE: BUILDING PERMIT INFO
•/ // -m C 6 , J- e-s /-t n.a2 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MI CH
w ieWW �(� R� �[ ❑ ❑ 0 ❑
LICENSED CON'TRACTOR'S DECLARATION QTY ELECTRICPHRMIT FEE
I hemby uflion that I um licensed under provisions of Chapier 9(cnmmenciny JOB DESCRIPTION
Q a'CA with Section 7MM)1ofDivision 3.f the Rusinessand Professions Codd,malny license is
W O PERMIT ISSUANCE E3 SFDW?NTIAI.:
in full forcers effect ❑SFUWI. El KITCHEN RF.MODCI.
ORDmense Class Cminf APPLIANCES-RESIDENTIAL ❑AUDITION ❑PLUMBING REPIPF,
rF<L Dam 7PS DELL
ARCHITECTS DECLARATION ❑MULTIUNIT ❑MODIFICATION PANELS
F.r�Z 1 understand my pions shall be used as public mrortls - MODIFlCATION
ZO
OZ -a UPT0201-1020o AMPS ❑IM'ROVE ❑CHIMNEY REPAIR
ul Licensed Professional 201-10MAMPS IMPROVEMENT
OWNTa..BUILDERm CLARATION
tY 6 I hereby efftm That 1 am exempt from the Cnmmctuls License Law for the OVER IDA AMPS ,q❑BATIi RE ODE EPAIR ❑DEMQ ATION
X 3 L F following reason,(Scetion 70713,Business and Pmfessiov GsJr Any city or county SIGNS ELECTRICAL. p OTH^R NM'_
uF1=O which re,mic,o permit m nntstruo,%alter,improve,demolish, o repair uny structure up ^ Q i( /% �
Prior to issuance,alstircquires theapplicanl for such pcnnnm Blcasignedstwement SPECIAL CIRCUIT/MISC. 11
} that he is licensed putsuum m the provisions ofthe Contruamrs License Law(Clmptarl)
00 (curmarreingwith Section70fador Division 3 ofthe Busmmornd Professions Grlc)nr TEMP.MET IiR OR POLE INST. COMMERCIAL:
li p,e C that he is omorrr therefrom and the basis for the alleged exemption,Any violation of EW BLDG/ADDITION El DEMOLITION
ti�Cl {°• Section 7(31.5 by uny applisom fora permit subject,lhcapplicanunucivil pntapy,oCES f POWER DEVICES y ENA ❑FOOD SERVICE
t ntnm than live hundred dollars(5500).
I.
Q 1,as owner of the property,or my employees with wages as their stile compensation, SWIMMING MOT.ELGCI'RTC
J - VI:MENT
^�S Ida the work,and the structure is not Intended or offered for sale(See.?044,Business ❑OT
and Professions Code:The Contractor's License Low does not apply to an owner of OUTLETS-SWITCHES-FIXTURESor
progeny who builds or improves thereon,and who does such work himself m through
his own employees,provided that such improvements sere not intended or offered for NEW RESIDENTIAL ELECTR gQ FT.
sale.If.however the building(it improvement is sold within one ymr ofcompletion,the SQ.FT.FLOORAREA E/SQ.FT.
ncr-builder will have the burden of proving that he did not build or improve for pur- p
poseof,a e). A
❑ Las owner of the property,am exclusively contracting with licensed contractors to TOTAL: &%,k—
cause
the project(Sec.7044,Business and Professions CMe:)The Comracmr's Li I 9AQ
cense Law)ties not apply to an owner of pmpeny who builds or improves themon,and QTY, PLUMBING PERMIT FEE W1 i /JV as
who contracts for such potech with a coneractomod licensed pursuant in the Coufactn's IJ ddVV��
License law. PERMITISSUANCE 35• �- LUfal
E3 am exempt under So ,B,$1'C for this meson
Ow Doc ALTER-DRAIN&VENT-WATT?R(EA) - VALUATION
ORKE S WI&PENR DECLARATION BACK FLOW PROTECT.DEVICE
I hemby self inn under penalty of perjury one of the following declarations
❑ I have and will maintain a Certificate of Consent to self isure lira Worker's Cnntpem DRAINS-FLOOR.ROOEARIA,COND' STORIES TYPI?CONS'1'NUCI'ION
salon,us provlAed for by Section 3700 of]he Lai Code,for the peron mncc of me
work for which this permit is issued. FIXTURES-PERT RAP
❑I have and will maintain Worker's Compensation Insurance,its required by Section
77U)ofthe Luton CMe,for the performance ufthe work for which this permit is issued. GAS-EA.SYS TEM-I INC.nc40UTLETS ACC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Cortise Policy No.: GAS-EA.SYSTEM OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This radion neM nes becomtM pleFair,permit is for..hundred dollars(SIM) BUILDING DIVISION HIS
lea..)(This
pLANCI{ECK FEE
Toy any Notinthe rostianynmanceo as to
for whichNis per Warkni'(7mshall SEWER-SANITARY-STORM EA.2110 FIF
not employ any person in any manner so as m booms subject m Ne Workcn'Compen- I ENERGY HE
QZ pplilaws of Califsmie.Date
AWATER HEATER WATNTIELECIR
Z Applicant GRADING FIEF.
NOTICE Inbj APPLICANT.WarmA after making this Certificate of Exemption,ryou should WATER SYSTEM/TREATING
barroom suhjad m the Worker's Compensation provisions of the tales,CMe,you muss SOILS PEIi
Uj Forthwith comply with such provisions or this permit shall be deemed merged. / WATER SERVICE a0
Q
� z CONSTRUCTION LENDING AGENCY NEW RESIDEN'TIAL PLMB, SQ.FT. PAID
Ihnralyttfnno Nat mere N oormtmcdon lending agenry tome performanmor [)am R<
O the work far which this permit is issued(Sao.3W7,Cie.C.)
Q U Lender's Nome T./AU
{Si Lender's Address TOTAL:
y 1 certify that 1 have read this application and state that the above information is BUILDING FEE
ZI correct.!now,to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT ,FEE
U building construction.and hereby authorize representatives of this city wenter upon the SETS
'M
IEE
above-mentioned propeny for inspection purposes. PERMIT ISSUANCE ELECTRIC HE agree to rove.indemnify end keep barmles the City of Catania.againad
liabilmex,judgmenu,ends and expenses which may inany way accrue against said City ALTER OR ADD TO MBcu. PLUMBING FEE
n consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON]](TO 10/100 CFM)
SOURCE 2�GULA'
't. /O zMECHANICAL FEE
i
//�/�J q AIR HANDLING UNIT(OVER 10.(MCFM)
�/ �! ^_14 / i / CONSTRUCTION TAX
Si I t ApplicaHAZARDO OSia Oum EXHAUST HOOD(W/DUCE) HOUSING MITIGATIO FEE
HAZARDOUS MATERIALS D15CLOSU121?
Will the nppllemn nr linnre building occupant score ar handle huxnNtius nmmrial IIGA'1'1NG I1N1'T(TO Im),000 IiTU)
as define)by Thu Cupeninn Municipal Cede,Chapter 9.12,unA Na Iieullh and Safety
Gde,Scedon 25532(a)'1 HEATING UNI'1'(OVEIt 100.000 111 G7
El Yes 1-1 VENTILATION PAN(SINGLE RISID) PAID
Will the applicant or future building occupant use equipment or devices which Doc aeipl A
emit hazunlous air condumiaEnts as defned by the Bay Area Air Quality Managemend BOILER-COMP(311P OR 100,000 BTU)
TOTAL:
District? BOILER-COMP(OVER II .004 BTU)
E3 Ycs hb
1 have most the haarduus materialsrements mule,Cooper 695 of Ne Cali- AIR CONDITIONER
royal ISSUANCE DATE
fomia Hwsco RSafely Cods.Sections 8509. s533 to notify the
shadif Ne NEW RESIDF.NTIAI.MIiCN. SQ.Pf.
building discount currently have a tenant,That it is my respm.'bilidy m notify the occupant
of NcICAn���1/t[�(t��(-tst he con Ari ssuaut;uRl Cenmof[kc
D strora doffird '` TOTAL: ISSUED BY:
OFFICE