00010129 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY oQ 0 1 C Q-01
CITY OF CUPERTINO BUILDING-t['EC1'RICA]. PI2RMI'T NO.
PLUMB IN -
I UILDING DIVISION APPLICATION/PERMIT BUILDING PROJECT IDEKQIIFICATION "0001
ITU ILIIINGAUDREsS. SANITARY NO. APPLICATION SUHMII'I'N.UATI
Jl G
OW :S NAME, PHONE: COVI'RACfOR'S NAME: LIC NO'
Y14 mar —C�:LO dl/e0 P� �� rv/c cflN'raol.a
CHITECF/CNGI,NF,ER: LIC NO: AOR SS. !1 V EJ
CONTACT: PHONE b'C.. BU ILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MECH
n� a53-CX-)8 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I berehy afrrm mal I en licensed Indo.......shim of chapter 9(eommeneing JOB DESCRIPTION
C=Z with Section 70M)of Dlvidon3 ofthe Business and Professions Code,ami my license is RESIDENTIAL:
W p p PERMIT ISSUANCE
Cµ'F in full force and effect ❑Slim. ❑KI'FCI LEN REMODEL
QUU License Class Lias, APPLIANCES-RESIDENTIAI. ❑ADDITION LUIJBING HI.-PIPIT
FZu) Date Contractor
m6a ❑MULTI-UNIT OSTRUC'iURAL
F,pm ARCHI'I'ICT'S DECLARATION PANELS MODIFICATION
Z O y shall Z 1 understand my plans all he used as public records UP TO 200 AMPS
p Z'-� ❑IN'IPRIOR ❑CHIMNEY REPAIR
F=�F•; Lifemsed Pore,ximeal 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
Y OWNER-BUILDER DECLARATION OVER IOINIAMPS OBATHREMODELIREPAIR ODEMOLITION
C C< I hereby a1Brtn that I am exempt from the Coalmanrs License Law fur the
xap6U following reacna(Section 70315.liminess and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
1+13LL y which rcyuirea n permit to enn.antet cher,iinpmvc,denudish,nr mludr unY simcuve
F NO< prior to its issuance.also requires the applicant for such Permit o file a signet xtacnrenr SPECIAL CIRCUIT/MISC.
f ly i` that he is licensed pormaarin the provisions of the Contractors License Law(Chapter 9
ac 2E (commencing with Section Division 3 of the Business and Professions Code)or TEMP METER OR POLE INST. COMMERCIAL:
a Iy c that he is exempt Nerefiom and the basis for the alleged exemption Any violation of NI?W'BLDG/ADDITION ❑DEMOLITION
Xm Section 91131.5 by any applicant for u permit subjects the applicant)o civil Penaltyof POWER DEVICES TENANT ❑FOOD SERVICE
not roma than Eve hundred dollars(5500). P EMENT
SSG Q 1.as owner of the prupery,or my employees with wages ua their sole coriNtiruliun, SWIMMING POOL ELECTRIC
F. will do the wOrrk.rod thcstrecmre is not imendixim.ffered forxale(SaJDW,Business T
µ13m and Professions Code.The Contractor's License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
L property who builds or improves thereon,and whir docs such work himself or through
his own employees,provided that such improvements fore not intended or offered for NEW RESIDENTIAL ELECfR SQ F-p
sale.If.however,the building or improvement is sold within one year of'completion.the cT.FLOOR AREA S/SQ.IT.
coviner-buildervill have me burden of proving the he did not build or improve Impairs E70
pose of-sale.). '1 OTAL V
Oo
I,as wner of Ny, me propertaexclusively contracting wish licensed contractors to
construct the pjeet(Scor 7(L ,Business and Professions Cute:)The Comments Li-
cence
i-
ce Law does not apply to un owner of properly who builds or improves therms,and QTY. PLUMBING PERMIT FEE
wcommnz for such projects with a coataemr(s)licensed pursuenno the Conrmmots
I,imnse Law, PERMIT ISSUANCE
O I am exempt under Sec. .B&P C for this reams,
ALTER-DRAIN&VENT'-WAI ER(EA) ` VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby ill maintain.
ai under penally of perjury one of the following declinations:
ns:
Jon.as and will main by eCion 3700Ce Labor Code,fore for Worker's Comp'he DRAINS-Fl,OOR.RII(IP,ARG.COND. gIYlRI1?S l'\'pE CONSTRl1CllOt
vain,,as provided i far by Section 3Wk1 of Ube Labor Code,for the perfnm+mtm of the
wr kyf r+���ich this permit is issued. Il%TURES-PER TRAY
r�jTh Iced will maintain Worker's Compcnsmion Insurance,us required by Section
37M ofihe Labor Cod,for the performance of me work for which this permit is issued. GAS-EA.SYSTEM-I INC.q OUTLETS OCC.GROUP DPN•
Cumer+fyyRnnnk Comrcorn lyra '^,,x c Poky No.Y}J VrN/SC/Z.�g GAS-EA SYS'1'I?M-OVER4fBAMYV" )
CE1RTIFIICAT .TION FROM WORKERS' O O
CRIiASFIINiIUSTRL WASTE IN'FERCIiY1Y)R
COMPENSATION INSURANCE r�� BUILDING DIVISION FEES
Crbi,teionneednollvoeofletW ifrhe perluti,fimmehumlredddllars(5100) GREASETRAP
or IessJ PLANCIiF.CK
Io,any shpt in the a.,ormanccofe,to Iwkfor whjectlrpermit is iawN,lehull SEWER-SANITARY-STORM EA.200 For.
not employ any person in any manner so as m become subject m the Worker:Compen- )9NERGY FIiF.'1, " r-
Z smma laws ofCuliliunia.Dale WATER HEAT ER W/VENT/ELEcTR GRAD '
zo
Appleton 1irtir
% NOTICE TO AVPLICANT.If,after making this Certificate of Exemption,you should WATER SYS']EM/BEAI'ING
become subject to the Wurkets Compensation provisions of the Labor Ced,you most SOILS PEE
Forthwith emmply with such provisions or his Ta.,it shall be dcemed revoked. WATER SERVICE
0 If U
A' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PIT t'PAID
U D I hereby iffirin that there is u construction lendings ens for the performance of ___zzzz
Reecipl#
LLf" the work for which this permit is issued(Sec.3097,Civ.C.) QT Y
OU lender's Name Ni
} Lender's Address TOTAL:
O. I certify Lha 1 have read do,upplicmion end sem that the above information n BUILDING FEE
Ftq correct l agnea+comply with all city and county midinaae:and store laws relining to QTY. MECHANICAL PERMIT FEE
V Z building construction.and hereby anthems,mpressmenivunfinis city mentor upon the SEISMIC FEC
above-mmntien vl property for in iseciinn purposes. PFRMI'F ISSUANCE
(We)agree to cave,indemnify and keep harmpe
less the City of Cunimo against IiLECI'RIC PEE
I abilines.judgments.coa.vand expen.ves which mayor any wary rectae:gan.a said City ALTT:R OR ADD 11)MECH,
in nxequence of me grunting of this Is,ont PLUMBING IEEE
APPLICANT UNDE A S AND LL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0Jg1)CPM)
U CE RF,GUI MECIIANICAI-FEL:
AIR HANDLING UNIT(OVER 1n.W0 CFM)) CONSI'RUCI]ON TAX
Signa p canUCon act ar DateV EXHAUST HOOD IW/DUCO HOUSING MITIGATION ITE
IIA]✓ROOUS MATERIALS DISCLOSURE
WIII the applicant or future building occupant store nr handle Itaoudoas material HEATING UNIT(TO IO tout BU)
as defined by the Cupeninn Menicipal Cxle,Chapter 9.12,and the Health and Safety
Calc.Suction 2553200'! HEATING UNIT(OVER IINLIXgU RTU))
❑Yes 0 N PAID
VENTILATION FAN(SINGLE Bps[])) Use Ret#
WIII the applicant m future hudding occupant use equipment or devices which
tit hazardous fir contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(JHP OR I00.IMp BTU) TOTAL
6)offer? HOLLER-COMP(OVER 100.000 BTU)
❑Yes ONo
AIR CONDITIONER
Illavcreadlheharardomered alsrtuimmentsuM,CTaryerfi95of Ne Cali- I$$ ChD E
Tomos Hmllh&Solely Calc,Su'f 55115,25533 anti 25534.I undcmmnA the d IM NEW RESIDENTIAL MECH. SQ.IT.
building dress, have 0,tor,th my resrymsibiliryto notify the occupant
me R n lien m met n m issaamc¢�p QAli 116b Pars'.
Ow rand meed ugen / ri-I( vDae TOTAL: ISSUED BY:
OFFICE