S 0735 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELRCr Ii nT NO.
BUILDING DIVISION APPLICATION/PERMIT t'LUMBING.ME ' ,AL. 0735
BUILDING PR(XJF, 'NT]111CAT N vJ
BUILDING ADDRESS: ANI .O. AT ICAI'MNSUBMITTAI.DATE
OWNS S AMH.. M` 'PHONE: CONI'RACI'DR:S NAM(:: LIC NO:
N NIC CONI ROLA
• ARCIIITCCT1CBMEEIC \�\ LIC No ADDRSSS r ❑ 95-77
CONTACT: [/''� \ PHONE: 'BUILDING PERMIT INFO '
^ 927 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MECII
pI,V T 2-`/I ❑ ❑ ❑ ❑
LICF.NSIiD A R'S CLLARATION QTY. ELECTRIC PERMIT FEF:
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
X00MMZ with Section lasso or Division 3 oflhe Business and Pianesslons Code,and my license is RESIDENTIAL:
in full force and e8'ect. �k PERMIT ISSUANCE.
.W= License Class Lia# ` D SFDWU C KITCHEN REMODEL,
:\ APPLIANCES-RESIDEN'RAI. DADIXTION I1PE
RUU
Date Convector CPLGMBING RIi.'
HARCHITECTS DHCLARATIONI,+' pAN:IS
CMUUR-UNIT CSTRUCTURAL
Zpmz
MODIFICATION
024 \,. UP TO 200AMP5
-,—Q El Licensed Pmfin,,inna] CIM'ROVE C SWIMMING I!PAIR
301-uXX1AM1'S IMPROVEMENT SWIMMING I'OOhS
a yyX.'.yI OWNER-exempt fr m Ce CournON OVER IL00 AMT'S C
yyx;P4 0.U I M1eaffirm that I 1 5,,�not from the Cession, o License Law for the C BATT{REMODEVRIiPA1R ❑DEMOLITION
W ar which inaujim,reason.ISovtlma 90315,Busiuess and Professions Code Any city nr county SIGNS ELECTRICAL ❑OT'HIiR
n1 v- which requires o pemut m ennstmn,cher.improve,Demolish,nr repair.any swear,
�� prior m its ixuanec.also myuiresthc applicant for suchpermit file.,igned statenmnt SPECIAL CIRCUUMISC.
y that he is licensed puntannn the provisions of the Contractors License Law(Chapter 9
ad 0 (commencing with Section 7000)of Division 3 ofthe Business and Profesniar.Code)it TEMR METER OR POLE INST. COMMERCIAI.:
0.q m tY that he is exempt therefrom end the basis for the alleged exemption.Any violation of D NyW BLDG/ADDITION D DEMOLITION
LLXl u• Section]Ili LS by any applicant for a permit subjects the applicant m a civil 1'erud y of P(i DEVICHS �/
w TP,NANT C FOOD SHRVICI3
F Z Y not mere than rive hundred dollars(5500). j
�=nQ ❑I,es owner of the pmpeny.or myemploymxwith wages astheirsolecmnpensetinn, SWIMMING I`OOL ELECTRIC IMPROVEMENT
W will do the w.rk..nd the structure is not intendcdorOffered for sale(Sce.1014,Business COTIBJE
a and Prol'essures Code:The Contractor's License Law does not apply to an owner nfy` 01JR.1'1'S-SWITCHUS-FIX]URES
property who build..or improves thriven,and who does such and,himself or thnmgh
his own employees,provided that such improvements um not intended or offered for �� NEW RF_SIDENTIAL HIXCTR SQ FT.
salo. th
Ir,however.the nuilAing or inaprovctnmv is ynlJ within one yutrof mnaplaian, e \ \ SQ.F..FILOOIAR.A $/SQ.IT.
owner builder will have the harden of proving that he did not huild or improve for put-
pose of sale.).
C T.as owner of the propeny,am exclusively contracting wits licensed cumruarm m l.\ /TOTAL
construct the project(Sec.70004,Business and Profession,Code,The Contracmrn Li- -
arise Lawduesnot applymanownerofproperywho builds orimprovesthereon,and QTY, PLUMBING PLUMBING PERM IT- FEE
who contracts for such Contractor's
with a contclund licensed pursuant to the Contnr's -{
License Low. PERMIT ISSUANCE r`11
C lamexemptunder .Sec. ,B&PCfnrthisonsor,
ALTER-DRAIN&VENT-WATFIt(EA)'S
Owner Dore VALUATION
DEVICI7
RS COMPENSATION DECLARATION BACK FLOW PROTECT'.
• Ihercby eWORKER'S
under penalty of Perjury one ofthe following d,clamtionc l;
❑l mwodwill mainainuCmdfunenrConsent¢,sell-insurcfnr Worker's Cnmpen- DRAINS-PLOONf 0i ARFA,1ONI1STORIES TYPE CONS1'RUCION
nation,us provided for by Section 3700 of the Labor Code,for the pe rrnrmmnce of the \ `� �01p'
work for whicnRS
tbis peread is issued. FlXI UR -PFR TRAP f7
0 1 have and will maintain Worker's Compensation Insurance,as required by Section t
37S)nilhe Laher Code,for erfrmanm of the work lot which this f:A.SYN'1'HM-ISINC.4Ol1'I'LBTS /,H
p pcnnit is issued. GAS- /y [. OCC GROUP APN
My Worker's Compensation Insurancearrier anumh
cnd Policy er are: - 1
Cartier. Policy Na: GAS-F,A.SYS'1'EM-OVER 4(CA)
CFRTIFICATE OF EXEMPTION FROM WORKERS' }
COMPENSATION INSURANCE GREASWINDUSTRI.WASTE IN I'CRCEFI'OR
(This nation aced be fo
d ncompleted if the permit is Rome,hundred doll ars IS 100) all BUILDING DIVISION THUS
lens.) seGRP.ASB TRAP \, ��' I'LANCIIECK FEH
I ceNfy that in the perfnmunceofthe work far which this permit is Issued,I.hit I SEWER-SANITARY-STORM EA;200 Fn
not employ any person in any omnner so as m becmne subject to the Workers'Compen- HNERGY PEE
O z nation Laws of Cali romia.Date WATIiR HEATER WNIiNT/F.LCC'IR
z O Applicant - - 1 GRADING FEIi
0 NOTICE TO APPLICANT,If.after making this Certificate of lixemptinn,you should WgTCN SYS3'CM/rREA'1'ING Y
a � become subject m the Workcea Crnnpensatien provisions of Ne labor Code,you must a SOUS FGF.
mdhwith comply with noel,provision,or thlx lednit shall he dean,l revoked WATIiR SERVICE
a �
�
CONSTRUCTION LENDING AGENCY NEW RESTDENTIAI.I'LMB. SQ,FT. PAID x" - Ihercby affirm that in construction landing agency for the rfarmnncu or Orae Receipt
LL r the work for which this Permit is issued Ser.3097.Civ.C.) r,
0 F•' Lenders Name TOTAL:
Lender's Address TOTAL:
y 1 I card ry that 1 have read Otis applicat inn and state that the ularce alormatino is - BUILDING FE
In rodect.Ingrce u,comply won an coy arta county mmmanan arta azo low.relatingto QTY. MECHANICAL PERMIT ' FEF.
GZ building commotion,and hereby authorize representatives afthis city to wterupontne SEISMIC FEE
above-nmmimod pmpeny for mspcnlmn pufoor,. PERMIT'ISSUANCE
(We)agree to new.indemnify and keep harmless the City of Canadian against ELECT RIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City' ALTER OR ADD TO M ECFL ) PLUM RING FEB
is emnse.psenco ur the grami ng ofill I,permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'T(TO 10.X0 CFM)
SOURCE REGULATIONS. MECHANICAL ITH
AIR HANDLING UNI['(OVER I(k(XO CFM) CONS'I'IHICT10N'LAX ,
Signature mApplicanJContractor Date EXHAUST H00D(W/DUCT7 HOUSING MITIGATION PIiG
HAZARDOUS MATERIAL S DISCLOSURE
Will the applicant or l umm building accupant.etom or hoodle hazimat,x material HEA'T'ING UNIT ROD 101,00011'1 lit
us defined by the Cupedian Municipal Code.Chapter 9.11,and the Brandt and Saba, A
Code,Section 25532(,)? HEA'T'ING UNIT(OVER 100,000 BTU)
❑Yes ON.
VENTILAT10N PAN(SINGLE RESID) PAID
Will Neccipt M
Will the applicant or future building uccupam use equipment or devices which
L
ihrdous air contaminants undefined by the Bay Ama Air Quality Management BOILER-COMP UHP OR 100,000 BTU)
TOTAL:Yes CNo BOII.I:R-COMP(OVERIUq(XX)13TU)
bavereaddichwutdous materials reyuircmenu ander ChupOcrfiJS of the Cull- AIRCONDITIONER ISSUANCEEEDATalth&Safety Com.Sections 5505,25533 and 25534.1 undersand Wm if the NEW RESIDENTIAL MECH. SQ.IT.oes amt currtntly have a ttwnt,that it is my respmslbilily tonotify the occupant norment, i, mustonCOUNouse ,gem Date TOTAL:
SSUED BY:
OFFICE