99100119 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ' O v I J
CPPV OF CUPERTINO BUILDING-ELECTRICAL PERMITRMITN�
BUILDING DIVISION APPLICATION/PERMIT PING PROJEM'ICHANICAL
FI
BUILDING PROJECT'IDF.M'IFICATroB '
BUILDING ADDRESS: 4111 SANITARY NO. APPLICATION SUBMITTAL.DAYi / C u �� ��- zz- �'i
OWNER'S NAME: PHONE: CO CI'OR'S AME: LIC NO:
FN�-^ t / D NIC CONTHOI.x
RCTBTECT/IiNGmr
INElilO ,A/r,A LIC NO: ADDRESSC /FN'e ❑ .
CONTACT: T_ e '1Y'I(�� PHONE BUILDING PERMIT INFO
Jct` -ant
El Consultant Fees Paid by Applicant(Initial) BLUG IiLECI' PLUMB MUCH
N )n ❑ ❑ ❑
LICTiNSEDCONTRACFOK'S DECLARATION QTY. ELECTRIC PERMIT FEE
mwzL hereby affirm mm 1 no licensed under prolnimu of Chapter 9(cit numiling � JOB DESCRIPTION
wo, cath Sesdnn700olifDivixion3ofthe Businexseod Professions Ceda,and mylicenxis RESIDENTIAL
I+IOp �t PERMIT ISSUANC'
F-1= in full force olid died./ FDWI. [I KITCHEN REMODEL
aVU Liccnw CBs• `� Lic.x APPLIANCES-REST EN"1'IN. to ITION ❑PLUMBING RF..PIPE
F Z W Dam Cnnradnr It
FN-7y ARCHITECTS D[CLAS TION C1 MULTI-UNIT []STRUCTURAL
PANELS MODIFICATION
op=t IunJcmanJ my plans shell he uscda public records UPT02WAMI:S
❑INTERIOR CHIMNEY REPAIR
F:4F� Licensed Professional 201-I gSIAMYS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION
OVER IWOAMT'S ❑BATH REMIJREPAIR ❑DEMOI.IT ON
I hereby afford that i am exempt from the Contractor's License L for the
k C
e.Ll' w RJI+ g reason.(Section)031.5 It ss nd Pr f x Cod \ Y tY county SIGNS ELECTRICAL ❑OTHER ! —I
which Poore,.psearrukt,cla,umd,nine,intmov,den Ilxh.tramurtay.mcmre
1_Y.pd poor ton . a Iso req .th ,plica tl M1pc 'oto fl g W q tomcat SPECIAL CIRCUIT/ SC.
nio _�jL
that he is licensed purmano the provisns of the Contractors License Law
P (co^mnencing with Section 7000)of Division3ofthe Business and Professions Code)or TEMP.METER POLF,IN, . COMMERCIAL:
Q.=.11, Ihm he is exempt therefrom olid the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION [I DF:MOLI'1'ION
LLX. H Section 7031.5 by any applicant for a pmt
eit subjects the applicant to a civil penalty of POWER DE CIS ❑ C]TENANT FOOD SERVICE
F Z.Y nm more than Eve hundred dollars($500) IMPROVEMENT
d (] Lnv owner of the pnq+cny,lir my cmpinyeca with wages ns their sole mmpensmion, SWIMMINGPOOLELECTRIG
Alldods,work.and the structure ixnotintcnded ondfoom Posale(Sce.70<4,6uxlness ❑OTHER
to 3 m and Professions Calc The Contractor's Licenae Law doex not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds lir improves thereon,and who does such work himxlf or through
his own employccs,pmrvlded that such impmvemcots arc not intended m offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL howeve,the buildingor hnptovcment is sold wlthioane yea
nd c.-Illlnn,the SQ.FT.FLOOR AREA $ISQ,IT.
caner-builder will have the burden of proving that he dul not build er improve fur pur-
ryrsc adult.). _
LJw owns of the Propmy,am uxemlisely utmntding with licensed comractorn to
consume,the project(See.VIW,Rosiness anti Proussine,Crde:)'ITe close QTY. PLUMBING FERMI FEE
who wmracu[or such pmjau with a commemgs)licent licensed pursuato the Caluments s ,
License Law. PERMITISSUANCE
I am exempt not,Sea .B.4 I'C for this.eaxan
ALTER-DRAIN VENT-WATER IEA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLAW 1'H ECT.DEVICE /per U QD
Ihereby affirm under penalty of perjury,one of the following declarations
t]I have and will maintain a Cenifiate of Consenunself-inmre for Workers Cooper- DRAINS-FLWR. OORAREA OND. STORIES TYPE CONSTRUCTION
xation,as provided for by Section 37W of be labor Code,for the performance of the ,S
work for which this rynnit is Lm cd. FIXTURES-PER'T AP
I have and will maintain Wo kers Compensation Insurance,as required by Section
3700idthe labor Crde.forthe performaaceofthe work for which this per mit is issued. GAS-EA.SYSTEM I C.d OUTLETS I OCC.GROUP APN
My Workerryirad cy _ -7 GAS-EA.SYST )VER i(EA)
Ca...v,: C� Nr
rp1
CERTIFICATEOFBXEMPITON FROM WORKERS'CyPliGRIiASFJIN STRL 'ASTE INTERCEPTOR INSURANCE BUILDING DIVISION FEES
(This section need not be completed ifthe permit iv for one hundred dollam(SIM) GREASE' AP
lir loot.) PLANCHECK PEE
I certify that in the performance of the wurk for which this permit i.v issued Lvhall SEWER-SANITARY- 'T ORM EA.2110 FT.
not employ any panto in in any manner so as to Become subject mine Walkers'Coarsen- ENERGY FEE
O Z nation Law,of Celifomia.Dam WATER HEAT17R WNENT/ELECTR
0 GRADING FEE
Z: APPlicum `
Vy NOTICE TO APPLICANT:If.alter making this Certificate of Exemption,you should WATER SYSTEM/TREATING
F become subject to the Worker's Compensation Provisions of the labor Code,von must SOLES FEE
forthwith comply IsPh.such pmvisiamor this permit shall hat deemed reveled. WATER SERVICE
Q
n' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.19'. PAID
VC) I hereby affirm that hem is a construction lembngagenry for the performance of Date Receipt#
F the work Inc which this pernm ix issued(Sea.31)9"7,Civ,C.)
C' lender's Name TOTAL:
C) IQLanders Address TOTAL:
y I anify that I have real this application and state that the above information is BUILUING FEE
FrA omect.I none in comply with all city and county ordinances and state laws relating to QTY. ' MECHANICAL PERMIT FEE
V Z huildingmnxomctinn,and hereby Pathorim vierrantativcsol'Iustily to enter cr pon the SEISMIC FEE
above-m et...red property for inspection mr,i . PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cuo pcninagaimt ELECTRIC FEE
Bali jadgmemx.costs and expenses which may in any way accmeagaimt said City ALTER OR ADD TO F.CH,
PLUMBING FEE
in sequenpermit
of the granting of this permi
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI TO to."CF.") MECHANICAL FEE
SOURCE REGULAIF TI(NS.
AIR HANDLING UNIT(\)VF.R RLDMCFM) CONSTRUCTION TAX
Signn..I, plieme/ ontmms Date EXHAUST HOOD(W/D T) HOUSING MITIGAi'ION FEE
HAZARD 1. M1tATERIAIS DISCI. RE
Will applicnm ter lumen BullJing mcnpam.unrI,lir handle hamalmv material HEADNG ON]'I'(TO 100,0k)BT>
ax ddinnl by the CapePim,Mun lcipal Code,Chapmr 9.12,and he I lealth and Safcry
Cada Section 2553200? HEATING UNIT(OVER I . BTU)
ex
4+ VENTILATION FA' .INW.GL E51U1 PAID Dmccei
e- Rpta
Will the applicant or future building occupant uvc cquipnam lir devices which
IF
tit hvm
aduus air comam1,as defincl bA.y the Bay AAir Quality S1onagcmem BOILER-CO (3HPOR I1B"TUj TOTAL: -
Dis¢idp BOILER-C(MP(OVER BIT T )
E:1 Yet 141 No
I have real the harardoex materials requiremenit under Chapter 6.95 of the Cali" Alit CONDITIONER ISSUANCE DATE
forms Health A,Safety Code,Sections 25505,25533 and 8534.1 understand that if the NEW RESIDENTIAL MECU SQ.FT. q
building docs notcartently Bavemm�:muhat it iv mrmapamibirty te notify the acupam
of he c,mrem a which mPvt mei ono lssuu le of a Cenilicnm of
^%
Owner or autho eed gen) Date TOTAL ISSUED BY:
OFFICE