29392 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. ^^ass Aad
BUILL93JVL
DING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECTIDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Ll 41 L LQ"-vIkd
W 'S AME: N CO M' OU NAME: LIC NO:
N/C COMROLp
4R ITECTIENG INE E : - IC NfY ADDRESS: ❑
!moi 'l
ONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Feta Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am(doe Business
under wood
Pe ism of Chapter 9(commencing JOB DESCRIPTION
COZ wiLo n]1l0))of Division Sof Ne Busineaa ooM Pmfmsions Code,and mylittnse is PERMIT ISSUANCE R SIDS FNTI�;
F n fand fy
QFU Lic .. J Li
�� ❑SFDWI. ❑KITCHP.N REMODCI.
WG eC, APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPF.Z g,pw HI Dfi rARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z y spublic records MODIFICATION
. OZ—Q UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
Lic cdP e.s' 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
he y 1. ]let I am exempt fano the Contractor's License Law 1'or the OVER ION)AMPS ❑BATH REMODEI/REPAIR ❑DEMOLITION
30. folia mg lees .(Section]031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
LL C which requires a permit to consumer.alter,improve,demolish,or repair any rmcmrc
ry. prior to its issuance,also requires the applicantfor such permit to file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions ofthe Contra is License Law lChaper9 -+ , g
[MY a (commencing with Sedinn](NNB of Division3nf the Business and Pmfessions Cndejnr TEMP.METER OR POLE INST. COMM
0. LL that he is exempt therefrom maids,basis Radio alleged excision,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
m Section 7031.5 by anyapplicamCol.permit subjects the applicant to a civil penalty of POWER DEVICES OTENANT ❑FOOD SERVICE
1- < not mom than Five hundred d.11ars($500).
I,os owners the norm IMPROVEMENT
willO ❑ pest ct yemeoithwageaosalei(See.c0m,Bintiien, SWIMMING POOL ELECTRIC
and do the work,and rbc he Cont is not intended Lice .r offered for sale(See.70W,an Business ❑OTHER
3 and Professions Code:The Contractor's there's License Law fires not apply to if owner Of OUTLETS-SWITCIiF.S-FIXTURES
property who builds or improves t thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECfR SQ PT.
sale.If,howevee the building.,improvement is sold within one yearo(completion.the SQ.FT.FLLv9ORAREAf�--5�mm I/%FT.
.anal-builder will have the burden of proving that he did not build or improve for put-
p.m of sale.). _
❑1,on none,of the propeny,oto ead mivcly 1-olow1 ng wilt licessod aanraatnrs m TO'PAU
construct the project(Sec.7019,Business and Pmfessions Co...,The Commnmr'.Li MAR1996
cense taw does not apply to an owner ofpropeny who builds or inmproves thereon,and QTY, PLUMBING PERMIT PEE:
who contracts fmsuch pmjeets win a cuntmctons)licensed pursuant nu the Contmcmle
License Lew.
❑I am eaempi under Sec. ,B&PC forliis reason PERMITISSUANCE CI IT yr wren l HYII
M:ITR-DRAIN&VENT-WATER(EA)
Owner pate VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
.44 I hereby affan under penalty of perjury one ofthe following declarations:
]I have and will maintain a Certificate of Continuo self-insum for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPO CONSTRUCTION
nation,ai pnwided for by Section 3]00of the Labor Cole,for the perfurmnce of the
work for which this permit is issued. FIX'I GRES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance ofne work for which this permit is issued. GAS-EA.SYSTEM-]INC.a OUTLETS Do
OCC.GROUP APN
MyaCompenmtion Insurance career and Policy number are:
Colmar:
Policy No.: GAS-EA.SYSTEMOVER a(EA)
CERTIFICATI!OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/1NDUSTRL WASTE INTERCEFIY)N
(This section need not he completed Wom permit k far one hundred dollars($100) BUILDING DIVISION FEES
IasJ OR EASE TRAP
I ecnify that inflan performance nof the work for which this permit is issued I hell PLANCt{ECK FEE
any
not employ any person in any manner
m usmbecome subject to Workers Conner- SEWER-SANITARY-STORM EA.2g1FT. -
.mss� ENERGY FEEZ cation Lawsnt California.Dote WATER HEA'1'CR W/VENT/ELECTR GRADING FEE
Applicant
NOTICE TO APPLICANT:If,after making thin Cenificme of Esemptlnn,you should WATER SYSTEM/TREATING
abecome subject to the Worker's Compensation provisions of the Labor Cndc,you must SOILS FEE,
W
barroom comply winsuch provisi.na.nhis pcnnirshall he decimal revoked. WATER SERVICE
� Z CONSTRUCTION LENDING AGENCY NEWRESIpEN'1'IALPLMB. SQ.FT, PAID
,UO I herchy affirm that there is a construction lending agency for the perfommnce of Data Receipt#
15s F the work for which this permit is issued(Sec.3097.Civ.C.) p
0 L) Lender'.Name TOTAL:
Lender's Address TOTAL:
y 1 ecnify that I have read this applicalion and state that the above information is BUILDING FEE '
V2emilel.l agree locomplywinnll city andc:mmy nrdinancesond rmclawxrdafngin QTY. MECHANICAL PERMIT FEE
'G F7 building canswction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
ab.ve.memioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Culmina Oil ELECTRIC FEE
liabilities,judgmene,costs and expenses which may in any way eceme...inn said City ALTER OR AUD'fO MECH.
in consequence ofthe granting ofthi^ m I. PLUMBING FEE
APPLICANT !DE TANDS ND i1LL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,INN1 CFM)
SOURCE ONS. MECHANICALFEE
AIR HANDLING UNIT(OVER R(M CFM) CONSTRUCTION TAX
gra re cant/C.mrcmr Me EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
W' aapplicant.r future building ocwpmm.mre nen handle hazardous nu.eshd HEATING UNIT(TO 100,00)H'1'(J)
as define by the Columbus Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Seed..25532(a)] HEATING UNI'((OVER 100,(1(10 BTU)
❑Yee F-1 No PAID
VENTILATION FAN(SINGLE RGSID)
Will nuse e int or devices which
Date Receipt#
emit hazardous air cotaminnts m defneA by the Bay Arco Air Quality Mmwge°tont BOILER-COMP(3)IP OR 100X1)BTU)
TOTAL: 3 0
istndl
❑Yes ON. BOILER-COMP(OVER 100,000 BTU)
1 hall,tend the humorous matenals AIR CONDUION13R
requirements a under Chapter 6.95 of the Cali- ISSUANCE DATE
forma Healgdoes&Safety Codehave
Sections 25505,233)7 and 25537.1 umlersmnd rout if nc NEW RLSIDP.NTIAI.MECH. SQ.PT.
building does not is which haves a event,that 0 is tory responsibility t.e notify the pancy.
of the requirements which most be nater poor m issuance of a Cenificnte of Occupancy. '
Owner nen amhonxed
at Date TOTAL:
ISSUED BY:`
OFFICE