B 0436 (2) ' APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILDING-ELECTRICALaql
PERMIT NO.BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICARUILpING YROJE6-T IUENTI FICBUILDING ADDRESS ANITARY NO. PI'll UONSUBMITI'AI,DATr
a . bOWNERS NAME: PHONE: COMRACI'OR:SNAME:vidlick (Ifni e , ` -7 -Q 1 N/C CON'FROL9
ARCHITE iNGINEER: LIC NU: ADDRESS: C ❑CONTACT: PHONE: BUILDING PERMITINFO
/���-Yy, ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
\ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby afrrm that I an licensed under provisions of chapter 9 cmani acing JOB DF,SCRIPTION
QZZ with$eaionT(XIO)o(Div icinn3 nfthe Business otW Rnfexximna Cock,and my license is RERR I
w O en PERMIT ISSUANCE
aVF in full force and effcat - SFDWL ❑KITCHEN kF.MOD[h
QVV 1,¢enx Clas Lich
GootmAPPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
y61 D.te cloo
F=y A.mall'ECI"S DE LLA PION PANELS ❑MUhTI-UNIT ❑STRUCTURAL
�'ZTIm Z 1 undemand my plana shall be Bud as public records MODIFICHIMNEY
REPAIR UI'Tb 2tNl AMPS
ON
�� C1 INTERIOR ❑GHIMNIITOOL
1-r3Fu1 Licensed Professional 201-IIIGIAMPS IMPROVEMENT` INCElSWIMMNG POOLS
OWNER-BUILDER DECLARATION
Ccw�l OVER Ibill AMPS El BATH REM DEUR'PAIR ❑DI?MOLITION
Q I hereby.(firm that I an exempt from the Contractor's License Law loo the
W 1 V which re reama permit
t 7031.5,Business and improve,
daronx case:My city ,,.only SIGNS ELECTRICAL OTHER [�� y[may,., nr
1113"I'- prim requires a email re comoum,alto,improve,h Wriceh,or repair any omctore
F-LL'�Q that h.sl,c,uence.aw re...Ihelbe .,i...am 6e Com ermit toicense gnMstaement SPECIAL CIRCUIT/MISC.
C
that with ril
theC B.,innna.lanaf Law(Chapter)
µ�jCp� that he is engwith ScrafranLt nd h h.,i,mnl he hc aleged esampon.An,euCode)or TGh1P.METER OR POLE(NST COMMERCIAL
:
0.a o C that M1e is exnnpt therefrom and the basis far the allegrnl exemption.Any violation mf Q NEW BLDG/ADDITION ❑DEMOLITION
Section?031.5 by any applicant laraperoul subjects the applicant to a civil pewlty of POWER DEVICES
W,, ❑TENANT ❑FOOD SERVICE
rn mom Nan five hundred dollar($500).
F Z i IMPROV17MENT
=Q ❑Lmowner k.the pestruc,or niy re isammended with wages aatheir sale c0mpBusinesstion. SWI MMING PO(JI.ELECTRIC
W
will Prthe work.and e ThaCureia1otl Licari Law offecoul
vle(sec.,,giro ne,os []OTHER
5 F"o
µ6l3 m and aProfmy who b Cone:Tbc ores thane's Lod w Law J«s not apply m nn owner ar OU'rIP,'rS-sWi'rC11135-Fix'TUBES
his own who builds or improves thereon,and who nts ameth work dee or
fo through
his own eywn,eroding Nat such improvements are not iyear ofd or completion,
for NEW RF,SIDENTIAI.[LECrk SQ F1'.
sale,11;however,ill havthehmnop improvement iswlhewithinirad
eyeoor improve
the SQ.FT.FLUOR AREA $/SQ.IT.
ownenlailJer will have the buNen of proving that he did nal bail]or improve for put-
,,,a or sale.).
I.as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
instruct the project(Seo.70W4,business and Professions CuJe:7'1'he Contra,",,I-,
cense Lawdocx not apply ns on owncrmfpmpcny who mildsm improvevheneon,and QTY. PLUMBING PERMIT FEE
who eontracu for ouch project,with n amtoamor(s)licensed mcnal l u+the Comnnvn'x
License Law. PERMIT ISSUANCE
0 1 am exempt under Sec. ,B&P C lit this reason
Owner Date AUTF.R-BRAIN&VENT-WATER TA) VALUATION
WORKERS COMPFNSMAON DECLARATION BACK FLOW PROTECT,DEVICE
I hereby affirm under Penalty of perjury one of the fallowing Jeclaraioro: _
ibuvc aoJ will molntninu CeniOcac+l Comm�no self-innurefmr Worker's Cnmpun DRAINS-FLOOR.ROOF AREA.COND.
nation m provided for by Section 3700 of the labor Case,for the petomarnme of the STORIES TYPE CONSTRUCrIOS
work for which this permit is issue1 FIXTURES-PER TRAP
6/�1 have and will maintain Worker's Compensation Insurance,ac required by Section
J ofthe"twi-Code.for the Performance ofthe work for which this permit is issued. GAS-EA.SYSTUM-1 INC.4 OUTLETS
(ICG GROUP AI'N
My WnrkCumxuliylpllnurnn�n wriwunJ Policy nt (yL
Carver: JTZ P FI ra Polis Na: Y. T(.,rZGxS GAS-EA,SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GHEAS[IINUUSTRh WASTE INTERCEI'fOR
BUILDING DIVISION
(This section need not be completed if the Permit is formic hundred dollars($100) FIiEs
ser less.) CRGASE'IRAP
PLANCII[CK PDE
Icenify thatinthe perfmmne, ca, ,,lmrkfmrwhicOhixro ,,p eWok.oil is er, omperll SEW(?R-SAN]'ITRY-STORM GA.2(111 i'1'.
nm cny+InY unY Pasmn in nnY manner co ax to Mcomc subject¢+IM1c Workers'Contpen- ENERGY FEE
station Laws of California.Date WATER HEATER WNENT(ELECIR
z O Applicam t GRADING HE
.N. NCTIICU TO APPLICANT:IL alter making Nis Cenifcam of Exemption,you should WATER SYSTEMIIREATING
a , hacomc subject m the Worker's Cmnpemaltion provisions of the LaMt Casa,you nolo SOILS FEE
fnnbwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
LL
Uz Catthem iso construction
onst LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
UQ Ihereby afhrm theubereiesued Sce 3097,,Civ.agency for the performance of Data Rcceiptp
the week Thr which,hi,permit is issued(sen.3097,civ.C.)
O Lender's Nome TOTAL:
U Leaders Address lOTAI_
1 anil'y That I have mad this application mJ stateNM
at IM1c urve information BUILDING FEE
ZI correct.I.greeu+comply with all city and roomy awhimse-ardome mwsrelming m QTY. MECHANICAL PERMIT FEE
V Z mildo......noutan,and thereby nutn—c reposmitivexol'this city mnnmrupm the SEISMIC FEE
.Mice-mernumad property for impeclimn proposes. PERMIT ISSUANCE
(We)agree m n rva,indemnity and keep harmlcsx Ne City of Cupenam against I ELECTRIC FEE
Iiabiliues.judgmems,costs and expenses which nay in any way acme against said City ALTE,RORADDTOMF.CH. `
in amsequcnce of IM1c printing of lhix permit. PLUMRINO FEE v-VQ
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AB HANDLING UNIT(OVEH IO.gM)CPM) CONSTRUCTION TAX
Slgnowre(TdApplicnnUCormcni, Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicunl or forum buildingoccuprent store or handle h....dmts malarial HEATING UNIT('IO Its)b,
as defined by the Cupaninm Municipal Code.Chapter 9.12.and are Health and Safety
Code.Seen.25532(a? HEATING UNIT(OVER 100,000 BTU)
El Ycs ;KNn
VENTILATION PAF(SINGLE RESIID 1r'
Will thea Beam or l umre b�ldin occupant mea m sip
pP b P Area
mlity Management
BOILER-COMP QHP OR IDk000 BTU) (
emit baarJous air contaminants m defined by the Bay Area Air Quality Management V O
District) HOILER-COMP(OVER 100.WO BTU) Tyr t
E3 Ya, �Nm UN
I have mad!'he lacerationsmamials mde
quimmets under Chapter of the Cali- AIR CONDITION ER
P ISSUANCE DATE
fmmia Health&Safety Cuda,Sections 25505,25533 and 25531,1 understand In.,if the NEW RESIDENTIAL MITCH, SQ.FI'.
building does not cummily have a mount,that it is my rexpntsibilay to notify the occupant
of the requireenenrs which must be met prim to issuance of a Caraficam of Occupancy. By T
Owner or authoriad agent Data TOTAL
OFFICE