00010110 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY U C? I V
CITY OF CUPERTINO BUILDING-ELECTRICAL PERM]'1'NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL _
• ; BIIILDIN(;PROJRCT IDFNTIF'ICATION4.f•-,dr/'rail
BUILDING ADDRESS: SANITARY NO. APPLICA ON SUBMI AL DATE
OWNER'S G: PHONE: CONTRACTORSNAME LICNO:
NIC CONTROL Of
�ARCHIT' WER: 1. ADDRESS: ❑
CONTACT: /� PuoNE: - /,;h. BUILDING'PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
.ICENSIDCON RAC 7)R S DPCLARATION "1; i s
QTY F,LECTRIGPI RMITs s + s;FEE:
1 hereby of rm m t 1 acemcd pork"am, am ar cmpm.9(shame g , +�i%N JOB DESCRIPTION
O
0.'Z wih Section 7000hpiDisip3oddicluespOx,mal Prof . ml Qe hcencels PERMITISSUANCE RESIDENTIAL:
L O
F� F in he force and acct. ❑SFDWL s ❑KITCHEN REMODEL
.0.—U License
N 6 Clus hicAPPTI
LIANCHS-ItF;51 DENAL ❑AUDITION [I PLUMBING RE-PIPE
Q Date Cnnnt nda
F,py IITCCT'S DHCI PANELS El MULTI-UNIT []STRUCTURAL
Z O y Z I t ndecmnJ my plans.Mill he u,rd us pnhli.recaN, MODIFICATION
UP10200AMPS
oz—,uI [I INTERIOR ❑CHIMNEY REPAIR
Licensed l'mfessinnal 2W-1000AMPS IMPROVEMENT E]SWIMMING POOLS
Wall 4 I hereby affirm ha�lamexempt Ro he Contractor's License Law for he OVER IT00AMPS [-IBATHRF.MODEUREPAIR [I DEMOLITION
�0.�( DECLARATION M U following rcasam.(Section 7031.5.Business and Profes,ians Cole:Any city or eamy SIGNS ELECTRICAL, []OTHER
ul a W h watch requires a permit to comauet,alter,improve,denmll.eh,or repair any emmmre
0� priorto its issuance,also requires the applicant for such penirto file a signed statement SPECIAL CIRCUTUMISC.
ggggg tyytyy that he is licctu'edpur.mem to he provl.000s of the Cnmmaor's License Law(Chapter 9
C�� (commencing with Seallon"IlJggof DlvislnnJ nl the Business and Prnfoaxiom CnJo)or TENTH METER OR POLE;INST. COMMERCIAL:
0.y sec
that he is exempt therefrom and he basis for he alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W rn Section 7031.5 by any applicant for a permit subject,the applicant to a civil penalty of POWER DEVICES El TENANT ❑POOD SERVICE
= in e'ban Bve hundred doll...($500) IMPROVEMENT
;SQO
Ll 1,as owner of he property,or my employees with wages as heir sole compensation, SWIMMINOMOLELF.CIRIC
Inc will do the work,and the structure,is not intended motlered for sale(Sec.TH4.Bu,inex, ❑OTHER
Wand Professions Code: The Contractor's Licence Law does nor apply it, o
to wner of OUTLETS-SWITCHES-FIXTURES
a' .. property who build,%or improves thereon,and who does such work himself or But
his..it employee,,provided inat such improvemems are not intended or ofternd fur NEW RESIDENT1AL ELECTR sisp.
sale.If,however,the building or improvement is sold within one year of completin.rhe SQ.PI'.BOOR AREA S/SQ.FI'.
ownerhadder will have he bntden of proving that he did not build or improve
torpor-
Pow
F1 1. f owner of the property. exclusively contracting with licensed compactors to TOTAL 111
coaame Thep meet(See.7044 Business and Proussions Code'.)Pic Contractor x Li , s- '• t - I t •.
ami Law does such
plyt n fp pony h hdp p eC -
whucontracwfisrsuchptjccuith ec mvaenr(s)l licensed pursuanimthe Cnnaa nor, r•r 2�Q
License Law PERMIT ISSUANCE! V
❑Ian,exempt under Sec. ,B&PCmono,rearm
Dwner, Date
ALTAR-DRAIN&VENT-WATER VALUATION
1 Wm ander:SCOMPfiNSATION OE CLARATION BACK FLON'pkOTECT.DEVICE V+1
Iherehy affimt under penally of pepury One Of the following Jedaration,: (/ (/
❑I travertine will mninwina Cenilieate at Consent msal(--in sure for Worker',Cnntpen- DRAINS-FLOOR,ROOF,A REA.CONT. STORIES TYPE CONSTRUCTION
9adion,n.provided for by Section 3700 of rhe Labor Code,far the peffomwnce of he
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will mainwin Worker's Compensation Insurance,as required by Section
3700offie "Con,f the per rat Outthework forwhich"his a Or,,ncd. GAS-EA.SYS'FEM.IINC.40UTLETS OCC.GROUP APN
My Work Cnn a nu I ur. aero P y umhr
Carica X�:� GAS-1!A.SYSTEM-OVER 4 H!A7 nnnn
' "IF 9''OP EX 1 l0 R ORKER. - '�W�
Sl1R GRIiASf%INDUSTIti.WASTE INTERCEPT OR
text�VJ�V/n/•ry,��'�,,7,7, "•'-��'+L/7."x,0, 1 B111LDIN0 DIVISION FEES
nr lc..)'Lha 11s,:i in the peA1A"ry tf e irYftfwfii tti.pe t'as.%ued'Ishae GREASE I RAI' PLANCHECK FEE
SEWER-SANITARY-STORM EA.200 FT.
pone employ any peoon in any nanu as m hcur mesO Object m the Workers pvn- ENERGY FEE
Cnm
z so.«tion Laws of California.DCT
ate WATER HEATER WIVVN'I/ELER
Z Ap dead ' GRADING FEE
.�.r NOTICE TO APPLICANT.If,after making his Certificate of Exemption,you should WATER SYSTRM/TREATING
a ' become subject to the Worker's Compensation provision,of the Labor Code,you must SOILS IEE
W l onhwih cornply with such provisions or this pema,hll he deemed tnvokcd. WATER SERVICE
CONSTRUCTION].ENDING AGENCY NEW PEMDESPAL('LMR. SQ.IT. PAID
U O I hereby affinotnut here sacmm.truvrum lading agency forme pcomparpecid Dare Receiptq
D. I"' the work for which this permit is i%sued(See.3047,Civ.C.)
O Lender',Name TOTAL:
W Lender,Address TOTAL:
etf fy the,I have prast th s application and sate hat he above infommt _ s. +,f BUILDING PEE
Z? Correct,13IMC to varriply with all City and county ordinances and state laws wining to QTY, , MECHANICAL PERMI'P r '( '-r; FEE .t
Uz huildin6 conswction,harm say umhnrixrcpresenmt vas afrhswytoetmnpot he : +^ -'.+ ..1 s " SEISMIC FEE
nMrvc-un,m mcd property for i nspection purpow, PERMIT ISSUANCE.
(We)agreo to sam
ma,indemnify and keep harmless the City of C.Pr nmo against ELECTRIC FEE
Iiebillties,jml,men¢,caewandaspens which may invny way accricid,onstsaid City ALTER OR A UD,10M, 11.
ss s
e nT the gomting of this permit. PLUMBING FEE
APP( T UNDERSTANDS AND\ 1.L COMPLY WITH L NO POINT AIR HANDLING UNI'T(TO 10,000 CFM) MECHANICAL.FEE
SOC EGULATIO "
(�/F� AIR HANDLING UNIT(OVER 10,000CFM
) CONSTRUCTION TAX
Sig L re oFXI7pTtcaptrC / Date EXHA UST HOOD(W/DUCT)
HAZARDOUS MAI ERIALS DISCLOSURE HOUSING MITIGA'T'ION FEE
Will hevppliem,O frame building occupuntsmis m heade hr,ardomormenal HEATING UNIT ITO 100,00D BTU)
as defined by the Cupenion Municipal Code,Chapter 9.12,and the Health and Safety
Cole.Section 25532(a)P HEATING UNIT(OVER 100,000 BTU)
Yes PAID
VEN ILA'I'ION FAN(SINGLE RESID) Date Rcccmr4
Will the applicant or, hurldI.,occupant use equipment or devices which
emit narcotic,air cmnwminan,as defined by he Buy Area An Quality Management BOILHR-COMP LEEP OR 100.0)(131 U)
District' TOTAL.
❑Ycs /�N. BOILER-COMP(OVER 100,880 BTU)
Out, 'aJ the hu.olpus\m:arrisk requirements under Chapter 6.95 fthe Cali AIR CONDITIONER ISSUANCE DATE
forma Heal Safety Cale.Sections 2W5,25533 and 25534.1 undemand thin if the NEW RESIDENTIAL MECH. SQ.IT.
building a r
w -currentpouve nten h a ccucyp.u
al
nofrha. t nIssuanceofa
TOTAL d ISSUEDBY:
OFFICE