30392 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAI. PERMIT NO. /� O/� ^/�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL - 3 �� 9L
BUILDING PROJIiCT IDENTIF'ICAT'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUUMITI' LOAII
OWNER'S AME: PHONE: CONTAAWS NAME: ` LI NO:
CNO
�i 1 A 11_ N/C CONTftOLp
ICHHECUENGINEER: LIC NO: ADDRISS:11, /� Q 1'! O V ❑
CONTACT PHONE:' VL - BUILDING PERMIT INFO
�' ���/�YVO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELF. PLUMB MECH
❑ ❑ ❑
LICENSCD CONTRACTOR'S IIECLARA'1'ION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisima of Chapter 9(cmmmcnnng JOB DESCRIPTION
�OO�Z th Section A100)of0i mn3nfthe Business and Pmfessinns Code,unJ mylicensc is RESIDENTIAL,
O wPERMIT ISSUANCE
IOU(r, in',ull force and cftcm. b C 9FDW L O KITCI II?N REMODEL
Licen Class p
NG0. Date Contmcurz APPLIANCES-RESIDENTIAL ❑ADDITION O PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT OSTRUCfURAL
Z O y 7J. 1 understand.,,]am shall be used as public records PANELS MODIFICATION
OZ^0 UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
F 4I" Licensed Noficalamul 201-IlXX1AMP5 IMPROVEMENT
2. OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Corrector's License Lase for the OVER E100AMI'S 0 HATH RIiMODHUREPAIR 0 DEMOLITION
iq5 6 U following Mason.(Section 703 1.5,Business and Pmfessiom Cade:Any city or county 0 OTHER
ss: O F" which requires u permit to comma,site,,improve,derrai h,m repair any swcwre SIGNS ELECTRICAL
prior to its Issuance,also requires the applicant for such permit to file a signed statement SPECIALCIRCIJI'P/MISC.
} that he is licensed pursuan to the previsions ofthe Contractor's License Use(Chapter 9
M y oC) (commencing with Section Mai)ofDivision 3ofthe Business and Professions Cade)or TEMP.METER OR POLE INST COMMERCIAL:
C that he Is exempt Ibercfmm uncirhe husk far the alleged exemption.Any Admion of 0 NEW BLDG/ADDITION 0 DEMOLITION
uXl 4y Section 7011.1 by any applicant far pemtit subjects Inc applicant to a civil perm y of POWIiR DEVICES O'FFNANT ❑FOOD SERVICE
I„ not more than five hundred dollars(SSW).
' Q 01,as owner ofthcprogeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
WF.t will do the work,and the structure is not Intended or offered for me(See.9044,Bmincar COTHER
-" and Professions Gyle:The Conuacmrs Licenu Law does not apply to am owner of OUTLET'S-SWITCHES-FIXTURES
6'3 property who builds an improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for i,NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however,the building or improvement is sold within one year of completion the SQ.FIL FLOOR AREA S/SQ.I.-n
owner-builder will have the burden of proving that he did not build or improve for pun
pose of sale.). /
I,as owner of the property,tum exclusively can noting with licensed contractors to TOTAL: (p
common the project(Sec.](144.Business rad Pmfcssiom Cade:)The Cnntmdors Li
ase Law does not apply to an owner of propenth
y who builds or improves ereon.and QTY. PLUMBINGPERMIT FEE Q
who com ucta for such projects with a Contractors)licensed pursrmen to the Commuters 5 `996
License Law. PERMIT ISSUANCE
0 l am exempt under See. ,B&P C for this reason
Owner Date ALTER-DRAIN&VEN-WATER(EA) ` 1 VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW• PROTECT.DEVICE ; rI Is I hereby affirm under penalty of perjury one of the following declaratiam: i I I 000
I have unit will maintain a Certificate of Comenttoself-insure for Worker's Catalan- DRAINS-FLOOR,ROOE AREA,COND. STORIES TYPE.CONSTRUCTION
orders,as provided for by Section 3700 of rhe Labor Code,for the performance of
work for which this permit is issued. FIX'FURM-PER TRAP ,
C 1 have and will maintain Workers Compensation Insurance,as required by Section -
1700oftheLabor Cole,for the perfo mance ofthe work forwhichthis permit is issued. GAS-EA.SYSTEM-1 INCA OUTLETS OCCGROUP APN
My Wmhers Camper fonlnsumnc icr and Policy num r
Cartier. 'py No.:�.� GAS-EA.SYSTEM 4(EA)
E T c F ,to
PrION FROM WORKERS'
COMPENSATION INSURANCE GRHASMNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION IIiC$
unless)(This section neednot bccompleted Bose Mind is fmrnne hundred dollars(SIM) GREASETRAP
PLANCHECK PCE
Toy any that inthe performyromanceof theworknnwhichthis the an is Workers
ed,I shallCosuen- SEWIiR-SANITARY-STORM CA.2IXIIT.
mol.reply any person i a any manner so us m hcarme subject m ilia Workers Conlpen- F.NI?RGY FEB
Z sable Luwx of California.Dam
�7 � Applicant WATER IIEATI?R WNENT/F.LECI'R GRADING FFai
�a rA NOTICE TO APPLICANT If,after making this Cunifcpmof Exemption,you should WAI'HR SYSTI?MnREATING
a ; become subject In the Worker's Compensation provisions of the Labor Gale,you must SOIIs FEE
Liz r forthwith comply with such provisions or this permit shall he deemed Invoked. WATER SERVICE
Q
0.
CONSTRUCTION LENDING AGENCY NEW RFSIDENq'IAL PLMI3. SUIT. PAID -
Qz Ihercby affirm that there iso conmmaion lending agrncy for the perfomlanee n( Date Receipt or
the work for which this permit is issued(Sec.309],Civ.C.)
Q U Lenders Name TOTAL:
E7 Ixnder's Address TOTAL:
I certify that I have need his application and am
plicatits Thar the ave boinformation is BUILDING Iq?E
i..th cement,l agree to comply with all city and county ordinances and state laws relating to Q'fY. MECHANICAL PERMIT FEF,
U 7building construction.and hereby authori,roprexenlmlve,alhi,city to anter a,m the SEISMIC FEB
above-menumned propeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep Imprimis the City of Cupcnino against ELECTRIC PEP. LAL
liabilities,judgments,costs and expenses which may in anyway acerae against said City ALTER OR ADD T'O MECIF
in asequence of the granting of this permit. PLUMB ING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00b FM)
SOU r���s\RE�GULI(�'ONS. / / MECHANICAL ME
A��r�fP AIR HANDLING UNIT(OVER 10 000 CPM) CONSTRUCNONTAX
Signature to[AJpplyicant/C7olnttraccmr~- I U;F- EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicaat on None mildlngoccupunt ammo,handle hraadousmaterial HEATING UNIT(TO 1011,111X0 BI U)
as defined by Ne CuMtino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)? HEATING UNI T'(OVER IBoa X1 BTU)
[:1 Yes 7 N VENTILATION FAN(SINGLE BUS Il)) PAID
ceipt p
Will the applicant a,far..
fure building..pan[use equipment or devices which Date Re
BOILER-COMP OHP OR 100,00(1 BTU)
mit hazaMnus air mam
minanLs as ddincd by the Be,Arca Air Quality Mangent
ameTOTAL
Distant"
0Y. ON. BOILER-COMP(OVER 100.0000a BI U)
I have read the hazmdeus materials requirements under Chupmr 6.95 of the Cali- AIRCONDMONER ISSUANCE.DATE
fomia Health&Safety Cafe,Sections 25505,25533 mid 255311 understand dial if the NEW RESIDEN'T'IAL MUCH. SQ.building does not currently have a tenant,that it is my responsibility m up
notify the mcana
of Ne rtquiremen¢which must be met prior to inaance mfr Cenifeme of Occupancy. ��
O.fam or mor nzed agent Date TOTAL: ISSUED BY:
OFFICE