30349 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING.MECHANICAL 30349
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESSr / SANITARY NO, APPLICATION SUBMITTAL DATE
b1 L�r-Gi �•
V1 i Se- 6r- . -
OWN 'S,AM��� P N—.�^ia` CO 'f CfOR'SNAME:ro' - LICNO:
I"'� I NI v GIV N/C CONTROLif
;•ARCHITECTMNGINEER: LIC NO: S: - ❑
2YOT4 or $'art Q�a�'.
CONTACT: PHONE: BUILDING PERMIT INFO
I V.<•j).M ��������� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
't'Le T'FvJ ❑ Qa- ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby aKrm that I an licetuml under provisions of Chapter 9(commencing JOB DESCRIPTION
O�Z with Section 7")of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
y�
00 PERMITISSUANCE
F, in full force and a te- SG 6 ❑SFDWL ❑KITCHEN REMODEL
FU Ej Licens .- Lin.M r
NQL Dom Contractory I APPLIANCES-RIiSiDEN'1'IAI. ❑ADDITION 'PLUMBING RF-PIPE
Dm . ARCH ITECCS DECLARATION PANELS if ❑MULTI.UNrr• ❑STRUCTURAL
ZP-n Z 1 understand my plans shall be used ae public records r MODIFICATION
DPT020n AMPS
OZ-0 ❑INTERIOR ❑CHIMNEY REPAIR
P:��WW Licensed Professional 2nd-IqO AMPS IMPROVEMENT
Qa y'9 y
OWNER-BUILDER DECLARATION UVERIMAMPS ❑BATH REMODEUREPAIR El DEMOLITION
"+fd W a 1 hereby affirm that I run exempt from the Comractof's License Law for Ne
O y U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Al 11,
a 4z h which requires a Permit to construct, he,improve,demolish,nr repair any structure
prior to it issuance,also requires the applicant for such petmiuo files signed'statemem SPECIAL CIRCUI 1C.
+gyp } that he is licensed pursuant o Ne provisions.odhe Contractor's License Law(Chapter9
u1 a0 (commencing with location 7000)dDivision 3oftbe Business and Professions Coj TEMP.METER LE INS COMMERCIAL:
S c Nat he is exempt therefrom and the basis for the alleged exemption.Any violmi,n of ❑NEW BLDGIADDTHON ❑DEMOLITION
Section 7031,5 by any applicant fora puraitsobjects the applicant to a civil penalty of POWER DEVICES
"m ❑TENANT ❑FOOD SERVICE
oat more Nae f ve hundred dollars y employees
m pl
" FZY IMPROVEMENT
xx< ❑ Lo the warof the property,mmyemptended with wages rsale( m.compensation. SWIMMING POOL ELECTRIC
wilF O and do the wons and theThs,Commicu e,re is not License aw ed dos not apply to an Buact.1 []OTHER
ul 3 end Rofessions Code:TM Contractors License Law does not apply m an owner of OU'TLLTS-SWITCHES-FIXTURES
„ �' pmperry who builds m improves thereon,and who does such work himself or through El
his own employees,provided that such improvements are not intended m offered for NI7W RESIDENTIAL El FCTR SQ FT.
k I
side.If.however,the building or improvers is sold within one year of completion,the SQ.FT.FLOOR AREA ESQ.FT
owner builder will have the burden of proving that he did not build or improve for pur, -
pose of sale.). "
O h n owner of Nm e property,aexclusively contracting with licensed contractors to TOTAL: AUGnstruct the project(Sec.7044,Business and Professions Cale:)The Committees Li- s A 91996 .
Li--
cense,law does not apply to an...at of property who builds or improves theon
re ,and QTY, PLUMBING PERMIT FEE ULl
who contracts for such projects with a contractor(s)licensed pursuant,the Contractors
License Law. PERMIT ISSUANCE
O l am exempt under Sec .B&P C for this reason l/III VI'4UF ut1IIXl,
Ower Dem ALTER-DRAIN&VHNT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION .BACK PLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations: '
O l have and will maintain a Certificate of Consent to self-insure for Workers Compen- DRAINS-FLOOR,ROOF.AREA,COND.
ration,as provided for by Section 37W of the labor Code,for the perfornuntt of the STORIES TYPE CONSTRUCTION
work for which this Permit is issued. FIXTURES-PER TRAP
ve and will maintain Worker's Compensation In ur ni as required by Section
I fate Labor Codcfor the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Work ' Cam Ensu ce carrier end Policy 9Ya�p�r)t�...
Comer: Policy Nu.:C+^M I��GT GAS-G.SYSTEM-OVER 4(EA)
CERTIFICATE F EXEMPTION FROM WORKERS'
COMPENS ATION INSURANCE GREAST•/INDUSTRL WASTEINTERCEPfON
BUILDING DIVISION FEES
(This section aced net be completed illhe permit is(mane handled dollars(S 100) GREASE TRAP
' or
jr.,)(This
FEE
I certify that in the predominance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
nm employ any person in any manor so as to become subject to the Workers'Comped- ENERGY FEE
.`G section laws of California.Date - WATER HEAT ER WNENT/ELECIR
O O Applicant GRADING FEE
Z y NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYS'1'EMRREATING SOILS FEE
become subject to the Workers Compensation previsions of the labor Cak,you must
forthwith comply with such powjsinnn or his pemdtshall be deemed revoked, WATER SERVICE
�L Q
CONST,is.common.
LENDING AGENCY NEW RESIDENTIALPLMH. SQ.FlI PAID
U I hertbydEmithat Nem iseconwction len ding agency for the performance of Dote ReceiptM
U. F+ the work for which his permh is issued(9w.J(N)],Cis.C.)
Q U Lenders Name TOTAL:
Lenders Address TOTAL:
I codify that 1 have read this application and stale that the aMwe information is BUILDING FEE
TaA correct l agree to comply with all city and county ordinances and.state laws relating ill QTY, MECHANICAL PERMIT FEE
U IZ building construction,and hereby authorize represenutives of this city to enter upon the SEISMIC TEE
shove-mentionedpmperty for inspection purposes.
(We)agreetorove.indemnify and keep harmlcsa the City of Capital..against PERMIT ISSUANCE 0 ELCCfRIC FEE O
inconiequnce of do,gorts mand of this esmit. may in any way acerae against sail City ALTER OR ADD TO MECH.
consequence of Ne granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL IRF.
• AIR HANDLING UNIT(OVER IO,OOp CFM) CONSTRUCTION TAX
Signature of ApplicanUContrecmr Dam EXHAUST HOOD(WMUCI) CONSWUCTION TAX FEE
HAZARDOUS MATERIALS DISCLOSURE'
Will theapplicam or future building occupant ime or handle hazadous.medal HEATING UNIT(TO 100,000 BTU)
n defined by the Capetian,Municipal Code,Chapter 9.12,middle Health and Sudety ,
Code.Section 255320)! HEAPING UNIT(OVER 100,000 BTU)
❑Yes ONo VENTILATION FAN(SINGLE RESUH PAID -
Will thea applicant or future building t use equipment or devices which Date Receipt is
pp gacupaBOILER-COMP(3HP OR 100X00 BTU)
emit heznNous air stonemason,as Defined lords,Be,BA.Air Quality ManagementO
District? - TOTAL:
❑Yes Otho BOILP.R-COMP(OVlilt 100.000 BTU)
I have rend the hazallous materials-requirements under Chapter 6.95 of the Cul- AIR CONDI TONES ' I UANCE DATE
fomia Health&Safety Corte.Sections 25505,25533 and 25534.1 understand Nat nine NEW RESIDENTIAL MECH. SQ.Ptr
building does not cuncndy have a tenant Nat it is my responsibility to notify the occupant
of the requimmenb which most be met prior to issuance of v Certificate of Occupancy.
Owner or authorized agent - Date - TOTAL: ISSUED BY:
OFFICE