S 0914 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-RUEcrRICAL P15ITNO, O �w w
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL J 14
BUILDING.PROJECT intiN rIFICATION
bUILDINGADDRESS'. (.QQTS "$ SANITARY NO, APPLICATION SUHSI11 IAL DAII
C( zei" 21230 HOr i'EArD 1 2`
OWNER'S NAME PHUNLkli,�O CON'fRAC'I'OR'S NAME: 1 LIC No
1
N/
off 1843NIC, unrROLa
H A[[( k t. ( �moi— Au_l
�ARCHITE GINFER: LIC NO: ADDRF_SS: ❑
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ONTACT. 41 PHONE: BUILDING PERMIT INFO
' 1 ❑ Consultant Fees Paid by Applicant(Initial) BLDG F.LE PLUMB SIECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
nfnnn than 1 ant heataed under,provisions of Chaprer 9 temnlneneinp ]OB DESCRIPTION
Cede. g ofDivision 3 of the Business and Pmfeasions Cale.and my license is RESIDENTIAL:WOC PERMIT ISSUANCEFs'Favi% ry 1 Lic �{JCSPDWL ❑KITCHEN REMODEL
V 1'Saa Contra �'-!!,Ly � APPLIANCES-RESIDENTIAL [I ADDITION El PLUMBING RE-PIPE
FDm ARCHITECT'S DECLARATION' PANELS
❑MULT6UN1'1' ❑STRUCTURAL
ZOO1Z I understand my plans shall Fie used as public rewards MODIFICATION
OZ
UP TO 2(m AMPS ❑INTERIOR ❑CHIMNEY REPAIR
[Fyf-Yl Licensed Pmlessional 2n1-IIXIBAMPB IMI'ROVEMIiNT E]SWIMMINGMOLS
OWNER-BUILDER DECCARA'1'ION OVER 1000AMPS ❑BATH RE�MO_DE`IIREPAIR 0 !WL§11TION
Q 1 hereby affirm that I am exempt from the Contractors License Law for the 4 [; '�
pl3 LL U following reason.(Sectinn]1131.5,Business and Prolbs.ionn Cale Any city or county SIGNS ELECTRICAL �OT�1rE�]tR C LQ r _
y which requires a permit to comrecl,alter,improve demolish,or repair any structure C%f LN
prior to its icsuana.also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUITIM ISC. ` -1.4-t•�
E y that he is licensed pursuant mtbe provisions oftbe Contractor's License Law(Chapmri) r
ku 0 (cmmrttencing with Swtion]falo)ol UivizionJaf the Bmineasand Professlom feed TEMP,METER OR POLE INST. COMMERCIAL
d y N than he is exempt Iheofra:n and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
YX7
Section 7031.5 hyanyapplicarn for a permit subjects the applicant aaavn pcnahyof MWER DEVICES ❑TENANT ❑FOOII SERVICE
nal mom than five hundred doll...($500).
F Z>' Las owner ofilmproperty,orm IMPROVEMENT
tynnpendeswilhwagesmnife(Sulerom.Best.n. SWIMMING F(NIL ELECTRIC
anhework.and the sic Cwt snoiLicens straw doesval not apply to an Best.,, OTHER
63 m and Pmfeaiobs Codon imp C e,themL....it se Law docs not apply ut if owner of WTLHTS-SWITClIES-FI%'CURES
h,rapiis own who builds or improve.thereon,and who nts a such not
ted(it or NmugM1
hisownowevercthees,gildingded mat such improvements sol within
on intended isf (it offered thelot NEW RESIUEN'1'IAI.ELECTR SQ FT.
t.4 ft
sale.IL urlder ill have the
bur improvement it at he iid non wild or improve
Flits SQ.FT F OEI/\fiP.A 5/Sp.lrl'.
owner-huiWer will have the burden ml proving than he did not build or improve for par- V
pose of wle.). Jq
I]I,m owner of the property,am exclusively contracting with licensed contractor.to TOTAL: ANIIII
o..umG,hc project(Sec.TW,Business and Professions Codet)Lic Cantracmrs Li- A _ �6
{/ 4#S
cruise Law does not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE •VV//f)Q
who contracts forouch pmjeAs with acontra.mns)licensed.....amut the Cancer rs Lu
cI] lam lawn leder Sec. .H&I'Cnixthis reason w. PERM[ ISSUANCE
Ow ate I' ACI'IiR-DNAINffi VLN'1'-WATER(EA) VALUATION
ER. COMPIiNSATION DECLARATION BACK PLOW PROTECT DEVICE y'J
I hereby affirm under penally of p jury one of the following declinations:
❑Ihave wJ will nmimuin nCenil'mane of Consanno.dGinmrc for Worker's CoaTm- DRAINS-FLOOR,ROOF,AREA.COND. STORIES I'YPIi CONSTRUC'I'IOD
sztion,as pmvidul for by Section 37M of the Labor Code,for the performance of the
work for which this permit Ix issued PINTO RES-PER TRAP
I]1 have and will maintain Workers Compensation Insurance,an required by Section
37IXtoflhe LabeCole,forthe perfarmanccofthe work forwhich Nis permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUT' APN
My Workers Compensation Insurance eerier and Policy number um:
Cartier: Policy No.: GAS-IIA.SYSTEM-OVI2R 4(EA)
CERTIFICATE OF;EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUS*1 RL WASTE INTERCEPTOR
(Ibis scluou need and be r ilordIIbe permit is for we hundred dollop($110) BUILDING DIVISION FEES
less.) GREASE TRAP PhANCI IECK FEE.
I acuity that in the performance ofthe work mrwhichiliepermitis issued,Ishall SEWER-SANITARY-S'IORM EA.200 IT.
non employ any pmt any manner sat as bt become subject m the Workers Conipen ENERGY ITT E.
z .Z union Laws ol'Califemia.Date en WATER HEATER WNEN'I'/EI.II,TR
O Applicant I GRADING FEE
h NOTICE TO APPLICANT:If,after making this Cenificam of Enemption.you should WATER SYSTEM,REAUNC -
a; become mbJm,mo It,Worker's Cnntpem.tio i provisions of the Labor Calc,you must SOILS FEE
W Forthwith comply with such provisions or this permit shall be deemed revoked. WAFER SERVIC1:
d
CON$ce iO.c0NmiNDINGAGENCY NEW RIiSID1iNT1AL1'LMB. SQ 17. PAID
U O k for
thunberc issued ion lending agency fur the performance of Date aeipta
OU ,he work fur whish this Parmil is innuol(ScfSa.3r91 Civ:C.)
Iendeex Name a I 'TOTAL:
Lenders Addmn TOTAL:
(}" G I certify that I have mad this application and state that The moms,information i. BUILDIN iC
C (Z) cored.I agree tecomply with all city and county ordinances and state laws relating m QTY MECHANICAL PERMIT FEE
) Z building conswction,and hereby authorize reprmenmlive.orchis city to enlcrupm the SEISMICITry _
above-mentioned property for inspection purposes. PERMIT'ISSUANCE(We)agree m sive,indemnify and keep hannlecr the 01yof Curti
peno aprim, IiLECTRIC FEE
bablline,odgmens,costs and expenses which mayinany way accrue against said City ATTER OR ADD TO MGCH.
in consequence of the counting of this permit, PLUMBING F:E
APPLICANT TI NDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT'(1010.(Nq CIT1)
SOURCEREG LArIONS. MECHANI AL FEE
�= fed AIR HANDLING UNIT(0117R IILDCONSTR: ION'I'AX
S' atureof APPlic.nVCon Date �O XI CFhD
BXHAUS'I HOOD(W/DUC'DHOUSING MITI \TION[:I.]:,HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfulurc haildingoacupam store or handle hazardous ttmtedal HEATING UNIT('1'O 100,00013TU) ir
as defined by In,entente.Municipal Code.Chapter 9.12.and the Health and Safety
Cars,Sectinn 25532(u)/ HEATING UNIT(OVER 100.000 BTU)
❑Yea ❑No VENTILATION FAN(SINGLE RFSID) PAID
Will the applicant or future huili ing occupant use equipment or devices which Dare Rep
a
emit monotone air contaminants as defined by the Bay Area Air Quality Management BOH.E,R-COMP(3HPOR I00,000BTU)
Disricn?
BOILER-COMP(OVER 100.000 BTID TOTAL:
EJ Ye, Fl No
I le 'e readthc marvelous matcn, mem,under Chapter h95of the Cali- AIR CONDITIONER Is DATE
fornix Heal, Safely ewe.Sections 255115.2 re d SSU.I undcrsmnJ that if the NF,W RESIDENTIAh MECH. SQ.ET.
building dtwsnnla
have,
tbm it's my resp ihilirymnutily Nc mcupanl
of be
m issuance of a nirm.c of(hcu icy.
{t
Owner m amhmrizcd agent Doe 'I(TEAL: ISSUED BY:
OFFICE