B 0371 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S000� 40371
BUILDING PROJECT bDENI'IFIC'ATION
EUI SANITARY NO. AI'I'LICAI'ION SUBMITTAL.DATE.
OW [ 'S NAA is PHONE: "T ACI'O 'S E: LI NO: -
1/Ai NIC CONTROL If
ARCHI'I"ECI'/ENGINEER: LIC NO: AID PSS 51 VQ'� ❑
rn
CONTACT: PHONE: BUILDING PERMIT INFO
0 / ❑ Consultant Pees Pail by Applicant(Initial) p40 O i;I L H
LICENSED CONTRACTOR'S DECLARATION l QTY ELECTRIC PERMi F PEE
I hereby vRnn Thal l am licensed under provisions of Chapter 9(commencing JOB DESCRIP ON
��Z wino Section nxxB of Divt.hrn3onhe Basime.us and vrofeommcode aha my Bcenson RESIDENTIAL:
W O p I 1'IA2M1'1'ISSUANCIi ��
F P:•' in full tome uaJ ellict. �1 el / //..� ')/ _/_ ❑SFDWL ❑KITCHEN REMODEL
QUU Liccnsc Cl..s OfV Lic.p ^/ 4' Ol lY ll�
FNF
APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
a ❑MUhT6
-5y RCHITECPS DECLARATIOPANELS UNIT ❑STRUCTURAL
Z O n KI undcamnd my plans shall Fz used tss politic rccarJ.v I M(IDIPICAll09
OZ.-0 UP TO 200 AMPS El INTERIOR [I CHIMNEY REPAIR
F Ental Licensed Professional ' 201-1030AMPS IMPROVEMENT E]SWIMMING POOLS
ry C-i - O`aNER-BUILDIiR DECLARATION
6 I hereby affirm that I am exempt from the Contom a',License Law for the OVER Hall AMPS ❑BATH REMODELIREPAW )17MOLITION
1P('O cc U olowing reams(Salim 7031.5,Imormss and ProfieWons Coln:Any city or county SIGNS ELECTRICAL
❑OTHER_` ,1
1y'3 IL y which requites a permit m atmo am,cher,improve,demolish, u mpsu any nmmurc ('d Al R Q U(l G
Fu•Oa pNstno itsissuance.also requires the applicant for such Permit o file a signed statement I SPECIAL CIRCUIT/MISC. r ,�+
��}•] that hcislimewd pmmusntmind provfsmarofthe Csmactlr's Limmc law(Chapmr9
(mmmenaingwoh Section TXXF of Division 3 ofthe Business and Profession,Code)or 'fl?MP.MI?'I'I?R OR POLI INST. COMMERCIAL,
d d
n= that he Is exempt therefrom vad the basis fur the alleged exemption.Any Orlaion of ❑NEW BLDG/ADDITION ❑DEMOLITION
��m
Section 7031.5 by any applicant forapermit subjects the appliem,to v civil penalty of POWER DEVICES ❑TE,NANT ❑FOW SERVICE
m more that five hundred dollars(5500).
HZ} OTHER IMPROVEMENT
< do owneroflite property or employees with whgad,,I,Sm.campcnsure , SWIMMING POOL ELECTRIC
Sarno will dothcwmk,Cody: he Com6notint License
Law
dosnotl apply to
owner
�QTHb?R
yl m pro I'.,who b Cold The Cantmcmrs License law d<cs not apply to if owner of OUTLETS-SWITCHES-FI%TU
pnopny who builds or improves thereon,and who dans such work himself or through
his awn cmplay,the provided that such improvements arc not imenor or offered for NEN'RESIDENTIAL LLLCTR Q
sale.ll:however,the molding nrimpmvontunt is sold within one ycansf utmplminn,the S . "PL00 SISO.PI'.
crhuildmvedl havethe human ofproviri Nm he did no build or improve for par- D
pose of sale.).
❑ 1,as owner of the pmpery,am exclusively contracting with licensed contractors to TOIA1.:
conFlruct the anicc,ISec,9044,Basins.and Profession Csde:)The Contactor',la-
,cm,Law
i-c eLaw docs not apply to an owner of property on,milds m,nis rix human,and QTY. PLUMBING PERMIT PEE N2 !1 �9a�
O
who Contracts for such projects with acomctor( nContractors
x)IicenscJ pumuannthe (1
License law. ' PERMIT ISSUANCE 3 O s�
I:nt exempt under S . ,B&P C far Nis mac
nn ALTER-DRAIN&VENT-WAFER(H)Q VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION PACK FLOW PROTECT.DEVICE
Iandhereby alarm under penalty of Perjury one of Ne following Workerts C.1 ' t
❑ Ili and will 'tit Cnf<I fC a II f Workers:Conten DRAINS-FLOOR.ROOF,AREA (.OND. U
wits p 'I l f r by S t 1910 I p L M C I f N ( I' a1 the S'I'URIHS TYPE CONSTRUCTION
work) which this man is d. FIXTURES-PER TRAP
I have add will maintain Workers C pa wt Insurance,as required by Section
3 X)of the later Csde.for Ne performance efthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLBTS OCC.CROUP AVN
My Wor,,yy Cturyry��ppss Inw ca cr and Policy n�mf� U"
Currier tlf kTY igy_pnw ori Policy No.�,l1J"IV�¢2193y GAS-EA.SY,STNM-OVER4(F.A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ; GREASUINDUSTRL WASTE INTERCEPTOR
(this section need not hit completed if the peman is famno hundred dollars S1hill BUILDING DIVISION FEIS
nr
less.) ORGASE'I'RAY PLANCHECK FEE
toy any Wis Ne my
rof as
themitisima'Ool'n SEWER-SANITARY-STORM EA.200 FT
not employ any poste in any manner as m become subject mi the Workers'Compcn' ENERGY PEE
z ,Z .stion Laws of California.Dam WATER HEATER W/VENT/ELECFR
Applicant 1 GRADING THE
y NOTICE TO APPLICANT:If,after making this Cenificale of Exemption,you should WATER SYSTEMTREA TING
a> become,subject to the Worker's Compensation provisions of the Labor Code,you most SOILS FEE
Dei forthwith comply with such printsions or Nis permitshillM deemed mvoked. WATER SERVICE
CONSTRUCTION LENDING AGENC% NEW RESIDENTIAL PLMN. SQ.IT. PAID
V O lfarvs affirm al there is..ed(S .300ending agency for Ne performmee n( Data ReceiptN
� '-' the work for which Nis permit is issued(Sm.3007.Civ.C.)
O U bender's Name TOTAL:
V Lcndar's Address TOTAL:
f}^ 0. 1 comity that I have read;his application and state that the above information Ler BUILDING FIA:
rn conn.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
C.>Z huildingcmnswction.and hereby authorize represenlativesofthis city toemer upon the SEISMIC FEE
aMrvomantiuncd pmpeny for invarion prirpoms' ' 'fir
(Wit)agred to cava,indemnify and keep harmless the City of Cupuriino againPERMIT ISSUANCE st J5' o EL17CI RIC FII?
Whilom,judgments,co.N oudexpnnseswhicnmayinvnywayuccrucagmr,1 said City ALTER OR ADD TO MECH.
in asequence of the granting of Nr
is permit. PLUMBING FEE
APPLICA "T UND[ STANDS AND WILL.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 1(I,fXO CFM)
SOURCs GULA l S. MECHANICAL FEE
( -•I1,I'I C1 AIR HANDLING UNI'1'(OVER 10,SX)CFM) CONSTRUCION TAX
Sih atom fApplicar omuctor T-I -D1ate EXHAUST HOLD(WIDUCT, HOUSING MI'lIGA9'ION Iti[
HAZARDOUS MATERIALS DISCLOSURE //��//��
Will the aptlicant or future huilding occupant store or handle hu'r.adois manurial ' HEADING UNI'F(TO 10x,00(1 BTU)/W
as defined by the Criterions Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 255320? I IHEATING UNIT(OVER 1011.000 BTU)
❑Yes Ar",
VENTILATION PAN(SINGLE RES ID) PAID
Will the...neva or forum huilding occupant use equipment m devices which Woe Receipt k
+nit hruardous air contaminanis as defined by the Bay Area An Quality Management BOBER-COME(DIE OR HMOM BTU)
Oran"
an"-? TOTAL:
C]yes )<No 11011ER-COME(OVER RX),000 BTU)
I beveamdthe hazarderanarteriols nyuireurram under Chvpter6.95 of Ne Cali- AIRCONDHIONER /y,sO
ISSUANCE DATE
L4g V,
main health&Safety Code,Sections 25505,25533 and 25534.1 understand Nat if the NEW RESIDENTIAL MECH. SQ.Fr.
buildingd«s(at curtently hmeatemrnn,Mathis mY responsibilirymnotify rhe occutant
.film 11 march mast h+tan or lem,nerriedar a Center muf 0..J
Ow thortmdc em Da TOTAL: ISSUED BY:
OFFICE