30971 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
_ CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. ^ 0 9 7 A
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. �KJ MV 11
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARYNO. APPLICATIONSUBMITTALDATI
OW R'S NA F: PHONE
^� NTRACTO ' NAME: LIC NO:
- f GLo PQr .Z ! )JD + C— �� N/C CONTROL p
qNPRCHITUCT/ENGINEER: .J LIC NO: ADDRESS I� /� ❑
Lp�pkK 00(_L
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Inifra) BLDG - ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. F.LECFRIC PERMIT FEE �
I Hereby affimt Inas I an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
1n1y a4Z with Section7(KX))of Divisionlof the Business and Pmfnsiom Coda and mylicenu is RESIDENTIAL:
Fqk,BPU. in full force and effect. - PERMIT ISSUANCE ❑SFDWL ❑ HEN REMODEL
6 Z W License Class Lia N -
i 6Z Date --rector APPLIANCES-RESIDENTIAL ❑ADDMON v1B LNG RE-PIPE
ARCHITECTS DECLARATION CI /❑STRUCTURAL
[F--.
C O�Z 1 understand my plans shall be used ss records poetic cas MODIFICATION
UPTO200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
r 4l:a0p Licensed Professional 2014000AMPS IMPROVEMENT
syr OWNER-BUILDER DECLARATION OVER III(g1AMPS [I BATH REMODEL/REPAIR CI DEMOLITION
d' I hereby affirm that 1 am exempt from the Contractor's License Law for the -
aall
0.V following reason:(Section 7031,5,Business and Prefessions Code:Any city or county SIGNS ELECTRICAL []OTHER
`O which onnmres a permit to construct,alter,improve,demolish,or repair any structure
prion,its issuance,also requires the applicant for such permit in file a signed statement SPECIAL CIRCUITIMISC.
�y dealt.islicensedpmstammtheprovisionsaftheCr,ntrecter'sLicenseLaw(Chapter9
X00 (commencing with Section 7g0)of Division 3 ofthe Businessand ProfessionscudOir TEMP.METER OR POLE INST. COMMERCIAL:
p IY Net he is exempt therefrom and doe basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
qx 4• Section]031.5 by any applicant for a permit subjects the applicant in a civil penalty of POWER DEVICES 1D�m ❑TENANT ❑FOOD SERVICE
not mote owner
five hundred ordollars y employees
- IMPROVEMENT
❑LnsuwnerkF and
property,amyempinyea wlthwted their sole compensation. SWIMMING POOL ELECTRIC
willC2C2 and doth scions ande The tumnnintended Lice Law rdoes of apply to an owner
of is
OTHER
W end Professions Cale:The ioContractorstherecLicense Law Ii«s not apply s if owner of OUTLETS-SWITCHES-FIXTURES
hpropeadyis own who builds or improves thereon,and who do.x such work himself or through
his own employees,provided thus such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
We.owner-builder
will h builthe bur en of proving
t at hewithin one y<or improve
the ESQ. REA $ISQ.FL
wio nari a.).will have the burden of proving tem he did and buil)or improve for Aur-
Pasionaria.).
sele
❑ h as ucttheowner of the pm.7W..am exclusively contracting with licensed contenders i- TOTAL: Q Zcy
muse La the project(Smapply
71k44,Business and property
whobuilds
Code:)The es thereon,Li- Q�
cense Law .adoes for..hply toanowner ofprnpeny wcenseddsrmant tovesthereon,ond QTY. PLUMBING PERMIT FEE CITY
echo comraafm such pmjecu withecomrecmds)licensed pursuanuodhe Contrecmr's f 1 Vi-
License Law. PERMIT ISSUANCE 1 INO
❑I anI exempt under Sm. ,B&P C for this reason
Owner Data ALTER-DRAIN&VENT-WATER(EA) - VALUATION
WORKER'S COMPENSATION DECLARATION BACK(LOW PROTECT DEVICE
I heresy arm under penalty of perjury one of the following dmlaations: - -
❑ I have and will maintain a Cenirscnfe of Consent to self-insure for Worker's Comped- DRAINS-FLOOR,ROOF,AREA,COND.
ration,as provided far by Section 37W of the Labor Cade,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Wormer Compensation Insurance,or required by Section
3700 of the Labor-Code,for the performancoof the work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My con Colltpe {�i o_n 1 td m artier and Policy nyry��@¢'L X12
Currier: Policy Nn,:t� 5(11 ✓24,1 GAS-EA.SYSTEM-OVER 4(EA)
'R 1FIC�E OAF HX1EMP ION FROM WORKERS'
COMPENSATION INSURANCE GREpSMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not ed completed if the permit is for one hundred dollar(S 100)
tar less.) GREASE TRAP PLANCHECK FEE'
I rectify that in the perfoncromerof the work for which this permit is issued,(shall SEWER-SANITARY-STORM IA.200 FT.
Z
not employ any person in a u
y munnerso as to become subject the Wnrkeri Comped- ENERGY FEE
sodium Law..rCalifornia.Dam WATERHEATERWNENT/ELECR
Z 0 Applicant GRADING FEE
y NOTICE TO APPLICANT.If.afar making this Certificate of Exemption,you should WATER SYSTEMOT EATING
abecome subject to the Worker's Compemafir,n provisions of the Labor Code,you must SOILS FEE
W forthwith comply with such provisions or this permit shall be deemed invoked. / WATERSERVICE
d Q
V O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID Date ReceiptN
1 hereby a'finn thm there is a cumwction lending agency for the performance of
[LI!-r the work for which this pert is issued(Sec.3W7,Civ.C.)
0 I-'� mi
Lender's Name A
LUkI Lenders Address TOTAL:
�}.II
aI cunity that I have mud dais application aid ante that the above information is BUILDING FEE
Ll Tp correct l agree to comply with all city and county ordinances and state laws relatingm QTY, MECHANICAL PERMIT FEE
V building consuncdion.and hereby aahorim representatives of this city m enum.pon the SEISMIC FEE
abovcmentioned property for inspection purposes.
(We)agree to save.indemnify and keep hamless the City of Capacitor,against PERMIT ISSUANCE ELECTRIC FEE
incoises,judgmentecons and exp 52s which may innmy way accrveagaidst said City ALTER OR ADD TO MECH.
inconsequence o(,(he p/6ndnBS�tmit. PLUMBING FLE
AP LT 6 (tSTA 6665 MD dpdpdp��/ILL COMPLY WITH ALL NON-POINT ,AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SO CE RE IONS X
/fir/— AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
SI ..of P mu m r Data EXHAUST GOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hassNoas material HEATING UNIT(TO 100,0110 BTU))
in defined by the CLpertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda Sectm.2553200? HEATING UNIT(OVER 100,000 BTU)
El Yes FIN. VENTILATION PAN(SINGLE RESID) - PAID
Dade Retaiptp
Will the air contaminants
in furore definng occupant use equipment or teslas which
emit hnzvdr,us air cr,ntaminums as defined by the Ray Area Air Quality Management BOILER-CGMP(3HP OR 100.000 BTU) TOTAL:
District?
[D Yes FNo BOILER-COMP(OVER 100,000 BTU)
AIR CONDITIONER
I
havere t�yyleee hauvdnm materials rcyuiremenu under Chapter 6.95 of Cali- ISSUANCE DATE
(omit Heal r, y Cale,Sections 25505.M533 and 25534.1 understand that fi the NEW RESIDENTIAL MECH. SQ.PT.
amt cntly huQaana d,tea" .pnnsiM1iliry to notify the mcupum
Tthe
not
hiciy use be p or so issuanlx ofe Cenificae of Occupamy.
/ 1_
Ow ror nuthorizeda Dom - TOTAL ISSUED BY:
OFFICE