S0001B0173 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-BLECI RIC-AL PERMIT N(�- O
APPLICNI'ION/PERMIT PLUMBING-MECHANICAL \a `(-n)`
BUILDING AD IlIV1510N BUILDING I'ROdRCT IDFYI'1FICATION `�ooOl
173
BUILDING ADDNIilS: All
SANITARY M1'Q. APPLICATION SUBMI'1-I'AI.UA'TI
IOLV
OeN 'S NAME: f'HUNS: N A QR'S NA 1F L` :` I
J -'J--Ill NIC CONI'ROLp
MARCHITEC1'/IiNG1NEEK: LIC NO: AD RESS' — ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BI.DG ELECT PLUMB M11F:C11
❑ ❑ ❑
I.ICENSHD CONTRACTOR'S DECLARAT ION QTY ELECTRIC I'ERMIr FEC JOB DESCRIPTION
1 hereby affirm men I ant licensed under provisin.,of Chapter 9(nom ntuc ng
DMZ with S,,,uon700(gofDlvlcinnJnfthe Roshnexs and PmfcavionsCnde.vnA my licenseU RESIDENTIAL,
❑]O O PERMIT ISSUANCIi
�1yF in full force andejtqt. �^ — �SFUWI, ❑KITGHI3N RIiM110DE1.
aUU Linens Lica APPLIANCES-RESIDENTIAL []ADDITION
❑PLUMBING HIiI'll'li
FZW Dom Contractor
VIQ2 ❑MULTIUNIT [_]STRUCTURAL
Oy ARCHITECTS DEC T N PANELS
F m Z I understand my plans shall t e used as public records MODIFICATION
OZN- UPT02MAMPS ❑INTERIOR ❑CHIM1INEYREI'AIR
I-4FW Licensed Proberfooal 2111-I0011AMP5 IMPROVEMENT �lWIMMING I'OOIti
OWNER-BUILDER DECLARATION OVER I(1(XIAMPS ❑BATH Ri;h10DELIREPAM ❑DEMOLITION
C C Q 1 hereby affirm that I eaempt from the Contractor's License Law for the
X 3 a am U ffollowing reason.(Section 7831.5.Business and Professions Coch:Any city or county SIGNS ELECTRICAL. ❑DTI IIiH
y which requires a perms to constant.alter,improve,demolish,or repair any%fracture
prior to its issuance,also requires the applicant potlatch permit o rile a signed statement SPECIAL CINCUIT/MISC.
f"a�a}•] that he is licensed pursuantto the provisionsofthe Contractor's License Use Chapters)W.i 00 (commencing with Sectio YOnO)of Division 3 oflha Business and Professions Code)or TEMP.METER OR POLE INST.
COMMERCIAL'
L Ee CG that he is cumpt therefrom and the basis for the alleged exemption.Any violation of ❑NE BLDG/ADDITION ElDEMOLTI'[ON
w lection 7031..5 by any applicant for apermit suhjuts the nPplicam bin civil pcnolty of POWER])17 ICE ❑IFNANi' ❑FOODSERVICE
not mare thin live hond:eJ dollars($5011). IMPROVINEN'I'
E � ❑ t.asnwnerol the pnespy.room Idea with wu :a mini,enle cont tion, SWIMMINGMIGI-I!L1101'RIC
Y cmP Y &sx pen"a ❑ONIER
Ir will Jo the work.and the structure is mrmmrdedoronend foliate(See 7(9a,Bus;nexs
3 m and Pod csxions Case:'Tic Cormactor',License Law does not apply In an owner nl OUTLETS-SWITCIIIil--SWITCHES-FIXTURES
pno,ey she build,Or Impnrve,thereon,and who does such work himself Or through
his own enmtnyces,provided that such improvementsum not intended or offered for NEW RESIDENTIAL ELECTR SQ F
sulc If.however,the buildingmirapnwornem iso,hl within nreyemcfcompletion.the SQ.IT.FLOOR AREA $ISQ.FT..
owncohmildcr will have the burden of proving that he did net Wild or improve for pur-
psnc of®Ic.L TOT
1,as owner of the praiedY,aet exclusively contracting with licensed contractors m
unstmct the i mject(Sec.)Bdi.Business and 6ofesamms Chep The Comracmr,Li-
cense law Jots not apply to an owner of property who builds or improves themon,and QTY. P G P i 1 s
who contracts for such projects with a coovacmr(s)licensed punuant to the Contmcmr's
L.iccn,c Law. IT
El I am exempt under Sec. B&P C for this reason
L & 'N WA'rE ) VALUATION
Owner Date
• WOR KER'S COMPENSATION DECLARNE[ON ACK WPRCI! DE CE
I hereby affirm Linder Penalty Of perjury one of the nis ng dalavn
❑ I have mW w 111 muimaina Cmnturee of Consent and r-Illi for Worker's' s S DDI;ROOV,AREA,COND. S'rURII:S "1.YP17 CONS'IRIICI'RR,
,noon,as provided Ib,by Section 3](g)of the Labor Code,Gm the Pcrhmnan
hr for which this permit is issued. INTO i5-PER'TRAI'
w have and will;neionow Workas Compensmion Imur:mro,as initial by Ss'•'on
3 In] laMn Care,for the performance of the work rot which this pannitisiss GAS-GA.lYS'C1iM-I INCA OUTLETS OCCGROUV AI'N
My WOr v�'° tion lnsu!m l[e Gamer and Policyy !i!g; "
Carticv ( (-�..11T1� IA` Pulicy Nn:/"yx)IhJ GAS-EA.SYSTEM-UVIiNAIFA)
CERIIFLCATEOFEXEMPTIONEROMWORKIiRS' GREASHIINDUSTNLWASTEWILE CF, /U\
COMPENSATION INSURANCE • I BUILDING DIVISION FELLS
('(Tis seetion need not be completed ifthe permit is forone forecast dollan($IM) OR ESE TRAP It Il
or less) 1
EI'1. Kcd ECK iT!€
I cmify thatmthe parmamece of the work for which this permit is issued.I shallrr�4'
SEWER-SANITAHY-S"IR)HM EA.2W'!' _I I �� Ihiii PEE '11
not employ any person in any manner w as to hcome subject to the wbrken'Compen-
Z soon Laws of California.Date WATER HEATER W/VENT/EiLECfR GRADING FEE.
z C) APPlicwt
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER Sys rEmnRCATING S IjSyyE��'
become subject o the Workfr's Compensation provisions of the Labor Codc,you most
forthwith comply still such provisions or this permit shall the deemed invoked, WATER SERVICE
a O
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMII. SQ,FC. PAID
a 'Z' Dmreby urtinn don there is a ecrunininm icmrng agency or doe p,:rbmamc
me fir Dmf ccipt»
O the work for sumach do,perout is I,med(See 3897,Civ.C.)
TOTAL:
Ol^ lxndcrs Name
U Lcmdcr's AJdrea TOTAL:
} C 1 cemly that I have read this application and state that the above information is HIJILDING til!
;Fs h correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MFCHANICAL PERMIT FEE SEISMIC Id::
U Z building construction.and hereby oatioriu representatives ofthis city bo enter upon the
alsoc nentioncJ pmM1ny for inspection purposes, PERMIT ISSUANCE: ELFCTRICF
(We)agree to.mvc,indemnify and keep hanoth-the City of Cupcnion against
liabilities,judgments.costs and expenses which may in any%wr care againstsaid City AITER OR ADD TO MECH. I'LUMBINGFE
consequencein of the growing of this permit.
API' [CANT UNDERSTANDS AND WILL COMPLY WE]if ALL NON-POINT AIR HANDLING UNIT LTO Io.g18 CPM) htECHANICALF
n
So "GUI TIONS.
' I _f R -� AIR HANDLING UNIT(OVER 10.000 GPM) CONSTRUCTION TAX
S mut roof Appliewd/Comincmr Date EXHAUST HOOD(W/DUCT) MM HOUSING MI9'IGATION FEE
I OSURIL
Will Nutpplinn�mlboom buldinoc,aind xuDOUS MATERIALS vcor handle hneanlom'ma¢riLo1 HEATING ON[I'(TO 100.00011'1'U)6o WO J�.90
nr AVIincA by Ibe CON"no Municipal Coale,Chapter 9.12,and Iles Health Lord Safety
CoJc,Section 25582(uYI HEATING UNIT(OVEN 100.001 BTU)
Yes No VF,NTILA'TION PAN(SINGUi RHSiD) PAID
Late Rcecipta
Will the applicant or future building Occupant use equipment or devices which EAIRCONEDITION
IiPOR Iq),(HN)B'1'U)
mit htiardous sir comamiear s as defined by the Bay Arca Air Quality Management
ni,merr is
?L:
V 1?R I00.0001OU)
❑Yes El NO ? �0 aI
JO WQ pISSUANC[DATE
1 have read tic hes adore mntenals requirements under Chapter fi.95 of NC Cali- ��/fmmla Health&Surety Code.e auons.arm i25533 andesp 2553J.L uonfify h that ifNe I.MECII. SG FT.
building Joel nm currently have a tenant.Nm it is my responsibility m notify the recupam
of the requirements which must be met prior to issuance of a Certificate of OccuPLONY. /J
Owner fir omhnrizeJ agent Dam TOTAL: ISSUED BY:
OFFICE