S 0488 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL I'F�WIITNO. O p
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. J O
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARYNO. APPLICATION SUBMI'PI'AL DATE
C/c3. ( I <— all—nt 7
OWNER'S NAME: I PHONE: CO RACTOR'S NAME: LIC NO:
4 / 1.7^5Zya�. Q NIC CONTROIA
•AROUTECT/ENGINEER: LIC NO: ADDRESS. ^� ❑
75. IL.t /�Za 6 l rs-k,
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG 19-I:Cf PLUMB MliCll
❑ ❑ 2� ❑
LICENSED CONTRACTOR'S DECLARATION QTY hLECfRIC PERMIT FGF.
I hereby affirm that I am licensed under pmvisions of Chapter 9(commencing JOB DESCRIPTION
WQ�z withSeclhm (gllBnfDivisionlolrheBuxinessa dPofessionsC de,and my license is RESIDENTIAL:
l
FO� in full force andff
effect. PERMIT ISSUANCE
W ❑SFDWL ❑KITCHEN REMODI:I.
�UZE'I LworDkineuClass Como APPLIANCES-RESIDENTIAL []ADDITION JaPLUMBING RE-PIPE
Q S� Dam C S DEC.
F-Om
ARCHITECTS IN use Us p1.ARATION PANELS ❑MULTI-UNIT ❑MODIFSTRUCTURAL
CAHO
z pv�x7j I understand my plans shall he asaJ as public records MODIIICA'fION
. Oz=fO UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
r4tW Licensed Professional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
Y
OWNER.BUILDER DECLARATION OVER IOWAMPS ❑BATH RI:MODI:IJRI:PAIR ❑DEMOLIFION
z I hereby alfrm that 1 oro exempt from the Contractor's License Law for the
KOLU following masen.(Section 70315.Bu.siness and Professions Code:Any city or county SIGNS ELECTRICAL. [I OTHER
W 3 LL which requires a permit to construct,alter,improve,demolish.or repair any st uctum,
1".,LLOg
put,,1.its issuance,also rtquims me applicant for such permiuo fileasigncdsmmmcnt SPECIAL CIRCUITIMISC.
f }
that he is licensed pursuanuo the pmvisions ofthe Contractors License law(Chapter9
Q� (commencingthSection]f10(Ilof Divixirn3 ofthe Business and Pmfessinns Qde)nr COMMERCIAL:
w4. TEMP.METER OR POLE INST.
PsGi�5 e C that he is exempt therefrom and the basis(a,the alleged exemption.Any vinlminn of ElNEW BLDG/ADDITION L1DLMOLITION
Wim Section 7031.5 by any applicant for a Fermi t subject the applicant to a ci vi l penally of POWER DEVICES El TENANT ❑FOOD SERVICE
Y
not more than live hundred donors($50(d IMPROVEMENT
a' ❑ Las owmcrtdthe floptruclu isnot mendeswimwngesavmcirsnle wWLnomion, SWIMMING POOL ELECTRIC
wm d r the wons ander no isnot Contractor's License La c dos not a pl y to an Business ❑OTHER
�_ and Ihnfwho b Cade:imp..exh License law does not apply m if owner of OUTLETS-SWI'TCHfiS-FI%TURES
Ila
properly who builds or improves therchn,and who fires such into himself nr through
his own employees,e provided rim such mentis void
w ere not intended or offered for NEW RESIDENTIAL ELECTR SQ Fp.
role.14 however,the building or improvement is sold within one year nfrnmpininn.the SQ.FT.FLOOR AREA USQ.IT.
nwnerhuilder will have to burden of proving that he did not build or improve for pm,
poseofsale.). ,
❑ 1.m owner ofthe property,am exclusively contracting with licensed comments to TOTAL:
conswct the project(Sec.70W 1.Business and Professions Craft:)The Continuities Li-
cense Law does not apply to an owner of pmpemy who builds or improves themnn.and QTY PLUMBING PERMIT FEE ``g ,S p aceta
whoconmct forsuch Famoca with uconmulon, Ile,mod piumanuothe Cnnmmor'x lb`J {D
License Law. PERMIT'ISSUANCE:
Q I tan exempt under Seo. ,B&P C for this recon
Owner Dam V CI 1
ALTER-DRAIN&V17N'F-WATER(EA) UV 1.ITY
WORKER'S COM PENSATION DECLARATION BACK FLOW PROITCT.DEVICE
I hereby affirm under penalty M Perjury one of me following declarations:
❑ I have and will maintain a Certificate of Consent to self-insure for Workers Coupon. DRAINS-FLOOR,ROOK AREA,COND. STORIES TYPE CONSTRUCTION
satin.,as Provided for by Section 37W of the Labor Code,for the ponfammars"of the
work for which this permit is issued. 8 FIXTURES-PER TRAP
El I have and will maimmin Workers Compensation Insurance,as require)by Section
37W of the labor Code,for the performance ofine work for which this permit is issued. GAS-RA.SYSTEM-I INC.Y OUTLETS OCC,GROUP APN
My Work
Chat et cation xun. ce carrier vnd Policy numMr are:
Comer:p �,. u� InI icY Nn.: CAS-PA.SYSTEM-OVER Y(EAI
CERTIFICATE OF Exu TION FROM WORKERS'
COMPENSATION INSURANCE GRFASFJINDIISTRL WASTE INTERCEPI'ON BUILDING DIVISION FEES
(This seetiomneedam heeomplemd il'Ihe permit is foronebundnoddallum($100) GREASETRAP
or Eco,) PLANCHECK Ilii? '
I certify that in the Performance ofthe work for which this Permit is i.ssunl.I shall SEWER-SANITARY-STORM EA.2W FE
not employ any person in any manner so as m subject become subjeco the Workers'Comper- ENERGY FEL?
ZZ s ttion Laws of California.Date WATER BEATER WIVENTBi1.F.C1'R
0 Applicata 1 GRADING FEE
Vf NOTICE TO APPLICANT,If.alter making this Cerificam of Exemption,you should WATER SYSTEMOAHATING SOILS FEE; hecnme subject to the Workers Compensation provisions of the Labor Code,you most
W fonhwim comply with such provisions or this peons shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RP.SIDEMfIA1.PLMB. SQ.PR PAID
U O Date Recelptk
I hereby affirm shm mere is a ttmsauninn lending agency for the Fcrfonnancu of
q.
the work for which this permit is i...od(Sce.3097,Civ.C.)
0 I"( Lenders Name TOTAL.
Wlenders Address TOTAL:
A. 1 codify that 1 have mod this application and state that the above informeliom is BUILDING FEE,
V) tamest.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
L) z Wildingcm,tmnim.mndherehyamhorino....nmtivesofmis city memerupamme SEISMIC PRI:
ti above-memimad!properly for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Chipman against ELECTRIC FEE
Iiahilitics,judgments,costs and expenses which may in any way name against said City ALTER OR ADD TO MECH. PLUMBING FEE
in coosequence of me granting of this permit.
APPLICANT UNDERSTANDS AND}}WLL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0(10 CFM)
SOUNCfi REGU A; LA -- ,J /� I� MECHANICTIONT.
/L-/////// /F / AIR HANDLING UNITLOVER IO.OW CFMI MECHANICAL
Sigm.mm nl p,IicmWCm Dote EXI IAUST HOOD(WIDUM)
HOUSING MI I'IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantmore or handle hazallous materiol HEATING UNIT 0'O I W,ggI BTU)
us defined by the Cupertino Municipal Cada Chapter 9.12,and the Health and Safety
Cade,Section 25532(x)? HEATING UNIT(OVER I(to"BTU)
E3 Yes ❑Nm VENTILATION PAN(SINGLE RESID) PAID
Dae Receipts
Will the air contaminants
infuture heeling occupant use equipment or devices which -
emithaanNouseirconmminantvsdefincdhytheBayArwAirQualiryManagemcnt BOILER-COMP(3HP OR 100,000 BTU) TOTAL:
Dismal
E]yr, E]No BOILER-COMP(OVER ILM),fKKI PTU)
I have read the hamrAous nateriol.s requirements under Chapter 6.95 of the Cull- AI R CONII'I'I ONER ISSUANCE DATE
lornia Health&Safety Code,Scallions 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAI•MECH. SQ.FF
hailing does nut cumntly have.tenant,that it Mr,re.epnnnihility m entity the recupont I
of the rgairemems which most Worst ptinr to issuance of a Cmifeme of Occupancy.
Owner or mumniv lagent Dam TOTAL: ISSUED BY:
OFFICE