00010076 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECPRICAI D/Yk / PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF.CIIANICA (C-.,l(lf l/Yrr
IIUII.DINf,PROJECT IDENTIFICATION BUILDING ADDRESS: Q SANITARY NO. APPLICATION SUBMI'TEAL DATE
J9 5 �EH� �E LR E 2m oto
O''N •NAMME rfloHE CONTRACTOR'S NAMOWZ511-31 18
Ankgo=-J,E LIC NO: / t N/C CONTROL#
HCHITECT/ENGINEER: UC NO: ADDRESS: ❑
CONTACT: PHONEILDING PERMIT INFO
❑ Consultant FCC%Paid by Applicant(Initial) BLDf ELECT PLUMB MIiCH
❑ ❑ ❑
LICENSED CONIRAC'I ORIS DECLARA'T'ION Cry ELECTRIC PERMIT FEE
I hereby alBnn that I am Iicensc l under provisions of Chapier 9(commencing JOB DESCRIPTION
WOZ with SeatimO700l)of Division 3nfthe BominessunJ Professions Code,and my license is RESIDENTIAL:
WOO PERMIT ISSUANCE
WU Lfene Class
dfmd. ❑SFDWL ❑KITCHEN REMODEL
aUU License Lica APPLIANCE¢-RESIDENTIAL []ADDITION [D PLUMBING RE-PIPE
N L Dote Contmc.or
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCURAL
ZFOhZ Iurafteaed my plansshall be usedas public..carit, PANELS MODIFICATION
OZND UP TO 200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
F.~W Licensed Professional 2014000AMPS IMPROVEMENT [ISWIMMING POOLS
Y�
OWNER-ItU11.DEH DECLARATION OVI7R I000AMPS ❑BATH REMODELIREPAIR E3 DEMOLITION
C C G 1 hereby ff that 1 am exempt I'r theContractor's L L for the
KOaU odlow g (Section 70315 Ensure,notIProfession,CodAY ty county SIGNS ELECTRICAL ❑OTHEiR
4:3LLy
which
4 pamando,emostruct.
life,imposture,dem sh. r pi, Y:broeame
Prior
t I : e, ,n y 'll fill suchpuilt t
SPECIAL CIHCIII"f/MISC.
that he is licensed no the nhe Contractors License Law 9
�} punuan of Division per
SCO (eonhe is exempt thetron,an0)of basis for the
theeged¢sand Prrde.wion%Codo)or TEMP.ME'1'Eft OR POLE(NST, COMMERCIAL:
a a e[1
that he is exempt Ihcrcfrom and he basis Liu the alleged exemption.Any violation of El NEW BLDG/AUDH'ION []DEMOLITION
X^LL Section 7031.5 by any applicanlhsr a permit subjects the eppli.alto a civil pcnalt,of POWER DEVICES ❑TENANT ❑FOODSERVICE
ILL,Zy not more dean five hroulmdld Ills($500). IMPROVEMENT
�=Q QLas owner of the propcny.or myempinyeeawith wngesas tbeirsole nimpenatinn, SWIMMING POOL ELECTRIC ❑OTHER
E- wil l dome woe k,and first....( a.anal in¢ndcduroffcrad Il(Sea Il44.Basiacnn — n
13m and Possessions Code:The Contmanr'a Licesswi Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves(hereon,and wilt)does such work hineelr or through
his own employees.provided that such improvements art not intended or ofrcmd for NEW RESIDIJJI'IAL ELECTR SQ Ff
sale.le.however,the building or improvement is wild within one year of annplctlnn,the SQ.FT FLOOR AREA ASQ.IT.
syr-fbsuiilder will have the burden of proving that he did not build or improve for pur-
rel the pnipertY..vn exclusively amtmaing with licensed contractorsto TOTAL:
ms0uct the project(Sce.7044.Business and Professions CW,:)Me Contactors U-
se Law duel umd apply m an III nar of pro,i who hit Ids nr imprnvaa thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contractors)licensed punu=t to the Comenctnr's
License Law. PERMIT ISSUANCE
❑I nm asamp t er Sea .B&P C`,this reason
ALTER-DRAIN R VI7NI'-WATER IEA) VALUATION
Ownc
WORKIiR' .OMI'ENSATION DECL '1'I BACK FLOW PROTECT.DEVICE O O O
I hereby anion under ally rte perjury one of the follow'in declurutions:
i I haveand will maintain aCenificom of ComenuoseB-insum forwomm,Compact- DRAINS-12LOOR,RO0I7.ARI?A,COND. S'I RIES TYPE CONS'1'RUCTION
stnion,a,provided for by Sellout t 3700 of the Lu or Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 hove and will maintain W..l ru Compaii,anon lnsurancc,as m,moad by Section
377 of the LnMu Code,for the performance tithe work for which this permit is issued. GAS-EA.SYS'I EM.I INC.4 OUTLETS OCC.GROUP � *a,?
rte^
My Warker'xConhre
peaion Insurance comic,and Policy numbre
s!a : ad V
Carrier. Policy pi GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATEOF VXEMM ION FROM WORKERS GRLASFJINDUS'IRI.WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed lithe permit is I or one hundred dollars S 100) GREASETRAP
ur las.) PLANCHECK FEE
I certify that in the pedimmmi,f the workfor whichlhizpermitisisstud,[shall SEWER-SANITARY-STORM EA.2011 FT.
no,arl,loy any per.Un In unynmmecr.m ux to hccnnhc whlecd In the Wnrkeri Compen- I-� ENERGYIFEEr_-
OZnmion Lax,oe Callihan. [)am WATER HEATER WNENT/ELECrit ilr)
Z 2 Applicant 1 GRADING PEE m " I,r
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING l U/ II I
F become subject the Workers Compensation pmvision%onIIS FEE Labor Code,you must a
" as
Rej 0 I'anhwilh comply with such provivinns nr this patent%hall be deemed mcoked. WATER SERVICE ( ass
u.l CONS"I'RUCTION LENDING AGENCY NEW RESIUENI'IAI.PLMH, SQ.ET. PAID C O
V O l hereby uRrm that is a construction lending agency for the pcifommnce of ❑ Dam R
the work I'ur which this permit is Issued(See.3097,Civ.C.) OI/
U Lender's Name OTAL:
O {U I.enJer's Address TOTAL: —+G._—
rea
I acetify that 1 have d this application and was lhm the above information is BUILDING ITEC
Ncorrect.I agree to comply with all city and county ordinances and state haws relating to QIY. MECHANICAL PERMIT FEE
UZ huildiog cosmmtion.and hereby oahnn>c repraseumniasol"this city tenter upon the SEISMIC FEE
r above-mentioned property for inspection purposes. I'F:RMI'f ISSUANCE
(We.)ngma n,%ova,indenmify and keep harmless the City of Cnpenims ogainsl ELECTRIC FEE
Iiabililics.judgments.cwt%and expanses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING PEE
in Iseyum ee of the grumin,of This permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITeI'010.003 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,I1(tt CFM) CONSTRUCTION TAX
SlgnamrcofApplicen/C(inlrncmr Dam EXHAUST HOOD(Will HOUSING MITIGATION HE
HA%ARDOUS MATERIALS DISCLOSURE
Will the applicantor future building occupant store or handle hazardous mammal HEATING UNIT(TO 100,000 BTU)
as defined by the CuNninss Municipal Cute,Chapter 9.12,and the Health and Safely
Code.Section 25532m)? HBAHNG UNIT(OVER 100,010 BTU)
r7 Yet, r-1 No PAID -
VENTILA'DONFAN(SINGLERE5ID) pate Receipts
Will the applicant In Enure hadding oecupom use equipmem or devices which BOILER (3HP OR IINI.t(111 BTU)
it hazardous air contaminard as defined by the Huy Arca Air Quality Management TOTAL:
aoicR RO1LER-COMP(OVER 100,000 BTU)
El YO, No
I have mad the hazardous materia,requirements notice Chapter 695 of the Cali AIR CONDITIONER ISSUANCE DKrE
Irma health fle Sale,C d,Seed 1,^_5505,25533 and 25534.1 understand Ihal If the NEW RESIDENTIAL MECH. SQ.FI'.
buddingdoes not cutremlybavea tenant,that it is my respim%ibllltylonmlfyhheoacopmd
onhe Rgai mends whim maw bent prinnu ismunce bra cenmt-ae or auapun,
owner or aulnonzeJ agent Data TOTAL: ISSUED Bs
OFFICE