30258 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F.LEM RICAL PERMIT NO. a� O ^ r
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J< L aVF VX
BUILDING PRWECI'IDENTIFICATION
BUILDINGADl SS: _ SANITARYNO. APPLICATION SUBMTN.DATE
/ 351
�nrivi,V ON nye J I37 Z 3;,
F
OWNER' E P E: ONTRACTOR'S E: a LICN
NIC CONTR 8
R /ENGG :ER: _/J 1 NO: ADD O O
CONT �V( NE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BL� HLECIPLUMB MECH
❑ ❑ ❑
LICENSED CONTRd amba'SDECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed unJer pmvieinns of Chapter 9(enmmarta i, JOB DESCRIPTION
OCz 'm Sectlon 71X10)ofnivluon3onhe eudness and' vi sd ny Ewnsc is RESIDENTIAL:
DO w'Poll fmax on cc. PERMIT'ISSUANCE:.�ZW m D. is e..An t ❑SFDWI. ❑PLUMBINREMOD[L
�UU ;-werse Cl ss I.ic.N Y APPLIANCES-RCSIUCNTIAL ❑ADDITION ❑PLUMBING RF.PIPE
sF<oo.. Date Commerce
f ARCHITECTS DECLA A N PANELS 0MUITI.UNIT ❑STRUCTURAL
z Oa2Z ndr Jmy plana shall be used aspu - MODIFICATION
OZ-, UP'102W AMPS
1 Licensed Ptnfcssional _ ❑INTI?RIORi1MNEY REPAIR
aSdS' OWNER BUILDER DECLARATIO -�aMAMPS IMPROVEMENT
-1 OVER lap AMPS D BATH REMODEIJREPAIR El DEMOLITION
4 6 I hereby arm that ffiI am exempt from the Committees Lima,Law for the
4ii��55 06 U following mason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a panni,to cors, at,alcor,improve,demolish,or monitory stmcture
prior ht its issuance.arm requires the applicant for such perinirto file a signed statement SPECIAL CIRCU IT/M ISC.
} that he is IicensW pursuant to the transistors of the Contractors License Law(Chapter 9
WtYOO (commencing with Sectinn7tX1f1)of DiviziunJaf the Business and Professions CalO or TCMP.METER OR POLE INST. COMMERCIAL'
6 d e C that he is exempt therefrom and the loris for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION D DEMOLITION
{+• Section 7131.5 by any applicant for a permit subjects the applicant "a civil penalty of MWI7R DEVICES
row nm more mm�five hundred dollars Wall. ❑TENANT [_1 FOOD SERVICE
Y IMPROVEMENT
6wiLas owneak,and propenr,or mycmntendes withwagee astheiram.compensation, SWIMMING PWLELECTRIC
E F O will Pr the work,and the he Contin to s License Law do Isnot a ply 7f an easiness DO'I'HIiR
G 3 and Professions Cale:imp ove,memos License Law dues not apply us an owner of OUTLETS-SWITCHES-FlXTURES
property who builds or Improves thsuch improvements and who docs such work himself nr through
his own employees,pmvidel Inut ouch mensiolw are not immnece or offered for NEW RLSIDENTIAL Ii1,LCI'R S f.
sale.If,however the huildingorimpnwcmcnl icndJ wi,hinone ycantl completion.the SQ.FT.FLOOR AREA ! �,t,$ISQ PII
owner builder will have the burden of proving that he did not build or improve for par- �� lw
you of sale.). TOTAL: C Q
D h as owner of rhe property,am exclusively contracting with licensed contmetots to
construct the project(Sm.70,14,Business and Professions Code)The Contractors Li. t/ Q
cense Law Ares not apply loan owncrof progeny who builds m intprovcs,hcreom and QTY. PLUM13ING PERMIT F /�Uh '996
whocontracta for such projects with a cunamums)licensed pursuant a)the Contractor's (J�/„
License Law. PERMIT ISSUANCE t/r
❑I am exempt under Sec. .B&P C for this raw n / It u
Owner
ALTER-DRAIN&VENT-WATER(CA) VALUATION
Dme
ORKER'S COM PSAT10N DECLARATION BACK PLOW PNO'1'CC'1'.DEVICE
yaffmt unJof penalty of perjury one of the following declarations:
Lalvc vnd will mainmina Cenificam ofConscnuo xlGinzure for Workers Compcn- DRAINS-FLOOR.ROOF.AREA,GOND.
sation,as provided for by Section 3700 of the Labor Calc,for the performarm of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
37M of the Labor Code.for the perfmmerim of Ne work for which this permit is issued. GAS-EA.SYS'1'IN.I INC.4 OUTIJUX OCC.GROUT' APN
My Workers Compensation Insurance carrier and Policy number am:
Cartier. Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INT[RCEPTOR
BUILDING DIVISION FIiF;S
(His section need not newmplumJ ifthe pennh lsf cone hundrcJJnllurs(511X)) CRGASETNAP
or Icss.) PLANCHIiCK FEF.
I certify that in the performance oftbe work for which this permit is i.ssued.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as m become subject m the Workers'Crimper- ENERGY 113
OZ nation Laws of California.Data WATER HCATER WNENT/ELECTH GRADING INCE
Z Applicant
y NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEMGfREATING
become subject to the Workers Compensation provisions of the labor Calc.you must SOILS PEE
forthwith comply with such provisions ooh'-penult whorl he dcemed revoked. NATER SERVICE
0.
CONS'1'RUCT'0 LENDING AGENCY NEW RESIDENTIAL I'LMH. SQ.FP PAID
U Z Dote Receipt It
U O Ihcrcbyahthis mer ,s stmchon landing egcneY fur the per[ortnonee of
E' the work fur which this ss d(. .3097.Civ.CJ
Lenders Name is TOTAL:
rum"
WLender's AJdrc>s TOTAL: BUILDING PEE
1 anay mm 1 havx re this"pidamiu"and nate mut the about inlormation i.
T0./] cortemJ ague m croody w all city county ordinances and state laws rcmtingm QTY. MECHANICAL PERMIT FEE
U Z building nmswction,and a. aumr.'e eprcmniu.cs of this city mentor upon the SEISMIC PCL
above-mentionimpropen forinspectionpurpo¢s. PERMITISSUANCE
I el agree to save.indemnify and keep hamdns the City of Cupcnim,against ELECTRIC FEE
ahilities,judgmemccnns an spemeewTich may in any way memo against said City ALTER OR ADD TO MECH.
in msationea of,hc gra gaf,hin permit. PLUMHING hEE
APPLICANT UNDE NDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 14000 CPM)
S URGE REGULA S. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000CFTO CONSTRUCTIONTAX
ignvw A I' an mrattor Dote EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS] 'IERILS DISCLOSURE
\ Ili a applicant or future b dintastmoramfoundlehaz.Nousmaterial HEATING UNIT GO 100,001)BTU)
m def d by the Copanino Munn al C :taa,9.12,,and the Health and Safety
Cada ,action 25532(x)'7 HEATING UNIT(GVHR 100.000 OTU)
❑Yes No A'DPAID
VEN'1'ILON PAN(SINGLE REMU) Date Receipt a
Will the applicant or future building occupant use equipment or devices which g01LER-COMP(311P OR 100,000 BTU)
•:mit hxcmduus air contaminants m contrast by the Bay Arca Air Quality Management
Uistria7
D Yes ❑Nn BOILER-COMP(OVF,R IIXI,00f1 BTU)
It react ehuranlnue materials rcquiremcnu unJer Chapmr ts95 of the Cali- AIR CONDITIONIiN ISSUANCE DAP Ii
forma 1 Ith&, ety Ca . ons M505,29533 m 25534.1 uneersmnd that if die NEW RESIDENTIAL MECH. SQ.ET.
W daanotouremly c amnsnL deft it is my tests ility mnotty the occupom
of luirtments whicM1 est tpdor to issu oven ifcae of Occuparey.
Owner or author zed ub Dale TOI'A L: ISSUED ItY:
OFFICE