30550 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. ^JK O � a�O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL xr J1
BUILDING FeWECT IDENTIFICATION "
BUILDINGADDRESS: SANITARY NO> APPLICATION SUBMITTALDATI
O � `7 cu .e
OWNER
WNE MEQ PN CO CI'O 'S NAM ,a LI
IK-/1 J NIC CONTROL#
AR ITECDENGINEER: CNO: ADDRESS: ❑
CONTACT: PHONE: , BUILDING PERMIT INFO
r ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB ESCRIPTION
,❑„OZ with Sectiod70010ot Division3of Ne Business nnJP 'feI inns Code,and mylicense is RESIDENTIAL:
�IyF in full force aar cHecVl� /L �1 PERMIT ISSUANCE
<VU�2 License Clas C— Lic.p 7 !J ❑SFDWL E3 KITCHEN REMODEL
FF.. {s4 Da¢ n cmrAPPLIANCES--RESIDENTIAL. ❑ADDITION ElPLUMBING RE-PIPE
HITECT'S ECLARATION ❑MULTI-UNIT []STRUCTURAL
Z02K Iunders n shall mpublieneands PANELS MODIFICATION
O Z UPT0 200 AMPS
❑ - ❑INTERIOR ❑CHIMNEY REPAIR
g4 � Literati]Professional 20i.100BAMPS IMPROVEMENT
' OWNER BUILDER DECLARATION OVER IOWAMPS El BATH REM URF.PAIR GDEMOLITIOy.,a
yy uu]] 1 hereby affirm that I nm exempt fmm the Co....end's License Luw for due In /kDEMEMEOLITTICI�e •
S!3 L V Is
following mason.(Section 7031.5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
Yu1l O which response pemtit to construct,alum,improve.demolish,or repair any structure
ren prior to its issuance,also requires the applicant for such permit to file a signed statement SPBCIAL CIRCUIT/MISC.
Tti
�'� �sthat he is licensed pursuant to the previsions of the Contractor's License Law(Chapter9(commencing with Section 7")of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POUR INST. COMMERCIAL:C Nat he is exempt therefrom end the basis for Ne alleged exemption.Any vialetion of D NEW BLDGIADDITION D DEMOLITION
m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES O TENANT D FOOD SERVICE
not mote than five hundred dollars($500d. - t IMPROVEMENT
2 G ❑ 1,as owner of the property,or my employees with wages ns their sole cmnpensation, SWIMMINGPOOL ELECTRIC
.will do the work,and the structure is not intended mattered for sale(Sec.7044,Business D OTHER
and Professions Code: v
The Combustions License Use does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
6 3 Fictively who builds or improves thereat.and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECSR SQ
se
It.If,however,the building or improvement is sold within one year ofcmnpletian,the SQ.IT.FLOOR AREA ,VSQ.FT.
owner-builder thur
will have e burden of proving that he did not build or improve for p -
pose of sale.). TOTAL:
D 1,as owner of Ne property,am exclusively contracting with licensed eantrecmrs to
construct Ne project(Sec.7044,Business and Professions Cade)The Cot toncmrs Li-
ciameLuwdoesnotapplytounownerofpropertywhobuildsorimprovesthereon,and QTY. PLUMBING PERMIT FEE
whocontmds for such projects with a contractors)licensed puauaat to the Contractors
License Law. PERMIT ISSUANCE
[:]1 am exempt under Sec. ,B&P C far this reason
Owner Date ALTER—DRAIN&VENT—WATER(EA) - AIUATION r
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE , 47996
I hereby affirm carer penalty of perjury one of the following decimations: /� ,
❑ I have and will maintain a CertificmeofCansenuo self-insure for Workers Comped. .DRAINS—FLOOR,ROOF.AREA,COND. STORIES TYPECONSTRUCf10N
cation,us provided for by Section 37M of the Labor Code,for the Performance of the •.l r lh�l
work far which this pemdt is issued. FIXTURES—PER TRAP 0
D 1 have end will maintain Workers Compensation Insurance,as required by Section
l7W of the lsbor Car,for the perfnttrrmtce o(the work for which this permit is issued. GAS—EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP APN
My Wo sora Ism comer and Policy
lNr� GAS—EA.SYSTEM-OVER 4(P.A)
Cartier. - Poicy o.:
CERTIFICATEOPXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section send not be completed ifthe permit is tsar one hundred dollars($100) OREASETRAP
or
less.)(This
FEE
Icertify that in the perfommnceofthe work forwhich flin,cnnit is issued i shall SEWER—SANITARY—STORM EA.2nd E7'.
not employ any Person in any manner so as to become subject o the Workers'Compen- ENERGY FEE
ZZ ration lawsof Culifndam,Data WATER HEATER WNENTXLECTR
O Applicant GRADING FEE
r y NOTICE TO APPLICANT.If,after making this Certificme of Exemption,you should WATER SYSTEM/1'REATING
(~ become subject m the Worker's Compensation pravisimo of the Labor Code,you must SOILS PEE
W (athwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
aQ
UO CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PUSH, SQ,FT. PAID Date ReceiptM
1 hereby affirm that there is a construction lending agency for the Performance of
tr the work for which this permit is issued(See3097,Co.C.) -
F� Lenders Neme
{U Leaders Address TOTAL: .
I scanty that I have read ab
this application and state that the above information is BUILDING FEE
aWr correct.I agree m comply with all city and commaws relating to QTY. MECHANICAL PERMIT FEE -
U building conslmciion,and hereby uutbodzen IiYes of this city tna oa the SEISMIC FEE
above-mentioned property for inspec 0 - PERMITISSUANCE
(We)ag.to save,iarcm y d kecp hanrdess Ciry of CLpcnino a lost ELECTRIC FEE
liahiliuea,judgmcnu,costs and pen swhich may in onyx yaccrve against said sty ALTER ORADDTO MECH.
I.consequence of the gm fthi emit. PLUMBING FE
APPLICANT UN tS A WILL COMPL' LTH ALL NON- INT AIR HANDLING UNIT(TO 10,WCFM) MECHANICAL FE
S tr ERE S.
AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
Signuturea ppllcasVContmator Date EXHAUST HOOD(WOUCq) HOUSING MITIGATION TEG .
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicantarfumeelmudingoccapanr storeorhandle Incursions mmerid HEATING UNIT(TO 100.01111 BTU)
as defined by the Caperton Municipal Cade,Chapter 9.12,and the Health and Safety
Cade,Section 25532(0)+ HEATING UNIT(OVER 100,000 BTU
El Yes No VENTILATION PAN(SINGLE RESID) PAID pate ReceiptM
• Will the applicant or(umrc building..,.m use equations,or devices which
emit hmmdovs air contaminants as defined b the Ba Arta Air Qualit Manaement BOILER—COMP(3HPOR IW,OW BTU)
y y y K TOTAL:
District?
❑Yes ❑Nn BOILER—COMP(OVER 100,0100,0011, 11 BTU)
J
I have red the hauNaus materials requirements under Chapter 6,95 of the Cali- / AIR CONDITIONER ISSUA ATE
ramie Health&Safety Code.Sections 75505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.
building does not currently have a tenant.that it is my responsibility to sanity the occupant
of On iequiremenn which most M metpn+ino issuance of a Certificate.1 Occupancy, -
Ownerarauthundul.gent Date TDTAL: ISSU BY:
OFFICE