30482 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
(BUILDING,PROJECT(BENT)F'ICATiON
BUILUINGADDRESS; SANITARY NO. APPLICATION SUBMITTAL DATE
/O5-S3 MERRtNAA &AD. pu CRTiND, CA 9-6-014
OWNER'SNAME: PHONE: /p CONTHALTDH'S NAME: LIC NO:
AZ4A4 IIN L1UDy TAMC ZJ_5682 NIC /� CON ROLA
\RCHITEC'1'11tNGINEER: LIC NO, ADDRESS: ❑ /'1x
NAPOA144 LkViff ►i 11ij b2 qVNWT8AP kP. WA&AI4 YV7
CONTACT: PHONE: BUILDING PERMIT INFO
TLt/I I Consultant Fees Paid by Applicant(Initial) x BLDG L PLUMB MECH
x}02) Q92-0 10(
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby aft that 1 am licensed under pmvt ions of Chapter 9(commencing JOB DESCRIPTION
W0Z with Section 7lMXq of Divizi.nJ.fine Business enJ Professions Crile,and mylicensc is
W O p PERMIT ISSUANCE
Fw, Licene full me Class
erica' S WL ❑KITCHEN REMODEL
aF.UZU License Glace Lie. APPLIANCES-RESIDENTIAL DDITION C1 PLUMBING RF:-PIPE
N 6 i Datc Contmetnr
ARCIII"TECTS DECLARATION []MULTI-UNIT ❑STRUCTURAL
F� PANELSZp�2Z IunJcrstand my plans shall he used a.+puMic rccoNs MODIFICATION
UPT02UTAMPS
P t:0 ❑INTERIOR ❑CHIMNEY REPAIR
'f�F'W Licensed Peram"iunal 201-1010RAMPS 11 IMPROVEMENT pp,, pp!�..
� � OW
DECLARATION OVER ILYIIIAMPS ❑BATH RL_8D�g4PVk El DEMOLITION
Q I hereby affirm OW 1 am exempt from the Contract.,',License Law for the
C LLF- Gdlowing min,ai (Section 7031.5.Business non PrON.Wer,Cale',Any city of enmity SIGNS ELeC RIC ❑OTHER
y which mefan s a penin n,co,orea.alar,improve,di melish,or miwir any sfucmrc
I"'�0g prior to in.issuance,also requires the applicant for such Permit to file a signed statement SPECIAL CIRC MIS
f y that he is licensed pmsuant1.me Provisions of the Ci mmnors License law(Cheater 9
�)Y0p (mmm<ncin iN Sccdon]lXXq of DivisionJof me Businexs add Professions Code COMMERCIAL:
gw )or TEMP. OR POLE IN tit
it%o y that he is exempt therefrom and the basis for the alleged exemption.Any violation n( [IQp)p•L(jtkAQ6 I0Pf1 I II]INEMOLITION
V• Section]031.5 by any applicant for a permit subjects the applicant to a civil peculty of POWER DEVICES
W^m ❑TENANT ❑IpOU SERVICE
ore than live hundred Jnlorry y employees W l�
E�>' IMPROVEMENT
'SSQ mLas ownsref the propeny,or myntendd or wages as fesadei(Sea 111..B¢ntinn, SWIMM1fINGPWL1il.F,CI'RIC
FC will do me work,end Nenrvcmreiatots License
offered fee not apply
7B i4.Business ❑OTHER
I�i13
and arty who builds Cade:The vex th reo License Lew does dot apply m if owner of OUTLITS-SWITCHF_S-FIXTURES
his own who ogees,or improves thereon,and who fires such work deed or m through
sal own owe employees,the building
)hat such ealI improvements are not intended of offered the NfiW RES IDENTIAL ELECTR SQ FT.
-(elf,however.thebuildingorinspmvemen) +enlJwithinone year of armplelinn,the —0M S "1 RARER 9,"SQ PT
car-builder will have the burden of proving that he did not build or improve for pun V R �' `
se.f sale.). 1✓ -
h as owner of ole peoperi am exclusively contracting with licensed comments to f
coasnmet the project(Sec.70M,Business and Pmmw10m Cedes The Contractors L
came Law does not apply it)an owner ofpr.lnny who builds or improves therenm;md QTY. PLUMBING PERMIT FEE 4
whnenntmete fofsuch p jeer,with ac.nmmmrx)licensed pmrsumn ,,the Orractor's
License U.. PERMIT ISSUANCE,
I am exempt under Sec. .11 d P C for Nis reason
r
•• / /¢ ALTER-DRAIN&VF. R IEA) VA U f
Date
net WORKER'S COMPENSATr6N DECLARATION BACK FLOW PROTECT.Y-1
1 frothy affirm under pcnuhy of acr my one of the following drelamtionv
M I have and will maintain a Ccrilicamof Consent to self-intim for Workers Campcm- DRAINS-FLOOR.ROOF.AREA,CONDSTORIES TYPE CONSTRUCTION
cation,as Provided for by Section 37M of the Labor Cade,for the performance of the
week for which this permit is is.+uad. FIXTURES-PER TRAP
M I have and will maintain Workers Compensation Insurance,as acquired by Section
37M of the labor Code,for the performance of the work for which this permit is issued GAS-PA.SYSTEM-I INC.4 OUT(.. . OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number ore:
Cartier Policy No.: GAS-EA.SYSTEM.OV ER 4 CA)
CERTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE GRFASFlINOUSTRL WASTE INTERCIiI'TOR
BUIL. NG ISION FEES
Ibisseeion need not be completed time permit is Torero hundred dollar(5100) GREASETRAP
or le"'.) PLANCHECK FEEL
I cenifythal in the perhmnnnee of the work for which this permit is issued,I shallopen- SEWER-SANITARY-STORM EA.200FT.
nm employ any IxYs.n in tiny manner cit os m baronet,abject In the Workers'Cnmpcn. ENERGY PG
� Z mtiun Laws of California.Date WATER HGTER WIVENTELECI'R GRADING FEE
Z 2 Applicant
.N.a NOTICE TO APPLICANT:If,after making his Cenificate of Exemption.you should WATER SYSTEMOREATING
(~ , become subject m the Worker's Compenwuon provisions of Ne Labor Cade,you most SOILS FEE
Wforthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
5Z CONST RUCTION LENDING AGENCY NEW RESIDENTIAL TIME SQ.FT. PAID D Rece tX
U,Q Iherebyfwhich rtn est there is suedconstruction(See
097.Cm agency for Ne performance of
� f-' the work for which this permit is issued(Sec.J(H].Civ.CJ
Leaders Name
U Lenders AJdrexs TOTAL:
Y lT•1 BUILDING F
[... 1 sonify than 1 have mud This application and stem that the aN.ve infnmmtinn is
Va] rorrcet.l agree br nrmply with un city and county oNinanecs and stmt laws relating 1. QTY. MECHANICAL PERMIT PGE T
U Z building cnnarvdion,enJ hereby aumove rcpresenmtives of Ni.+ciDmenmrugmthe SGISMIC FEE {.7
above-mentioned property for inspection purgat PERMIT ISSUANCE �1
(We)agree m save,indemnify and keep hamticss the City of Cmpealm agaimt ELECTRIC Fl Ls
liabilities.judgments,costs and expenses which may in any way acerae against said City ALTER OR ADD TO MECH.
in .sequence of the granting of this permit PLUMRI E `
APPLICA NI'UN DERST ANDS AND WILL COMPLY WITH ALL NON-POINT AI R HANDLING UNIT(TO 10,IXX)CFM)
SOURCE.REG ULATIONS. MECHA Ali.FEE
AIR HANDLING UNIT(OVER 10.0009 CPM) CONSTRUCTIONT 7j•�
Signature of ApplicaMComracmr Date EXHAUSTHOOD(MMUCf) HOUSING MITIGAT FEE
HAZARDOUS MATERIALS DISCLOSURE
Will)hcapplicom.rl'ururc building occupant tore or hnndlc bmamemncle,iul HEAPING UNIT(FO 100,000 BTU)
as defined by the Cupenino Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt X
Will the applicant or future building occupant use equipment or devices which
mit Macaroons air emnmnrimmis ax defined by lm Buy Area Air Quality Manage enl BOIL(?R-COMP(JIIP OR 100.00D BTU) _
District?
TDistrict?
[:I Ya, ❑No BOILIiR-COMPIOVER 100.00h)(ITU)
1 have read the hoaallous memo.],fequiacments made,Chapter 6.95 of the Cali- AIR CONDITIONER
ISSUANCE DATE.
fomia Health Se Safety Coda Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECH. SO.FT.
buildingdresnot arentlyhove xtctmm.
dean it Lsmy rv, mffidtymnotifythe occupant
of the requirements which must he met prior m issuance of a Certificate of Occupancy.
Owner or auNorimd agent Data TOTAL: ISSUED BY:
/7C/\ OFFICE