S 1093 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 01111.DINl:-ELEC'TRICAL 1'IiRMIT NO.
BUILDING.DIVISION APPLICA'1'IONIPERMIT PING PROTECT IDENTIFICATION
S 1093
� /n/ ItUI1.U1N0 PROTECT IUENI'IF'ICATION
BUILDING Al)I)Ro2 y8 • a O r4 � SANT I'ARV NO. APPLICATION SUlihtl'ITAI.DA'l li
LL �2
ra
OWNER'S NAME O COQ OR'S NAh� F LIC NO NIC CONTROL
' ARCHIJECTIENGINEER: LIC NO:ar ADDRESS: Y ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ >k
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 bnrehy afdrn+mat 1 m„bcen.c l made,p,nvidnr..of chapter 9(colrt
JOB DESCRIPTION
pZ with Scelinn"IIXNIIof Division 7,fthe Business and Pndessinns Code,and mY license is RESIDENTIAL:
O PERMIT ISSUANCli
CLLF in full force and cli'vO 7,l y[,/ / ❑$FDW'I. ❑KITCHIiN REMODEL
aVU License C)�`�1��'�L�Lic.a'haZIF APPLIANCES-RESHANI[Al. ❑ADUHION C1 PLUMBING RE-PUT
�<L Date—L�a1�K=--I--Can DECLARATION �MUI,TI-0NIT ❑STRUCTURAL
ZOtrZ I undersand my plans shall M used as public retard. /r PANELS MODIFICA'170N
OZL'-a UPT0200AMPS C1 INTERIOR El CHIMNEY REPAIR
F4E'W Licensed Prufessinwl 201-1000AMPS IMPROVINENT E)SWIMMING TOOLS
<•tf� OWNER-BUILDER DECLARATION OVER I(Xp AMPS ❑HATH RIiM WLREpAIR_[I DjjivIOLID4N
C:Y Q I hereby affirm that I am exempt focal the Contractor's Livence law for the
�axOiu fallowing reason.(Section 7031.5.Bmineus and Professions Cale:Any city or caumy SIGNS ELECTRICAL ❑OTIIIiR
W 3 LL y which requires a permit to cauxuact,altce improve,demolish.or repair any strumure
F ; prior to its issuance,also requires the applicant for.mch Permit o file a signed statement SPECI AL CIRCUI VMISC.
y that he is licensed no...ammta,aosiaion,of nmvacv+r'..License law(Chapter 9 COMMERCIAL'
SCO (commencing with Section 9000)of Division J ofthe Business and Professions Cade)or TEMP.METER OR 1101.17 INS'T.
it.a e y than he is exrntpl IhervGnm and the basis for the ulleycd uwmptim+.Any violation of E)NE HLDOIAODITION El DEMOLI9'ION
y Section 7031..5 by any applicant for a permit subjects the applicant m a civil rymalty of POWER DEVICES ❑I17NAN'I ❑FOOD SHRViCE
n(nwm(into five hundred dollars($500). IMPROVEMENT
� d E] I,ucowne,ol'the propcny,arnll employees wall wages as)hour sole eo.. son,alion. SWIMMING POOL.ELECT RIG
S 0 will du mho work,and nhcmrvcture ie'not imm�JN a..ffcred forsale[Sec.91144.B-mrss [:)01111;R
F' OUTLF I -S W O Cl IIiS-FIX'I URES
d'3 and Prof essinnc Code:The Contractor's License Law,discs mat apply m un owner of
propuny Wan hudds no improves thereon.sad who domsuch work Ill chin through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENT TO,ELEIMR 5
SQ I'I'.1100N AREA S/SQ.19'.
sale.If,however,the building or improvement is sold within one Yom of annPletion,,he
wnerbuilder will have the burden of pmving that he did not IwiIJ nr improve far pur-
Paseafsale.). TO
1,sex owner of the prnpeny.am exclusively contracting with licensed contractors to
consumer the vanjce,(Sec.9BW.Business and Professions Lc:)I he Comracwrs I, �Y�. /�
cense law drwe not apply to an owner of properly w has holds or improves thermal.and QTY PLUMBING PERMIT PA A r D
who catnrves Ln such projects with a commends)licensed pursuanuo the Contractor's
License law. PERMIT ISSUANCE
❑ I am exempt under Sec. .Ir&P C for this mown DEC a
ALT17R-DRAIN&VENT'-WN'ER(EA) 'AL 1
Owner Date
WORK ERS COMPENSATION DECLARAI'ION BACK PLOW PBOIECE DEVICE L(J r VC
Ihen'hy aft innunder penalty of perjury one it he li+llnwing Aeclxrmions: VVI'
❑ Ihnvc endwillnminwinnCunifica,m ofCnnccnuo sclGlnsure far WudcrR Cnmpun- DRAINS-FLOOR.ROOP,AREA.COND. S'II)RIRS X. ONS'I'RUCfION
amim,,nx Prov WcA fur by Sce ina 39tH)of the Labor Cale,f a the perlbnnance of the
k fur which this permit is issued. FIXTURES-PER'IRAI'
IVN hove and will maintain Worker's Compemalion In...racc.as refuted by Section
37N)of Ne)shot Code,for the performance of the work nim whish this Penni(is iss GAS-IiA.SYSI IAT-I INCA OU'l1,IiT5 OCC.GROUT' AI'N
My Wark C '11 Insurance 'er and Policy nu r
Comics '� o yV E Policy N'+,: GAS-EA.SYS IN OVER 4 WA)
CER IF FE EMPTIONFROMWORKERS' GREASUINDUSI'RL WAS'1'E DO 17RCEP011
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thissection purl not heeompletal ifhe permit is float hwWrtddollan(5100) GREASETRAI'
I'LANCHIiCK hili
ar less.)
ley any that in the performance as he
for subjectch 10 permit iocsued,I'Condk11 SEWER-SrW1TARY-STORM IiA.2(p Ff.
not employ any person in any manrrcr so as to become subject m the Wnrken'Compen- IiNIiHGY Igili
Z motion Law'c nl Conforms Date WATER HEATER WNENUITECTR GRADING FEE
Z o Applicant
NOTICE TO APPLICANT:If,after making,hin Cenificteof Eacmption.you should WATER SYSI EM1VTRENrING SOLISPER
h' Note..¢subject to the Worker's Cumpencmon provisions of the Labor Cale.You must
Fault,all comply with such pro,lossoso,this permit shall be he cal revoked. WATER SERVICE
aQ
CONSTRUCTION LENDING AGENCY NEW RESIUIiN11A1.I'LMB, SQ.FT. INTO
I herebyallirnt that there la o construction leulln limit limnnmco of Uulc Roccip,#
U 0 . . .agency per
{! H the wank tier whlcN phis)+comm is iswed(Set.3097.Civ.C.) TOTAL
C) Leader'.%Name TOTAL:
Addmcx
U
>' F$1 I ecndy that I have mad this application and.mc that the ob:rve inf nartien is RUILDING THE,
F V0.) cones".l agree to comply with all city and county ordinances and state lawn relating to QTY MECHANICAL PERMIT FEE SEISMIC FEE
U Z bnildingeon.amction,and hereby authorise represenmtivesnf this city menrerurym the
above mentioned property far inspection pm,sl PERMIT ISSUANCE EI.licl RIC ITIl
(We)as.m,save,indemnify and keep harmlcs the City,,(Cupcnino I,unst
Iiabilities,judgmentc cons and expenses which may in any way same against said City ALTER OR ADD I'O MECIL PLUMBING THE
in canaqurnce of the eroui.,of this pe.it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON]'I'(TO 10,000 Cpst MECHANICAL F1:E
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.004)CPM) CONNCificr1ON l'A'
Signature of A,plicantlContral Da,c EXHAUST HOOD(W/DUCT') HOUSING MITIGATION FEE
HA9ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle ha,oadcxanterial THEATING ON('[(To 100,(4X)IT U)
sex dermal by the Cti enino Municipal Calc,Chapter 9.12,mol the Herld,and Safety
Code.Swlin i 25552(a).' HEATING UNIT(OVER 11X an)aI'U)
❑Vcs I]Ns VPN'I ILADON I'A N I NGLE Mild D) PAID Umc Itnccip(#
WIII he.,,liven,or fumrc bmildir,lcci,an,asecy+dpnncm nr Aevinx which BOILER-COMP(3111.OR 1000)0 HI
mit hnardaux air commain.nts as defined by the]my Area Air Quality Mmm,va al TOTAL:
District? HO1LER-COMP(OVER 100I)COBIG)
]Yes ❑No
I have rand the hmardous matermsraNiremems under Chapter 6.95 of the Cali- AIR CONDI'1'IONGR ISSUANCE DATE
food.Heald,&Safe,y Coale,Satire 25505,25513 and 25574.1 understand that If me NEW RESIDENTIAL NIECH. SQ.ET.
building dons not currently have a tenant,that it is my responsibility to notify the ineupant
nDhe ascii h t t 1 ante of n -m
p ' � ' h TOTAL:
Owner not vx agent Date / ISSUE[)BY:
OFFICE