29573 (2) APPLICANT TO FILL IN INFORMATION WITHIN REO LINES-.USE BALL POINT PEN ONLY
CITY OF CUPERTINO B RUILDING-ELECTRICAL PERMIT NO.
..�9 5 7 3
BUILDING DIVISION APPIACATION/PERNIIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPLICATION SUIIMI PIAL DATE
pW'NER'S NA E. tSCUNE:AIS, ONTRACI'OR'S N i LIC NO:
f�.1AJ LNt l J
NIC
A C I CCT NGINIiIiN: LIC Nil: ADDRESS: ❑ —
cc``ONTACf:Y _ ei Owl
a l 4�j'H°,N�f.� 944b BUILDING PERMIT INFO
jCC� l• thJ (� ❑ Consultant Fees Paid by Applicant(initial) tl.uG .:CECT rl,u 0 MECII
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm the 1 am licensed under provinianx of Chapter 9(commencing JOB DESCRIPTION
{Q{s1aZ with Section Tl(b)af Divivioa 3ol'the Entire,and Profa,mr,Cude,and my license In �`. ^ 51DENTIAI.:
F00 in full force and effect. PERMIT ISSUANCE •�
wwr License CWsx pica r)WL C KITCHEN REMODEL:
Q U APPLIANCES-RESIDENTIAL ADDITION [I PLUMBING RF.-PIPE
In Q L Dae Contmeor
F,yDm ARCHITECTS DECLARATION PANELS [J MULTI-UNIT ❑STRUCTURAL.
Z ZJ Z I undereund my plans.shall be used as public records MODIFICATION
J UP10200AMPS ❑IN'T'ERIOR El CHIMNEY REPAIR
FBFW Licensed Podessianol 201-100AMPS IMPROVEMENT
tY C C Q 1 hereby afRrm ha I am BUILDER DECLARATIContractor's LicenU Law for the OVER 1000AMPS [I BATH REMODEUREPAIR CI DEMOLITION
following ream...(Section](131.5.Business and Profcoions Calc:Any city or county SIGNS ELECTRICAL ❑OTHER
LL13 w hG which requires a..Hath w cantmc6 alter,improve,dnmohsh,ter repair any mama ,
Fqy0J prior to its issuance,also requires the applicant for such wroalto file a signed statement SPECIALCIRCUDIMISC.
2 Y that he is licensed pursuant to tire provision of the Contmcmrs License Law(Chapter 9
�pCp(D (commencing with Seen Division the Business and Pmfnsien Came) COMMERCIAL n
)a. TEhf P.MEf-R OR POLE DIST.
a that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITIONI Q DEMOLITION
NSection 9D1.5 by any applicant for u permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT yC FOOD SERVICE
Spnot mm,than Eve hundred dollars($50(d. IMPROV' Tn�
❑Las owner of the pmpenas their my employees with wages theirxnle compcnsaion, SWIMMING POOL ELECTRIC ❑OTHERJF,�B/ 1r I'
(_ will do the work,and the% ucture is not intended or offered for aide(See.]ikil.Business V ,e 1<1n-
y�j sa and Professions Cudc:The Contrvctoei License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
6'3^ property who builds or improves thereon,and who docs such work himself or through rl I Y (JI-
his two employees,.....video 111.1 su.It improvements arc not intended or offered for NI7W RESIDENTIAL.ELECTR S '
sale.If.however.the building or improvement is sold within one year ofaimpletion,the �/� SQ.FT.FLOOR AREA'.VV $/SQ.FT.
ver builder will have the burden ofptoving that he did not build orimprove fn-pur. ZZ20 ,��,/ 1 % 2:z-
",
:
..ase of sale.). G•• {„�,•l i Ct.,J7
TOTAL:
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to /�
nmarna the project(Sea 91044,Braver,and Prolaxvinre GdeJ The Contractor's Li-
cane Law does nm apply to an^wn^.ol'property who builds or imprnvexdmn..n,and QTY. PLUMBING PERMIT 17EE
whocontmasfor such projects with a contractors)licensed pursuant to the Contractor%
License Law. PERMIT ISSUANCE
I am exempt under Sec. .B k P C for this reason
ALTIiR-DRAIN.W VENT-WATER(EA) � VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE LS ^�
1 bandy elan under penalty of perjury on of the followingW vers Co
�Ihave andwie maintain sCen37.00of he Labor
Cow,for for Wbrkcta Copper. DRAINS-FLUOR.ROOHARLA.COND, STORIES TYPECONSTRUCTION
waited,as which
the for u Section PW of the LaMn Gde,for the perfnnounce of the
work lin which this pandit is issued. FIXTURES-PER'I'RAP
1 have and will ede.Torr Wooer's Cmmpensai w I i,finwe,ll flux
car ,i Section
3]118okerlabor Cede.fonhsurance cancer and woo forwhich thispermitisissued. GAS-EA.SYSTIiM-I INCAOUTLETS DEC.GROUP APN
My Worker's Compensation Insurance eerier and Policy number are:
Cartier. Policy Nu.: GAS-EA.SYSTEM-OVER 4(EAI
CERTIFICATE Of:EXEMPTION FROM WORKERS' GHIiASPJ1NDLIS'1'RL.WASTE IM'IiRCE1T(.)H
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This umewt
cdun mind be compined erm
ifthe pit is hours,hundred dollars Is 100) GREASETRAP
or le".)(This
FC:C
Icmify that in the perany aance,, ,, reinhe ork become
uich p,xito he Woris ker,
ort,cll SEWER-SANITARY-STORM EA.2W FT.not enlpiny any person in any manner m us m M1ecomv snhjcn 1n the Warkcri G,mpen- ENERGY FEB Zp
O Z smma i,o%of Culifomin.Dam WA'T'ER HEATIiR WNENTXH.ECTR GRADING FEE t
Z Applicant
.N. NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSIEM"CREATING
F become subject to the Workers Com tion f me Labor Code,you mus. SOILS FEE
..cora eriodshasa
W � fnrhwith comply with sn<h provision or this permit shall be deemed revoked. WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.1^f. PAID i
1]1 I for w hick rte the thenissue (Sec.30lending agency funhe performanceof Dme Recciptp
(-' the work for which this permit is issued(Sec.Jo9],Civ.C.)
C) Lender's Name TOTAL'
UJ
W BUILDING FEN.Lendcr'e Address TOTAL: OO
')+
[.. 0. 1 anify that I have read this application ad sloe that WB above'in6m
rednn ix
Ili, correct,l agree to comply with all city and county ordinances and state laws relaingm QTY. MECHANICAL PERMIT FEE
U C1 dil
Z building construction.and hereby iumorim representatives of this city m enter upon the SEISMIC FEE
above-mentioned property for inspection purposes' PERMIT ISSUANCE
(We)agree m save,Indemnity and keep hanac,v,the City of Cupcnino against ELECTRIC FEE S� (/O
liabilities.judgments.costs and expcnes which ney in any way acme against said City AEI'ER OR ADD TO MEER.
in eonmquence of the granting of this Permit. PLUMBING FEE ` VQ
APPLICANT UNDERSTANDS AND WILL COMPLY WITI ALj L)OM1-POINT AIR HANDLING UNIT(TO IO.000 CFM) MECHANICAL F�Ii S�
SOV L EGULATIONS. �,///�rl'q(-
AIRHANDLINGIINIT(OVER 10,()N)CPM) CONSTRUCTION TAX
Signature of Appllcom Cm racer Date EXHAUST HOOD IWMUCT) HOUSING MITIGATION FEF.
HAT IDOUS MATERIALS DISCLOS RE
Will theapplicvnt or far..building occupantnmrco.handle lisomius material HEATING UNIT(T010R000 BTU)
as metaled by me Cupcnino Municipal Code,Chapter 9.12,and the health and Safety
Cala Section 25532(q'I HEATING UNIT(OVER 100,000 BTU)
[D Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Date Receipt
Will me applicant or future building occupam use equipment or devices which
can, air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR Rllick BTU) TOTAL:
District! BOILER-COMP(OVER 10,000 BTU)
❑Ycs No
I have read the hmzrdeus mucrialx is under Chapter 6.95 of die Cali- AIR CONDITIONER ISSUANCE E
5,255
fmnia Heapsn Snfety Crisis.Section.cement,
25505.255JJund 255.)4.1 undersand thatifthe NEW RESIDENTIAL MECH. $Q.FT.
building does noreurtentlyhove vtenant,theo ismyct,ol a C,riry anotifythe meupum
of the reynirememx which must Fz..tet prior m issuance of a Cenllic;ne of(kcupunuy,
Owneronaumorved agent Date TOTAL: ISSUEDB .
OFFICE
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