S 0931 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY,
ISUILDINC-ELECT I, FERMI I NO
CITY OF CUPERTINO ,
�
BUILDING DIVISION APPLICATION/PN:RMIT PING PROJECT IDENT CAI.
BUILDNG PROJI!L'1'IDF:\TIF'ICATI(lN \
BUILDING ADDRESS: Va
SANITARY NO. APPLICATION SUBMITTAL PAI I
OWNER'S NAME: I•HONE: CONI' CI[R'$N MF:: LIC NO'.
Op SIC CONTROL#
• ARCIIITECI'/F.N INEHR: ~ LIC NO: ADDRF_SS: �oo /1�- 4 ❑
CONTACT: ' t1I��1 /..F.Mi.('� PHONE: `lv7_� BU ILDING PERMIT INFO
'too44U I lY�µ�F ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MUCH
lb 0
LIC ENSF.DCONTRACfOR'SDIiCLARATI N QTY ELECTRICPERMIT FE
1 hemhy aBour
that 1 an Ecemesl under busiaion,of Chapter 9(commenting JOB DESCRIPTION
O�'Z Ih Section Wulf 1Division Jofthc Businea,aod Pnfcason.Codaand my license is
fa'00 wt PERMIT ISSUANCI? RESIDENTIAL:
CLLF i lull forcenmdlbvlt, O ❑$PUWh ❑KI FCHHN REMODEL
FQUU License Class Lien i APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING REPIPE
N G L Dam Contmcee
F_7on
ARCHI'TECT' PANELSS
S DECLARATION ❑MULTI-UNIT ❑STRUC'TURAI,
zbt2z 1 undebaanJ my plans shall M1c oats ns public record, MODIFICATION
OZ-O I1PTO 2fNtAMPS ❑INTERIOR bCHIMNHY REPAIR
��,F'.,W Licensed Professional 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
OWNER BUILDER DECLARATION OVER BXMAMI:S [IBATH REMODEUREPAIR )FMOLITIGI;
CL C d 1 hereby affirm that I um Overan from the Cmnmcmr'y License Law fnr the )I
X3 i U following.,,,a (Section 70315,Business and Profession,Code:Any cit.or.county SIGN'S ELECTRICAL ❑OTHER
LL LL ya which m4uims a pertain hi emidnel,.her,improve,Jemohsh,nr repair any anaure 1 .Ia
1"ti�J prior In if,issuance,also"mot,the applicant for such Permit to a signed statement SPECIAL CIRCUIT/MIS ��s2
�. that he islicensed pmmm
,untheprrwisions of the Convncmr's License Law(Chapter 9
X00 (commencing with Section 7W)of Dof sion9 of the Business and Professions Codc)or TICMP.MI?TI?R OR 1?INS'I: COMMERCIAL:
a y e C mal he is cxcmpt therefrom and the basis for are alleged exemption.Any violation of ❑NEW BLDG/ADDITION C3 DEMOLITION
Xm LL Section 703Iti
.S by any applicant for a permit subjects the applicant in a civil penalty of MWI7R DEVICE
Rl�tn ❑TENANT EJ FOOD SERVICE mom man five hundred dollort(ES(X)'
ASO ❑Las owner ofthe pmpcnY,nr mYcmployceswimwages os thcirsolc aimpencaion. SWIMMINGOOL ELECTRICIMPROVEMENT
F. will do the work,and the structure is not intended anifiered forsale(Sce.70,bL Busineasair
[]OTHER6,3 m and Professions Cole:The Cor rector's License Luw does not apply to an owner of OUTL -SWITCHES-FIXTURES
property who builds or improve themon,and who doei och work himself nr thnmgh
his own employees,provided that such improvements arc nal intended or offered for NIi RESIDENTIAL.ELECIR SQ FL
sure.IL however,the building orintpmvement is soldwithinone yearofcompletioo.'he SQ.IT.FLOOR AREA S/SQ.Fl:
owner builder will have the burden of proving that he did not build or improve for par-
quc nLwlc.).
❑1,as owner of the property,am exclusively contracting with licensed coo aria s m TOTAL:
cnmtran the project(Sec.7044.Business and Professions Code:)Tac Contractor's Li-
teLawdoe,not appl.It,anevareldpmpeny who builds or improves domain. ad QTY. L GPERMIT FEE
who contracts forsuch projects with a contnctons)rcenscd pnnmtm to the Commemrs
License Law. PERMIT ISSUAN E
❑ I an exempt muter See. ,B k 11 C fee this reassm ZZ I
Owner Date ALTER-DRAT ' V - Al RVALUATION
WORKER'S COMPENSATION DECLARATION 13ACK FLOW PRlir 'VI IJ 75a-
/C v ob
I hereby from under penally of perjury one of the following declarations: [ /(J
❑IM1uvc imd will mnimninuCenifiatc of Cnmcntto ml6inwm for Wn kcr's Contlxn- DRAINS-FLOOR,ROOF GOND. S'I'ORIIS 11 TYPE CONS"fRUCf1Oh
I sxtion as provided for by Section 3701 of the Lothar Code.for the perfatnwnce of the
y
work for wlikhthis pcmtit is issued. FIXTURES-PER TR AP
WI hove and will main Win Wnrkch Com,asun ob Immune,as required by Section
3IIp of the Labor Code.for performance of the work for which this permit is issued. GAS-17A.SYSI Efts-I INC.40U41.F. OCC.GROUP APN
IdWorker Can saints rutd Pnlic q
Carrier: S4G A-O surancerai'rtr Policy Nie ri Or/JUL14IY� GAS-RA.SYSTEM OVER 4(F.
CERTIFICATE OF•EvXEMPT1ON FROM WORKERS' tv 7((/QPq
COMPENSATION INSURANCE '6pp1(A1M1 GREASFIINDUSTRLWAS'1 ' NTERCEPTOR BUILDING[)]VISION PHIS
(Tait section need not becompleed ifine permit is Leone hundkd Jol n0($11 1 GRI?AS[TRAI'
or less.)
PLAN'CH17CK FEE
I cembcm,io the perfonnun,cul work fnrwhichtlik,emit istssued.Lshad SEWER-SANITA -S'IORM EA,200 FL
not employ any person in any manner,,,,as m loco c.subject m the Worker.,Cmnpen- ENERGY PER
zz ration Laws of California.Dam W'A'TER HEATH NENT/ELECT'R ^I
Q Applicant GRADING PEE
=
NO]ICI:TO APPLICANT.IL offer making this C,mbh,ac of Exemption,you should WATER SIC issli RF.ATING a l�Income object In the W.. Cotnpanvaion pmvisir of the Labor Code.you mud SOILS FEE(,/`,
forthwith comply with such provisions or this permit shall Ne deemed p revoked. WATER iRVICE r
oz CONSTRUCTION LENDING AGENCY NE RF.SIDF.NTIALPLMB SQ.FC PAID
C..) O Thereby affirm that mem is a construction lending agency for the perf'onbance of Date Re2trfi�1yy
0. 1-' the work for which this perms is issued(See.909.Co.C.)
O U Lcndcr'.Name TOTAL:
Lender's Address TOTAL:
1r^ I certify that 1 have read this application:sed state that the above i,,I union is BUILDING FEE —
(Z) cori l agree to comply with all city and county ordinances and.nate laws reining to QTY. MECHANICAL PERMIT FEF
(..) z building construction.and hereby authorize representativesofthis city locnteruNn me SF.IS M IC THE
oMve-mentinnad property fnr m"cetinn pnrpuvvs. PERMIT ISSUANCE
(We)bg.to sme,indemnify and keep hobble..,the City of Cr,mm,r,mr,, ELECTRIC FEE
Iiabilities,judgmenla costs and expenses which may in any way accrue against said City ALTER OR ADD TO AIECH.
in consequence of flat grwning of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WI'1'II ALL NON-POINT AIR HANDLING UNIT(TO[0,000 CFM)
SOURCE REGULATIONS. MECHANICAL FET?
AIR HANDLING UNIT(OVER 10.(0X)CF CONS'TRUCIION TAX
Signature ofgpplican/Carinueor Date EXHAUST HOOD(WNUC17 HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building eventual store or handle hmardoas material HEATI NG UNIT(TO I(XI,(Xx)R
ns defined by the Cuperina Municipal Code.Chapter 9.12,and the Health and Sale,,
Calc.Section 2553200? H17AI'INO UNIT(OVER 100 1 ETU) -
❑Yes �7 n
VENTILATION PANS CLE RES I Of PAID
Will me applicam or future building wcopom use e,.fp.un,or device,which Date Rocipt p
mil h o,solous air contaminates its defined by the Buy Area Air Quality Management BOILER-COMP IF OR 100.(X10 BTU)
Di,tnct❑Yei BOILER-C IP(OVER Ifp,000BTU) -
P�a
I Health
,Safest h ode Sis her,2 5 5,25533 an under Chapter b.95 nllhc Coli- AIR Cf )U IONI?R ISSUANCE DATE
lomia f1wRh k Safety Gdc,Sections 255(15.25533 and 255311 understand Thal if the N' 'RESIDENTIAL MECH. SQ.1T.
building does not currently have a tenant.Ibal it is my msponsibilily to notify the occupant
ofthc myuimntent,which must le met prior it)issuance of Ccmft of Ovet,smry,
JIi
en
Ownnbolumle gen Dto ITOTAL:
ISSUED try,
OFFICE