S 0296 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL Plil{MIT NO. O
BUH.DING DIVISION . APPLICATION/PERMIT PLUMBING•MECHANICAL. S
296
BUILDING PROJECT IDEN'TIF'ICATION
BUILDING ADDRESS F SANITARY NO. APPLICATION SUBMITTAL DATE939 Rpu v t E IN C.Es CT NO
OWNER'S NAME: gF - — C fR1k RS e ( lO[(g,[�1 NIC k CONTROL#
�ARCHITEC'GENGIN:CRL:IL FAVI LIC NO: )(I:SS: N J `.7-I r ❑
ST
CONTACT: PHONE: /V1 w BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG LE PLt B MM
LICENSED CONTRACTOR'S DECLARATION QTY ELHCTRICPERMIT FEE
I hereby afllat that 1 am licensed ander provisions of chapter 9(commencing JOB DESCRIPTION
EOZO with Section 7")nl Division 3o fine llusiness and Prnfcssinns Coda and ou,notnse is PERMIT ISSUANCE RESIDENTIAL
:
Fw� in full force vnd eRecsfa= Q 3�� ❑SFDWI. [I KITCHEN REMODEL
c, �a, Date y�RI—I`(_ pPPL1ANCES-RLSIDFMIAL ❑AUDITION El PLUMBING R6PIPE
Uma Cnntrvctnr
tnGp, ❑MULTIUNIT [-]STRUCTURAL
ARCH UF.CLARATION
Zpnz, I undemmed my plans shallMused.,publ is records PANELS MODIFICATION
Oz o UP TO 209 AMPS C1 INTERIOR [I CHIMNEY REPAIR
;:4k LicensedPm(essinnel 201.1000AMPS IMPROVEME?NI []SWIMMING POOLS
56 Via? OWNER-BUILDER DECLARATION OVER III(1(IAMPS ❑BATH RF:MOUh�I�[:PAI$O DEMOLITIO
I hereby affirm that L am exempt from No Counselor's License Low for the 6( {'—'ps-�f7J, it I
O d U following ressnn.(Section 7031.5,Business and Professions Code:Any city or county SIGNS I;LECIRICAL C1 OTHER
31y F which requires a permit to construct,alter,improve,demolish,or repair any structure
FSO prior to its issuance,also requires the applicant for such permit o file a signed statement SPECIALCIRCUMMISC,
ytnmheislicenaedputsua.I to the pmiiiions of the Contractor's License Law(Chapter 9
X00 (commencing with Section 7(po)of Division 3 of the Holmes,and Profession,Cwte)or TBMP.METER OR POLE DIST. COMMERCIAL;G. e' that he is exempt therefrom and the basis for the alleged exten ion Any violation of ❑NF.W BLDGIADDITION ❑DEMOLITION
lay Section 7031.5 by any applicant for a permit snhjcete the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
❑QOnet marc than five handled dollars l$50o). e IMPROVEMENT
❑ Las owncrof the property,or my entpla,ms with wages as theirsnlc compensation, SWIMMING POOLELECTRIC
2F- will dmhcwnrk,andwi
thvsemo .nm inmodedereffered fnrsalc(Sec.7614,Business ❑OTHEN
a,3� end Professions Core:The Contractor's License Law does not apply to an owner of DO'[LEI:S-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such wink himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELEC fN
soleal,howeveq the building nrimprovemem isusld withinoneywrol'cnmfiletinn.the SQ.F IiA SISQ,FT.
r-builder will have the burden of paving that he did nm build or imprnvc fm par- Q
Lowe ).m"ele. UG 4 RE'
❑1,m I he p of ct property,am exclusively mntmcting with licensed commmara m TOTAL: avV
nostrum @c projce[(Stu.](44,Business and Professions CedeO Tno Contractors Li )1.
cense Law Ns mr,oupplytoanvith.efnotooy wcerneddsormet totes N,reen,and QTY PLUMBING PERMIT �I/ (JJ'
who enmacrs mrsn,b pmieeu who aeemmnroq,I reenxa pamoate roNe cenwmnr" �UIf)
EHIINU
License Las.. PERMIT ISSUANCE -
IamexemptunderSm. .B&P C for this reason
AL'I'HE-DRAIN&VENT-WATER HEA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION [JACK FLOW PROI'ECI'.DEVICE
I hereby affirm under Penalty of perjury one of the fnllming declarations:
❑ I have and will maintains Certificate of Consent to self-insure for Worker's Comfier. DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 37W of the Lahr Carlo,for the Performance of the
wo for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section '
3709 of the Lbm Code,for the performancenf the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Work ompe 'bin a ance,merand Policy ppp{{r t `-
Cartier.. �l�olicY �+� GAS-EA.SYSTEM OVER 4 LEAL
CERTIFTCATHOF MEM PION FRO WORKIiRS' GREASF%INDUSTRL WASTE INTF.RCGPTUR
COMPENSATION INSURANCE. BUILDING DIVISION FEES
('Tnis.,ormidnotMcomflitted irthe ps:nnit is ounce hundred dollars($1001 GREASETNAI'
or Icss.) PLANCIiF.CK FIBi
I certify that in the perl'nmmnce of the work for which this permit is issued,Iclall SEWER-SANITARY-STORM EA.209 FT.
not employ any person in any manner so as to Mame subject d
o the Waerd Compen- ENERGY FEE.
zZ scion Lawsof California.Date WATI2R HEATER WNENTIE:LECIR
Applicant s GRADINGhGE
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEh1/1'REATING
F ; became subject a the Worker's Cnin,rusnon proviviom id the Labor Cwle,you mstuSOBS PEP.
4x11 fonhwiNcomply with such pavixlonsorthis permit shall Mdmned revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U O Ihereby affirm that there is a constroction lending agency for Ne performance of Dale Receipt
4. F the work for which this permit is issued(Sm 3097,Civ.C.)
O U Lenders Name TOTAL:
U Lender's Address 'TOTAL'
I cenify thin 1 have read this application and safe and the above information is BUILDING FEE
Ls V) cornet.lagree m comply wish all city and county calm...stand state law,relating In QTY. MECHANICAL PERMIT PEE
U Z building constrre uction,and hereby amhadrepresentativesof Nisciry toemerupnn the SEISMIC FEE
aMwe-mentioned properly for inspection purynsas. PERMIT ISSUANCE
(We)agree to pe
save,indemnify and keep harmless me City of Cuninn against ELECTRIC FEE.inn
ami expenses which may in any way access,against said City ALTER OR ADD TO MECH. PLUMBING PEE
in asequence of the granting of his permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,001 CPM)
MECHANICAL FIiF.
SOURCE,REGULATIONS.
AIR HANDLING UNIT(OVER 14000 CFM) CONS7RlICl'[ON TAX
Signomrc of ApplicanVContractar Due EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FTE
HAZARDOUS MATERIALS DISCLOSURE
Will Neapplican[or to,..buildingoccufiamsareor handlchosrdaus material HEATING UNIT ITO IW,O(IH BTU)
ns defined by the Caparison Municipal Code.Chapter 9.12,and use Health and Safety
Code.Section 25532(01HEATING UNIT(OVER 100,000 BTU)
❑Yes VENTILATION FA N(SINGLE RESI D) PAID Mote Receipt If
Will the applicant or future building mcupvtn use equipment or devices which BOILER-COMP(3HP OR 111(,000 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Managemen[ TO'T'AL:
District? HOLLER-COMP(OVER IWI,(M BTU)
❑Yes 1
I have read the hazardous mmcnals tequiremems under Chapter 6.95 of the Cali. AIRCONDITIONF.R ISSUANCE DATE
noun Health&Safety Code,Sections 25505,25533 and 25534.1 understand Nm if Ne NEW RESIDENTIAL MECH. SQ.FT.
building does urn currently have a[count,that it is my mspnmihilo a notify the escapism
of them uiremmu[.swhiche[P rtoissuanceafa Can¢ate nl'sRcu obey.
Owner whnneedagcm Date TOTAL: ISSUED BY:
OFFICE