99110118 (2) PPQCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY q 0 0 OF
CITY OF CUPERTINO BUILDING-ELECTRICAL PHRM�1'FN--O. gq���qgq..yyy
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
,, t',BUILOBSG PROJRCTTi
IDENF'ICATION"
B UILDIN .ADDRESS: SANITARY NO. APPLICA'T'ION SUBMITTAL DATE
OWNPR'S NAME'. IONE: CON"1'ItACTOR;S NAME; LIC NO:
N/C CONTROL#
RMI
' T G EER: LIC NO: ADDRESS: E]CONTACT'; PRUNE: S •HU ILDING PERMIT INFO
ElConsultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
ID ED El PC-
LICENSED CONTRACTORS DECLARATION TY ELFCTRI(7PERMIT• +hCG,,,,•
F hereby alrmt m I T lid a..............f Chapn•r r(cm ome•tans z -t. . JOB DESCRIPTION
lai with Section 70M)ofDivision 3 ofthe But s dProf oinm CWe,and mylcense is RESIDENTIAL:
F-LdO Lifull
crirarcesa^n %LRMIT ISSUANCE ❑SFDWL ❑KITCHIzN REMODEL
F1-czJU L¢vnse a. uc.# �� ���9
NQ� Doe Contras wry �'aS AI'P NCHS-RF:SIDEWIAL []ADDITION [_1 PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS OMULTFUNIT El STRUCTURAL
zonz Iunde`stand my plus don be used as public records MODIFICATION
C)z--Q Ill,TO 200A S [I INTERIOR ❑CHIMNEYREPAIR
G4 Licensed Professional 2014000AMPS IMPROVEMENT (]SWIMMING POOLS
gg OWNER-BUILDER DECLARATION OVER IIK#TAMPS - El BATH REMODEL/REPAIR El DEMOLITION
'S 6 I hereby affirm that I am exempt train the Contractor's License Law Tim the
3 d V following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS PIT RICAL �THER _
y which requires a permit to construct,masa improve,demolish,or repair any structure T rP is L>�-
1"'LL'0� prior m its issuance.also requires the applicant for such permit m file o signed statement SPECIAL CIRCUIT/MTSC. �C`�" ��
44444 vWvW�ryN xxx
that he is issued pursuant to the provisions of the Contractors License Law(Chamor9
CpO (commencing with Section 8X00)of Division 3 ofine Business and professions Code)or TEMP.METER OR POLE INST. COMMERCIAL'
a 6 m C that he is exempt therefrom and the basis for the alleged exemption.Any violation of C1 NEW BLDG/ADDITION El DEMOLITION
-,y Section 9031.5 by any applicant for a permit suhcco,the applicant ma civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
not more man five hundred dollars(&500.=O
0 SWIMMING POOL ELECT IMPROVEMENT
I,aa uwnerof Ne prnpeny,ormyempinyees with wages as Meir role compensation.
will do the work,and the swctom is not intended en+dered for sale(Sec.]OCs,Business [10 rHER
and Profesaim,Crxic:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHE 'I RES
0. r propeny who builds or improves thereon,and who does such work himself_..rough
his own employees,provided that such improvements me net intended or opened for NEW RESIDENTIAL Ti FT.
e:ila.IL however.the holdingorimpmracrom iseold wimmone year..I completion,the Or SQ.FT.FLOOR AREA $/SQ.Err
ser-builder will have the burden of proving Ilia,he did not mild or improve fur pur-
pose ofsaleJ.
F,as owner of the no,cor y,am exclusively contracting with licemsed contractors m TOTAL:
must the project(Sea 7044,Business and Professions CsatO:)the Cioracmr's Li- - -
cane Law does not apply to an owner of propany who builds or improves thereon,andQTY, PLUMBING PERMIT - FEE
who contracts for such projects with a contractor(%)Ileenaal pursuant o the Contractor's
License Law, PERM( SSUANCE
T va exempt under Sec. ,B&P C for this reason
ALTER-DN IN&VENT-WATER(F,A) VALUATION
weer Date
WORKERS COMPENSATION UECLARA'TTON BACK FLOW P ECT.DEVICE
I hereby affirm under penalty of Perjury one of the following decla nuions:
❑ l have and will maintain a Ceniftcate of Consenfto self-insure for Workers Cooper- DRAINS-FLOOR•I OEAREA•COND' STORITiS TYPF,CONS'IAUC'I]ON
sullen,as providul Ibr by Scmiun 3]00 of the Labor Code,far the lerformnnm nl tae
work for which this permit is issued. TEXTURES-PER TRAP
®-T have and will maintain Worker's Compensation Insurance,m required by Section
3800 of the Tabor Gale,for the performance of the work for which this permit is Issued. GAS-EA.SYSTEM-I INC, IITLETS OCC GROUP APN
My Wo omisakse ion Tns anceemrierend F'nlicy num rare: GAS-EA.SYSTEM OVER 4(G
Cameo Policy Nm.: 'b
CER IMCATEOFE EMPTION IBOM WEIR R GRIiASElIN1IDSTRI.WASTE INTER TIOR
COMPENSATION INSURANCE - i, ' ' BUILDING DMSIUN F2ES ¢
(ThissectionneN nobecomplmed ifthepetmitisformnehundmddollan($IW) GREASETRAP
or less.) PLANCHECK FEE
I eerify that in the performance ofthe work for which this permit is ismod,(shall SEWER-SANITARY-STORM EA 2;FT.
not employ any person in any m:mner so its m become subject to the Workers'Compeer- ENERGY FEE
Z scion Laws dCrillfarat Data
z O Applicant WATER HEA'T'ER W/VENT/F.LECI'R GRADING FEE
rn NOTICE TO APPLICANT:TL oiler making This Cedihcam of Exemptimh you should WATER SYSTF.MITREATING
? become subject On the Workers Compensation provisions of the labor Code,you mus, SOILS FEE
LTJ I'mmom comply with such provisions ar this permit mall Ise deemed revoked. WATER SERVICE
Q
7 Z CONSTRUCTION LENDING AGENCY NEW RFSIDEM'IAL PCMB. SQ,FT. PAID
V 0 work
whichtmlhethe iisoro!sce.3nlending agency for the per(ormance of R 8i t#
W he Under,for which Ibis permit is issued(Seo.3097,Civ.C.) 27—, I
Q U Under,Name TOTAL: I'
Lender s Address TOTAL:
I sect fy that l have read this application and state out the above information is I - ., I3UILDIN inn
y um.unt I gree to co nply IT II ly t Ic ty J' a mJ seam lows mlat tgm •QTY..% MP.CHANICAL PERMIT t FF.B ,`,
L) Z baking construction th
and hereby auorise m pesentaties of this city cheruptm.e va
SEISMIC
above-mentioned propery for inspection purposes. PERMIT ISSUANCE(We)agree to save•indenm ify and keep hio nless the City of Cupenioo ngai air HLECTRIJ PE
liuhilities,judgments•caslsand expenses which may in any try.,me nguiastsaid City ALTER OR ADD TO MECH.
in on wspience mate granting of this permit. PLUMB(
ID
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SO+1pCB RF,GULA'FIONS. MECHANICAL FEC
�`) CCnn A%.
_ rs FAa AIR HANDLING UNII'(OVER I()WO CPM7 CONSTRUCTION TAX
�1 �`
Signmoreo1iApplicunl)OanDem EXHAUST IIOOD(WIUUCI') HOUSING MITIGATION FEE
HAZARDOREO US MATERIALS DISCLOSURE
Will the Capetian
petianMuniipal odac Capt store or handlehmardmus material HEA'L'ING UNIT(TO 1W,0fq BTU)
as defined by the Cupenina Municipal Crete,Chapter 9.12,and,ha Henhh and Safety
Cnaa Section 25532(n)'! / HI?A'I'ING UNIT(OVER I W,flfl(1 BTU)
❑Yes .?- VENTILATION FAN(SINGLE RMID) PAID --
Date Receipt#
Will the applicant or knots building by the fit use a Air sent or devices which
mit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR I00,000 BTU)
Disvic@ / BOILER-COMP(OVER 100.000 BTU) T L:
❑Y<s it�'IG
I have read die hazardous manrials requirements under Chapter 6.95 of the Cali- AIR CONDI1'IONER ISSUANCE DAT o
forma Health&Safe,y Code,Sections 25505,25533 and 25534.1 understand in.,if the NEW RESFDEN TIAL MHCH. SQ.ET
l Id rrrr����dos urn cumntly have n tmuln,.mut itis my resgmsihility to roily me occupant
olGhe hekvl
nirenem which moss d:mel prior rrsissuance ofaC fcale(�of(kcupfancy.
Owamorautmrtaed agent Data TOTAL ISSUED BY'
OFFICE