31354 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUII.DIN(;.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMRING-MECIIANICAI.
31354
Ii/r(//fO/ /n( ' BUILDING PN(yJECI'IDEM'IfICA'1'ION
9UILDING ADDRESS: � I /�X�l /�! — SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER' AE:: �'O/ ^ JAW-� CONTRA 5 LI
O'/J✓ NIC CONfHOLp
\RCHITI3CT/13NGINEER: LIC NO'. ADI / _ ZAzloD I'„ ❑
CONI'ACI': PHONE: BUILDING PERMITINFO
v"�1
/ El Consultant Fees Paid by Applicant(Initial) BLDG EEE PLUMB
f-' LICENSED CONTRACTOR:S DECLARATI✓ON' QTY ELECTRIC PERMIT FEE El ❑ E
1 herebr affirm tear 1 am IiaenaJ mud«prAisions of Chapter 9(cmmmencWg I JOB DESCRIPTION
ADO with Section70)0)of Division 3 O the Business and Profe,ionsCode.and mylicensais PERMIT ISSUANCE /) RESIDENTIAL:
Cto_ mfullforceund of/cctAryY •i�lL /� `' ❑SFDWL ❑KITCHEN REMODEL
aUV Licenn (�/✓ Contra .,
intr 'I'Y/✓ k!� APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
Ga Dam Cn DECL
t.Dm ARCHITECTS DECLARATION PANELS []MULTI-UNIT ❑STRUCTURAL
Z 0 n 3 I understand my plans.Imll he used as public mconf, MODIFICATION
UPTO 200 AMPS
O Z..C ❑INTERIOR C1 CHIMNEY REPAIR
�
F, �Jcense
Lid Prolesxinnnl 201-I(NH)AMPS IMPROVEMENT
Y
OWNER-BUILDER DECLARATION OVER IWBAMPS O BATH REMODEUREPAIR [I DEMOLITION
C W a 1 hereby affirm that 1 1. exempt from the Contractor's Anye Law far the
F.06U followinguiresa (Section 7031.5.Buxinns and improve.
demolish.
Colic:Any city arcounty SIGNS ELECTRICAL ❑OTHER
413 c h which requires a permit m cunrmn,alter,improve,demolish,or repair any drvnuru
F"��g prior to its issuanc,also requires the applicant for such permit to file a sileadmitwunnt SPECIAL CIRCUITIMISC.
f Y that he is licensed Pursuant m the pervionas Of the Com ries License Isw parrpter 9 6di!'
�yp0 (commencinth Sution]OOOj of Division3 ofthe Business and Professions Code COMMERCIAL:
gxi )or T[MP.METER OR POLE INST.
A.a c y that he is exempt therefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION
_4•y Section?031.5 by any applicant for a permit subjects the applicant ^a civil penalty of POWER DEVICES OTENANT ❑FOOD SERVICG
r more than five hundred dollars(3500).
F Z A IMPROVEMENT
p6
C]1,as Owner of the pmpeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the suucmte is our intended oroBsord f r salc(Sec.]IWq Business ❑OTHER
W 3 and I'rdessions Code:The Contranor's I.Iccosc Law does not apply to an Owner of OUTLET'S-SWITCHES-IT%TURES
property who builds or improves thereon,rand who Joessueb work himself or through
his own employees,provided that such improvements are not intended or ollbreJ Fir NEW RESIDENTIAI,ELECT SOFT
sale.IL however the building or improvement it sold within one year of completion,the SQ.FT FLOOR AREA $cSQ.FT.
overer-budder will have the burden of proving that he did not build or improve for puts
pace of tale.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.]BN.Business and 14afosiu^s Case:)The Contractor's Li-
nt law does not apply,.an owmn.d property who builds or improves thereon.and QTY. PLUMBIN IT FEE
whocontmets for such projects with a contractors)licensed pursuant o the Contractors
License Low. PERMIT ISSUANCE
1 am exempt trader Sec. .B&P C for this isoson
Owner Dee ALTER-DRAIN&VENT iR iA) VALUATION
WORKER'S COMPENSAl'[ON DECLARATION BACK PLOW PRO'IEC'K DEVI 9DG
1 hereby affirm f p
under penalty oerPry noc ol'the following declarations
[] Ihnve nnJ will mamtmn aCoriOcote of Cnmcnnn mlr-insure fest Worker's C^mpca DRAINS-FLOOR R)OR AREA.CO,
,earn,as provided for by Section 3]1X1 of the Labor Code,rot the performuncc ol'the STORIES 'I'YI'li CONSTRUCTION
t far which this permit is issued. FIXTURES-PER TRAP
w I have and will maintain Workers Compensation Insurance,as required by Section
3]0)uf,hc Labor Code for Ne performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.J OU'TLET'S OCC.GROUP APN
My Worker' tap tib r J Policy yympaa/fie �s
Carrier. Policy No:(N7(l lD/TS GAS-EA.SYSTEM.OVER 4(EA)
CERTIFICATE OF �XBMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(Mussection cedumbecumpleted ifthe i isforonehundool Jo1lan6100) BUILDING DIVISION Ri1S
pcmu CREASETRAP
art less.) PLANCHECK FEE
Loy any that,,she pcymanenrof,to orkbee which this held isissued.lshot[ SEWER-SANITARY-S'TOHM GA.HX)FT.
not employ any Pusan in any manner sat ax to M1eenme.vubjeet m the Workers'Contpen. ENERGY PF?P.
Z sirdom Lows of Culifomia.Date WATER IIEA'TER W/VENT/HI_I.CIR
�Q Applicant GRADING PEE
z H NOTICE TO APPLICANT:If,afrn making this Ceridieue of Exemption,you should WATER SYSTEM]TREATING
^' bes:ome subject to the Workers Compensation provi ism.of she Later Code,you most SOILS FEE
forhwith comply wish such previsions or this Permit shall be deemed revoker. WATER SERVICE
M
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMN. SQ,FL PAID
U Z hereby which
that there iso ed(See innlendis.agency for the performana of Dae RtteiptM
U O the work for whish this permit is issued(S«.309].Civ.CJ
Lts I"' Lenders No. TOTAL
L.) Lenders Address TOTAL:
0. 1 cerify that I have read this application and state that the above infuriation is BUILDING FEE
F' V) correct.l agree to comply with all city and county ordinances and state laws relating ht QTY, MECHANICAL PERMIT FEE
U building c^nsction,and hereod
by authec mpmsentadm vev of this city enter upon the SEISMIC FTP,
tm
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupenina against ELECTRIC FEE
iubilities,juJgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
nxeyucncc of a`farm,od d is pemtit. ' ^
APPLICANT UERSTANUS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0k000 CFM) MECHANICAL FEE O�
SOURC , )1 TTONS. J
AIR HANDLING UNIT(OVER 10.0110 CFM) CONSTRUCTION TAX
gmdamof Applicant/C � 262Zenv
ate EXHAUST HOLD(WADUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harmdous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cuperino Municipal Cole,Chapter 9.12,and she Health and Safety
Code Section 29532(a)^. HEATING UNIT(OVER I IX.000 BTU)
0 Yes o VENTILATION FAN(SINGLE RESID) LAID Date Rccciptp
Will the applicant or fumrc building oreupam use equipment nr devices which BOILER-COMP(311P OR IINI,INNJ BTU)
.mit humrdous air contaminants os defined by the Bay Are.Air Quality Management TU'I'AI
Disvict?
ED Yes BOILER-COMP(OVER 100,000 BTU)
I havc«aJ the haruNco,trutcriak rcyuirttnenn under Chapmr 6.95 of the Cali- AIR CONDITIONER D
ISSUANCE DATE
forma ilealsh&S tY Cade.Smians 255(15.255P mJ 25530.I umlerstanJ th t if the NEW RESIDENTIAL MECH. SQ.En
builJingdtws dy have atenant,that it is my mpmvialiry to twtif pont
of the urren tpdnnninuvntt ofa Cenifi u y/T/a
� en TOTAL:
Owt rtud agent Dat ISSUED BY:
OFFICE