S 0110 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL Pli Il'NO 1 1
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING-MECHANICAL 0110
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: s SANITARY NO. APPLICATION SUBMI'T'TAL DATE
OWNE 'S NAM—E:— �I PHONE CONTRACTOR'S NAME: LIC NO:
BGG dS 5� /yo E G Msi Q NIC CONTROL#
JARCHDTECI LIC NO: ADDRESS: Q, ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB M4
81
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
d'Z with Semian]RDl)of Division 3 of the Business and Professions Cade.ami my license is RESIDFNTIAL:
1-00 in full farceand Offal. 6 t �OpOp / PERMIT ISSUANCE
<4F.UZUUUC License Class Lic.4 O G ❑SnnITI [I KITCHEN REMODEL.
NQS Dam ��Cnntry O APPLIANCES—NISIIII?#TIAL ❑ADDITION [I PLUMBING RE-PIPE
Ton ARCHITECT'S DECLARATION PANIi1.5 ❑MULTI-UNIT ❑STRUCTURAL.
Z O�K. I undemmnd my plan.shall be used as public records MODIFICATION
OZ O UP Of 21X1 AMPS NI ERROR El CHIMNEY REPAIR
�F(y
....11 Licensed Professional 201.100AMPS IMPROVEMENT []SWIMMING POOLS
Q OWNER-BUILDER DECLAMATION
ykd .a OVER 1010 AMPS ❑BATHOTHER REMODEUREPAIR ❑DEMDLLTIGN
yy KK Q I hereby. oRmn Ihn 1 am esempl from the Conlmnors License Law forma X 06U fallowingreason.Permit
]onstr Businessmpr improve.
demolish.
Code:Any city mcounry SIGNS ELECTRICAL ❑OTHBR _
YY77 3 LL,I- which rryussu a permit re cores the aalter,pplicant
improves h Permit
t fi repair any structure
FSO:} pat heir s TssuancaaNn.quires previsions ntfar Conrxtmiuoicese signedstatementSPECIAL CIRCUITM115C. �1O r/)R
qyC y ibulheislicenwit pursuant to provisions 3 the Contractor's License Lnw(Chapter de)or ` P<f �-
ul 00 than he
esiwi,h Section FIIX11 ofbasisoCr the
the
eged Business n,visCade)or TI;MI'.MF.'TF.R OR POLI?INS'I'. COMMERCIAL
Sec he is exempt therefrom and the basis fm the alleged exemption.Any vipen ion of ❑NEW BLDG/ADDITION ❑DEMOLITION
trXl lard•
Section 7031.5 by any applicant fora permit mM1lccu the epplicannavcivil penalty of POWIiR DEVICES ❑TENANT ❑FOOD SERVICE
not more than five hundred doll..($500). IMPR VEMENT
E�aO ❑1,as owner of the pmpeny,or my employees with wages is their sale compensation, SWIMMING POOLF.LECTMIC
wnes .o
ill do the work,and the x ccom,is intended for sale(Sac.7044,Business FR
and Professions Code.The Commcme,La,...a Law dces not apply to an our of OUTLETS—SWITCHES—F XTURES
proFeny who builds or improves thereon,and who does such work himself or through
his awn employees,provided!that such impsocmctns are not intended or offered for NEW RESIDENTIAL.HI.FCTR SQ I'll
sae.If,however,the hailing or improvement is said within one ycarol completion,the
SQ.Ef.FLOOR AREA $I$Q,IN',
ownef-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: /
construct the project(Sec.]OYf,Business end Profesiiars Cade:)The Comnctors Li-
censic Law does not apply to an owner ofinablacoy who builds or improva.s themon.and QTY. -PLUMBING PERMIT FEE PA
who contracts for such projects with a contmcmg.)licensed pursuant m the Contractors I b
License Law. PERMIT ISSUANCE
l am exempt ander Sec. ,B&1'C for this reasonMAI
A I;1'HR—DRAIN&WMT—WATER(EA) l(9pATJpN
Owner DateLV
WORKER'SCOMPEJSA'I'IONDECLARATION HACK FLOW PROI'T:CI'.Ill?VICE ^
I hereby itTrm under penahy of perjuryone of the following dalarvtiom: An��r Ul'
❑Ihave and will main.ineCmiOcate of Conmmmself-insum for Workers ComlKn- DRAINS—FLUOR,BOOK,AREA.GOND. STORIES TYPECON.SIRUCfION
ration,a provided far by Section 3700 of the Libor Cade,far the fi fotmunce of the
work for which this permit is i.s mal. FIXIDRES—PER TRAP
❑ I have and will maintain Workers Compemution Insurance,as required by Section
3700.01he Labor Cnde,Iiathe ptafmaim.oftho work forwhich this lwrntit is Issued GAS—EA,SYS'I'EM-T INC.4 OU'T'LETS OCC.GROUT' APN
My Workers Compensation Insurance carder unit Policy number arc:
Carrier: Policy No.: GAS—IEA.SYSTEMOVER 4(PAT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASI%INDUSTRL WAS'T'E INTERCEPTOR
BUILDING DIVISION FEES
(This scc,ion need nes fxcompleted ifthe permit is furore humanistdollars 0$100)
or lased GREASE TRAP PLANCHECK FEE
Icanify that in the pedommnct,ofilm work for which this permit is issued,Ishall SEWER—SANITARY—STORM F.A.200 IT.
but employ any person in vby manner so us m hecome subject to the Workam'Compan- ENERGY FEE
OZ satinn Lawsof Cullfnmia.Date WAI HIT HEATER W/VENT/IiLECI'R
Applicant GRAGRADINGFEE
yy
q y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMO REATING
a ; become subjmt .,he Worker's Compensation pmvi.,mr,O f the Iad¢x Cole,you must SOILS FEE
{LI forthwith comply with such provisions or this permit shall ba deemed revoked WATER SERVICE
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM#, SQ.IT. PAID
n1. Z I herehy affirm thmomm iso milrouion lending agency for tbeperfonnanceof Date Naeiptp
U . m
the work far which this permit is ismed(See.30x7.Civ.C.)
Hr Lender,Name TUTAL'
U Lender's Address 'TOTAL
I..� I certify that I have read this application and same that the above information is BUILDING PEE
it fA corers l agree to Comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby author'rie representatives ofthis city m emerupomhe SEISMIC FEE
vMve-mentioned property for inspection purposes. IiRMIT ISSUANCE
(We)egaba m save,indemnify and keep horst the City of Cx F,rdm.,.in,, ELECTRIC FEE
liahilities,judgmems,costsmdexpamm.whichmay in anywayvccrueaguim,,aid City ALTER ORADD TO MECH.
in .sequence of the gradingpermit.
nof this peit. PLUMBING FEE
APPLICANT UNDERS'T'ANDS AND WILL COMPLY WITH ALT,NON POINT AIR HANDLING UNIT('I'T)111,("I CFM)
MI?CIIANICAL PEE
SOURCE REGI :'PIONS
AIR HANDLING UNIT(OVER HO0(RCFM) CONSIRUCT'IONTAX
eo ppficant/ int nor Data EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERAI S DISCLOSURE
Will the applicant or furore building oecuptrustom orhandle hazardous material HEATING UNIT(TO 100,001 BTU)
us defined by the Cupenina Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 2553260? HEATING UNIT(OVER 100.000 BTU)
E]YO, o VENTI LATION FANS I KOLE RESID) PAID
Date Receipt IT
Will the applicant or future building occupant use equipment or devices which
emit haurdans air contaminants is defined by the Bay Area Air Quality Management BOILER—COMP GHP OR 100.000 BTU) TOTAL:
District, BOILER—COMP OOVER 100,0011 BTU)
Yes 6&No
AIR CONDITIONER
Ihave mad bha 0.1c. uemm,15505,25533msunderC 1 cadboard the Cali- / ISSUANCE DATE
furbuilds Health&Saity Oxha a aann.2that i is ray andtmoili,I u ratify
shot if the NEW RESIDENTIAL.MECII. SQ.PI'. //V/n r(l 9
ofthengdoesnotcnwhich have metpthato ismyce ofa cifi cinmifytheoccupant
of the requiremcros which mux be met prior to issuance of a Certifcme of(kcuponcy.
Ownerora.hodredagent Dore TOTAL' ISSUED BY: 11L
OFFICE