31039 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. �O^
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. "`�l V{{9
BUILDING PROJECT IDENTIFICATION
BUILDING ADD@ESS: //AM • - SANITARY NO, APPLICNI'[ON SUBMITTAL DATE
OWNER'S NAME?: /y/,J_ P/H,Oj/v/N(iN—,�� 'e//%W/•/'WOOjANI'RJ-AC
G SIC CONTROL
ARCHITECT/ENGINEER: LIC NO: AI ) i5 1,afAA A& /].a ❑
CONTACT. / PHONE / ❑ Consultant Fees Paid by Applicant(Initial) �V1�/ BI DG BUI ELECTDING PERM'MD E II
LICENSED CONT'RACTOR'S DECLARATION QTY ELECTRIC PERMIT FEId
1 hereby affirm that i am licensed under previsions of Chapter 9(commencing JOB DESCRIFFION
"Z still Section 7")of Division 3 of Ne Rusiness and Fmfe<sions Code, d tylicenseis
I OO PERMIYISSUANCE RESIDENTIAL:
an full force and t
F�uu License Class LIC.M ❑SFDWL ❑KITCHEN REMODEL
Nab Date Contractor APPLIANCES—RES
IDI?NTIAL [I ADDITION ❑PLUMBING R&PIPE
DHITEGT$DECLARwTII ❑MULTI-UNIT ❑STRUCTURAL
F a N PANELS
Z O 4 1 understand my plans shall be used as public rewmts- MODIFICATION
OZE''O UPT021NIAMPS El INTERIOR - [I CHIMNEY REPAIR
I"J Licensed Prefs,,io,ai 201-10010AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER TWO AMPS
C C I hereby affirm that I am exempt from the Cmdmetor's Llcen.e Law for the ❑HAITI REMODEUREPAIR ❑DE 01.1'f10N
ciy5�6 V following reason.(Section 7011.5,Business sad Professions Card,An)'city or county SIGNS ELECTRICAL ❑UTNER
I. O F' whicheq
requires a permit to consumer,alter,improve,demolish,or repair any structure
JJJd prions its issuance,also rcquircc theapplicamfor such permit to file a sign' indicate SPECIAL Cl RCUIT/MISC. '
Nat he is licensed pursuant provisions of the Contrecmfs License Law(Chapter 9
a�0 (commencing with Section 7")of Division 3 ufthe Business and Professions Code)mr TEMP.METER OR POLE INST. OMS MERE
a Qo e' that he is exempt thereffant and the masts for tbv allege)oxvmpdnn.Any violation of, ❑NEW RLDC/ADDITION ❑DEMOLITION
ox,
Z1i• Section 7031.5 by any applicant for.pemtii subjects Ne applicant DEVICESo a civil penalty of POWER DEVICES I+I N []TENANT [I FOOD SERVICE.
not more than lift hundred props doikrs D5W). IMPROVEMENT
,Q ❑ has
ottieowner k.the pmpenyor mycmplended oroflewages
rsaltheir(Sec.cmnpensminn, SWIMMING POOL ELECTRIC��f' will Jct the work,and Neswcmreis not intended oroflercdfor sok(Sec.71144,Business ❑OTHER
W;j.2 and Poreselo,x GNC:The Cingurr rs License Law does not apply to an ownter of OUTLETS—SWITCHES—FIXTURES
p' property who builds or improves thereon,and who Anes such work himself or through
his awn employees,providrd that such improvements are not intended or offered farNEW RESIDEN'T'IAL ELECIR SQ FT.
sale.If,however.the building or improvement is sold within one yearofrompotion.the SQ.FT.FLOOR AREA $/SQ.FI',
weer-huilder will have the burden of proving that he did not build or improve for pur-
pow ofxnley '
El 1,as owner of the property,am exclusively contracting with licensed conami
m 1'OTAi.: /
construct the Protea(See.]11W,Business and Professions Code:l The Carl...us's
connote Low does not apply it,an owner ofpmperty who huilds or improves thereon,and QTY. PLUMBING PERMIT FEE
who enntmets for such projects with a contractors)licenced punuont no Contractor's
License Low. PERMIT ISSUANCE -
❑1 am exempt under Sec. B&P C for this reason ,.
Owner Unto ALTER—DRAIN&VENT—WATER(EAU VALUATION
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT.DEVICE?
I band will
under penalty or perjury one of(lie to ell following declarations orkcr` .
❑Ihave andwieformaintain eCion 37leof,hc amrCode.surelin Compeo DRAINS—FLOOR.ROOir.ARRA,GOND. STORIES TYPE CONSTRUCTION
wiles,,ns provided for no Section 3]W of elle Labor Csde,for the performance of the
for which this permit is issued. FIXTURP.S—Pl?R TRAP
wiles,1 have and will maintain Workers Compensationw Insurance,h required by Section -
My oboe LaFwuC d1.fa the perfommnceufNewark for which this pertrdt is issued. GAS—FA.SYSTl1.41 INC.40U'ILEfS OCC.GROUP APN
My Works . sec a rtlerunJPN.: GAS—EA.SYSTEM-OVER 4(EA)
Carder. EXEMPTION Policy FROM
CERTIFICATEOMPE SATIONIFROM WORK[RS'
COMP replete ON INSURANCE GREASFIINDUSTRL WASTE INTERC[ITOR
_ BUILDING DIV ISION FE FES
flhissatinn need nm he completed if the permit to lirrnnn hundred dollars($100) GREASETRAI'
or less.) PLANCEI[CK PI?G
(certify that in the any annex ofri to becoock me
which this the Wosissued,Compishall SEWER—SANITARY—STORM EA. Il'.
not employ vny person In any manner an vsmheu�mesnhjecuothc Wmkcrst Contpcn- GNEROY FEC•
z ,'� salon Lows of Celiermia.Dale WATER HEATBR WNBNT/ELECTR
O Applicata GRADING FEE
y NOTICE?TO APPLICAN'P:If,after making this Cenificam of Exemption,you should WATER SYSTBMIIREAGNG
I+ecome subject to the Worker's Compensation pomdkimm,of the Lulwr Code,ysu must .SOILS FEE
foMwith comply with such provisions or this perit shall be deemed revoked. WATER SERVICP.
7z - CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FK PAID
L) Iherebyamrm Nauhere ise ronstmnion lrnding agency for the performance of Date Receipt
ti the work for which this permit is issued(Sec.3(19],Civ,C.)
O f~ Lender,Name TOTAL:
Lenders AJdrcss - TOTAL:
y 1 certify that I have read this application and state that Ne above information is BUILDING FEE
Z) correct.)agree In comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
V Z building construction,and hereby iuffamn representatives of this city to rancorous the SEISMIC FEE
above-mentioned Emperty far inspection parpooes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamlees the City of Cupertino against ELECTRIC FEE
liabilities,judgments.costs and expenses which may many wayucem boli msaid City ALTHR OR ADD TO MECH.
in consequence of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL PIiE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Slg,w,m of Applicnnro circtur Dam EXHAUST HOOD(W/DUCT( IIOUSINO MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building cecupant stoat or handle barnrdons material 14EATING UNIT(TO IW,f100 BTU)
as defined by the Cupeni,o Municipal Code,Chapter 9.12,and the Health and Safety
06 1
Coda.Section 25533($)7 / HEA'T'ING ON IT(OVER 100.000IETU)
❑Yes !/q7� PAID
VF,M'ILATION FAN(SINGLE RESID) Dale Receipt p
WIII the applicant m lams building by the Bt are equipment of devices which BOILER OR 100.000 BTU)
emit hazardous air contaminants as Defined by the Bay Arca Air Quality Management TOTAL:
❑Yes qN
District? /n BOILER—COMP(OVER 1110.0110 BTU)
1 have tend the hon/Nous materials m ummunme under Chapter 6.95 of the Cali- AIR CONDITIONER
4 P ISSUANCE:DATE
comic g no Surf-Gxla Sections 25505,is it, and 25534.1 understand that if the NEW ItISIUENTIAL MECH. SQ.FT. i-- ^/ _97
building nate nilly haveatenont.that it is my responsibility to notify the ceapum s
ofthe or m issuanceafn Ger c
Owner tho- d agent 'TOTAL: ISSUED BY:
OFFICE '