S 1735 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PET NO
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. 1735
t� BUILDING PROJECT IDENTIFICATION
11LDING ADDRESS: V I AJ& - .SANITARY NO. APPLICAG NSUBMITTALDATE
W L 2 all's o . cn'4-q19
OW Ek'S NAME: PHONE: CONTRALTOR'S M CNO:
�-f NIC CONTROLp
FARC ITECf/ENGINEER: LIC NO: gDURF.SS: \ g,VV��ss! ❑
Go /2
CONq'ACT: PHONE: BUILDING PERMIT INFO
T r oYD401-- f-16-3- e El Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
C3"
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm mat 1 am I ch,cil under pmebaions of chapter 9 nor meneing JOB DESCRIPTION
1y�1y4'Z Ih Section 7000)of Division 3 oft he Basion,,and P..fosions Code.and my license is �' ��
Fop with
force and etlim. PERMIT ISSUANCE RESIDENTIAL'
a'Uin fall eC st LIeM 3�7� _ ❑SFDWL ❑KITCHEN REMODEL
N<L Dale Contractor 9 0-
ARCHITECTS
APPLIANCES-RESIDENTIAL El ADDITION C]PLUMBING RF:-PIPE
ARCHITECTS DECLARATION ❑MULTLUNIT L1 STRUCTURAL
ZOy4 lunderstund my plans shell be used ie puM1lic recordsPANELSJA MODIFICATION
OZ UP TO200 AMPSF ❑aq Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
OWNF,R-BUILDER D[CLARA"f10N 201-IIHNIAMPS IMPROVEMENT SWIMMING POOLS
I hereby affirm that 1 am exempt from the Connector's License Law for the OVER.1000AMPS ❑BATH REMODELR2EPAIR ❑DEMOLITION
Ffollowng reason(Section]11315,Business and Professions Code:Any city m county SIGNS ELECTRICAL ❑OTHER
W W y which mgmres u permit m con.slruct,alterimprove,demolish,or repair any structurepr10r 1.it,is,aanw,alwrquirds thet,dicam Fascia penniuo file,to,and„alnnent SPECIAL CIRCUIT/MISC.d� Thu'heisIndoedpursuantlntheprovinonsoftheComowasexGienstLiw(Chvpler9p0 (commencing with Section 9W0)of Division 3 ofthe Business and Profssions Cada)or TEMP.METER OR POLE INST.ti4 mNat he is exemptterefrom and the basis forthevlleged eacmplion.Any violationof :W BLDG/ADDITION ❑DEMOLITION
iC Scclion 90315 by any applicant fora permit subects he applicamm a civil Loc of POWER DEVICESW.ry TENANT ❑FOODSERVICE
�+ not more than five hundred dollars y($500)
emplIMPROVEMENT
Q ❑Lothe workfthe progeny, remyemntended wiNwagef reale( ee 7flmpensiiess SWIMMING POOL ELECTRICandwilPooh work,and Cose:e he Core a for s License Law hrod due, ,ilapply 7(H4,Business ❑OTHERand Professins Codc:The Contractors License Law does nm apply s if owner of OUTLETS- TCHES-FIXTUREProperty who builds or improves thereon,and who does sock work himself of lhnmghhi.v own employeese provided that each Imp,is sol ware not intended o ufferad for RL EGFR ownef,howevee,hevethbmenofpecten ithat be ithinon build or improvelfouthe SQ.FT.PLOOR AREA $/SQ.Ffwnetrade.erwill havethe burdenaf proving ohm he did nal huilJ nrimprove far par-pose ofsale.).❑I,as owner of the progeny,tun exclusively comment,with licensed contractors to
instruct the project(Sec.7044,Bu.vinees and Professions Code:)The Contractors Li-
,e Law does not apply to an owner of property who builds or improves thereon,and QTY Z__`pLUMNj3NQPERMIT FEE
who contracts for such pmjecu with a commemre)licensed pursuant to the Commences
License Law. ,R ANCE
1 am exempt under Sec. ,B&P C micros reason
LTER-DR VENT- (EA)
�� TIOag N VALU�ATION
( � WORKER'S COMPENSATION DECLARATION BACK FL PR .DEVICE (� U
-�yyl hereby alRrm under pcnehy of perjury one of, following dedarminn,: S .7 \�
❑ (have and will maintain aCenificam of Consent to self-insure fur W..kees Camper- DRAINS-FL OF,AREA.11c0ND.1 STORIES TYPE CONSTRUCTION
sation,vs provided for by Section 3700 of the Labor Cole,fur the performance of he
work for which this permit is issued. FIXTURES-EBR
❑ 1 have and will mainmin Worker's Compensarian Insurance,as required by Section
3]00 of Na Labor Colc, the perfmmaneeofthework hie shlchtha,scraitlsi.ssued. OAS-EA SYSTEM-I IN 4OU'1' E'1'S OCC.GROUP AEN ,
My Wr Co ran�rvrzieranly No YlYPbrNL J� GA - STEM-
MyW, + Policrand No.: 511 OVE (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' //��
COMPENSATION INSURANCE Gk' SPAN USTRL TERCEPTOR BUILDING DIV151QN FEGS _
(fhissee,ion need nothecnmpleted if Nepermit isfrronehunireddollars($10d) GREASE TRAP
or less) PLANCHECK FEE
tenuity tM1ut in lbsperformanceoftha workforwhich this permitlslssued,Ishan / J,,-
amemployanypersoninanyminnereta,It resume suhjecl to the Workers'Compen- ! SEWER SANITARY-STORM EP:21N1 FT. ENERGY FEE
0 Z sation Lows of Califomia.Dote WA'T'ER IIEATE TELE '•
0 Applicant ` ir GRADING FEE
q ti NOTICE TO APPLICANT:if,after making this Certificate of Exemption,you should WATER SYSTEMOREATI
.4t become subject to the Worker's Componsvdon previsions at the Labor Code,you must SOILS
}orthwith comply with such provisions or this permit shat l be deemed revoked W E
Q
'(�7L CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL SQ.ET. IFEE
PAID )ole Reed
U 0 1 hereby affirm thvmhe.1,a...stmclitn lending agency for the pedormance of LT. Hthe work for which this permit is issued(Sec.3097,Civ.C.)
Lender's Name TOTALU Lendee,AddressI cenifthe,1 have midthis applicaion andslate that the cMwe information is BD I G FEEy recover,I agmen romp QTY. MECHANICAL PERMIT U ,o7. ,unSETS CPEP.aMve-mention¢ mperty rinspection purpows' PERMIT ISSUANCE
(We). .,e,u indemnity and kmp hmmlesa rbc Ci,y of Cupenint against ELE RIC FEE
liabililies.jument. tele and expenses which may in anyway accrue orbital said City ALTLR OR ADD TD MECH.
in amseque tingof this permit. PLUMB GFEE
APPLICA WO- WILL COMPLY WITH ALL NON-POINT AI R HANDLING UNIT(To I QWO CPM)
SOURC EG TIONS. ^ MECHANICAL FEE
qtr. AIRHANDLING UNITCOVER 10,WCFM) CONST RUCTION TAX
G f
5ignvwmo pp vnUCommcmr Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
vpplicam at future building occupant store or handle haanksts material HEATING ON I'P(To 100.000 BTU)
a,defined by the Calabar.Municipal Code,Chapter 9,12,and the Health and Safcry
Code,Seclinn 25532(x)] HEATING UNIT(OVER I00,0N)BTU)
❑Yids [-I No PAID
VENTILATION FAN(SINGLEkP.SID) Date Receipt If
Will the applicant or future building occupant use equipment or devices which t
'mill hazvrdtus air contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(3HP OR I W,fl(10 fir
-'District? TOTAL
❑Yes ON. BOILER-COME(OVER II)EMOBTU)
I have read the hazardous materials myuimshents under Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE DATE
fomin Health&Safcry Code,Sections 25505,25533 and 25534.1 understand,het if the NEW RESIDENTIAL MECH.
building dacenot correctly have a oenent door i,Is myrespnnsi diry,,bmify themcapam
of the requirements which mus,be met prior m issuance alit Certificate of Occupancy. \w�..■��1//�')''�
Owner or moterized agent Dote TOF— TSSUED BY: -
OFFICE