S 0278 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BWI.DING-ELEITFRICAL Plgmll No 0278
BUILDING DIVISION APPLICATION/PERMIT 1'LIINIBING-MECHANICAL CV
BUILDING PROJECT innKrIFICATION
BUILDING ADDRESS SANITARY NO APPLICATION SUBMITTAL DAT E:
104•TS PIC-)"PART • "I LO Ct
OWNER'S xNAME: =C l PHONE: CONTRACTOR'S NAME: LIC NO:
M sz J, LIZ -4-46—CiS"y� NIC C/O�NTXH�OI�X
ARCHITEC1'7ENIGINEER LIC NO: l> ADDRESS: ❑ «I\` �_
�/ID P�-P C 21 -re, CJ V
CONTACr: PHONE: BUILDING PERMIT INFO
r� 1 Q ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
() �i46-38`t G p N ❑
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMIT' FEE'
1 hereby anion that I am licensed under provisions of chapter 9 lammmeneing JOB DESCRIPTION
9Z with Sermon 7gR)nfDiAnu.3oftbe Business and Prolbssioms Cade.undmy licensers / RESIDENTIAL:
w O PERMIT ISSUANCE
FIF infullforceundefiect ❑SFDWL ❑KITCHEN REMODEL
N License Class LicX APPLIANCES-RESIDENTIALADDITION ❑PLUMB ING RE-PI PI?
I-zt Date Common
ARCHITECTS DECLARATION ❑MULTI-UNIT E3 STRUCTURAL
z O O I undemm id my plans shall M used as public record. PANG MODIFICATION
Oz�Q UPTD200AMPti ❑INTERIOR ❑CHIMNHYREPAIR
L�gFW Licensed Profiamional 201-I(NNIAMPS IMPROVEMENT E)SWIMMING POOLS
06G y j OWNER-BUILDER DECLARATION OVER 1000AMPS [I BATH REMOOEUREPAIR ❑DEMOLITION
C sc 1 hereby nffitm mbar 1 em eannpt floor the Commetor'a License Law for the
xtLO 3.0 following reawm(Section 7031.5.Bruins;and Professions Code:Any city or county SIGNS ELECI-RICAL [I OTHER
W y which requires a permit m conamct,alma improve,demolish or repair,any machine
Cy) Prior m its issuance,also requires the applicant for such permit file a signal smamam SPECIAL CIRCUITIMISC.
y that he is licensed pursuant the pmvMdonsotthe Conmwler's License l.aw(Cb- -
u1900 (commencing with Section 7000)of Diviaion 3 ofthe Business and Pml'essions Code)or TEMP.ME'1'1?R OR POLE RsFeV
a q e K that he is exempt therefrom and the basis for the all,acl exemption.Any violation of ❑ BLDGIAODITION ❑DEMOLITION
i(^It Section 7031.5 by any applicant for a permit subject%the applicant o a civil Penalty of POWER DEVICES Q4JU&NOT ❑FOOD SERVICE
LL1 z not more than five hundred dollars(55110).'-Q :MI?NT❑],as owner ofthe property,or my employees with wages as tell comsame on, SWIMMING POOL ELECTRIC
will do the work.and theamaua is rot Intended moRcred far sato l Sec.7014,13miness ID I{E
and Povic,liens Code:The Common's License Law Jtce oat apply to un owner nl' OFI'LE'il5-SWI'T'CHES-FIX"1'UIt IiS
property who builds or improves thereon,and who Jots such work himself or through
his we employees,provided that...h improvements are not intended or offered for NEW RESIDEN'T'IAL ELECT N SQ FT.
sale.If.however the building or improvement is sold within one year ofatopletion,the 41Q RA A $/SQ.FE
.parhuilder will have the burden of Abrin,than he did not build or improve far Pur-
pose of cele).
❑ 1,as owner of the property,am exclusively conrnetlng with licensed contractors 10 - 1—
construct the project(Sec.7RI4,Business and Prafexsiuns Code:)The Conracrors Lk
cense Law does not apply man ownerodpropedy who builds or improve%tbureau,and QTY. PLUMBING PERMIT FEE
who mmructs fors ch projects with ucnntrectortsl licensed pursuanuothfe.C1/4D.racmis
License Law. �II/1 /� PERMIT ISSUANCE.
❑I am ea t under Sec. .B& n t mann
ALTER-DRAIN&VENT-WATPIt WA)
Date VALUATION
Owner
_ WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICH T{�[,� �e
I M1ercby utfirm under fanuhy of pe jury one mf the following dedamtinns: -10
I have and will maintain a Certificate of Comenuo self-insure for Workers Comped- DRAINS-FLUOR,ROOF.AREA.GOND. STORIES TYPE CONSTRUCT ION
w0on,as provided for by Section 37M of Ne L.aM1m Crile,for the prof......a of the
work for which this permit is issued FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Inavmmce,as required by Section
3700 mf the Labor Code,for the porlinmance ofthe work for which thislwnnit is issued. GAS-EA"SYSTEM-I INC,4 OUTL1?TS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Carries Pal icy No.: GAS-EA.SYSTEM-OVER 4 RRA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEtINDUSI'RL WASTE INTERCEPTOR
BUILDING DIVISION PIi uS
(This section need not bennnpldeJ ifthe permit is(Drone M1undmol Aollam(81010 GREASE TRAP
nrles%.) PLANCHECK FEE �r
I ccnify that In the perlisrmunwnfthewark fnrwhlch his pumth ix lxsneJ.l shall SEWER-SANITARY-STORM EA.200 IT.
not employ any person in any manner so us m become%uhject m the Workeri Comped- 1?NIikCY PEIe
zZ action Law%of California.Data WATER HCAT17R WNENTIE LEC'IR
O Applicant 1 GRADING PEE
fq NOTICE TO APPLICANT:If,afar making this Cadificale of Exemption,you should WATER SYSTHNUTREATING
f•+ become subject m the Workers Compensation provisions of the Labor Code,you must SOILS FEE
GaLI forthwith comply with such provisions or this permit shall be deemed revoked WATERSERVICH
Q
CONSTRUCTION isac ONLENDINGAGENCY NEW RESIDENT Al.FUME. SQ.FT. PAID
r7 z Date Receipt p
C.1 O Pf whiby ch
that econ(Sao.30 lending agency for the performance of
the wok for which dais pemtit is issue)(Sec.Jf197,Civ.CJ It
�' l••' Lenders Name TOTAL:
L) Lender's Address [ f I
34 1 certify that I have rend this application and sine that the nMrve Ir(nation is
BUILDING FEE
In coal uildin ingreemcomply
and herebylohysud reuntyntatmmoftandhis stem lnwstelling m QTY. MI?CI9ANICAL.PERMIT FEE
U � building rnnammion,and hereby umhmriu representatives of this city mercer upon the SEISMIC FEF. �
abnvc-mentioned property for inspection purposes. PF.RMI'I ISSUANCE
(We)agree to have,indemnify and keep harri the City of Cupenion agaiaa IOTCTRIC FEE
liabilitoes,judgmeno,costs and expenws which may in any way acetue agnlmt mid Cory ALTER OR ADD'TO MECH.
in consequence of he gmming of this permil. PLUMBING hili
APPLIC IN F UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT I(I,gID C 11M)
SOU REGULATIONS. ✓14/^ MIiCIIANICAI.FEEFEE7 / / l l AIR HANDLING UNIT(OVER 10.000 CFM)- CWRCTION'IAX
Signature of Applican/Contmctor /Date EXHAUST HOOD(W/DUCT') IIOIISING ON IEE
HAZARDOUS MATERIALS DISCLOSURE
Will multiplicand or franc building ocavpantmore or handle hamnlous material HEATINGUNIT T(101W,IM)H GO
as defined by the Canadian Municipal Code,Chaplet 9.12,and the I ladth and Safety ju
Coda,Scedon 25532(a)? I(EATING ON['I'(OVER IfSI,hop RPO) It(1111V
❑Yea ❑NoiftO
PAID ry
VENTILATION PAN(SINGLE RIiSID) a
Data Receipt Or
Will the applicant or or flame building ovetr a,me equopmem or devires which
t hasrdom air amtaminams m defined by the Boy Area Air Quality Management BOILER-COMP(3HPOR HIO,0001ITU)
Domic6 'TOTAL:
C3 Y., No 1301LEk-COMI'(OVER IfXIJNkI RTU)
I have and the harerdous materials requirements under Chapter 6.95 of the Car- AIR CONDITIONER ISSUANCE DATE?
forma Health&Safery Cede,Sections 25505,25533 so125534.1 mudcrstand that if the NEW RESIDENTIAL MECH. SQ.Er
building it,.not commonly have.harem,that it is my agnansibilirymnoify the occupant
of the mgaitemems which must he met poor to issuance out Certifica,of Occupancy. LL
Owner or mihonmd agent Data T "I ISSUEDBY:
OFFICE