99100104 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 9 Cl 1 0
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. p
APPLICATION/PERMIT
PLUMBING-MECHANICAL' cnnnl 31'
BllILDI+.^.DIVISION BUILDING-PROJECT,IDENTIFICATION
SANITARY NO. APPLICATION SUBMI'CI'AL DATb
BUILDING ADDRESS:
/0 /6 UF/ LNI e)
it I
OWNpF'S NA;E: W PJr�Z l� CONTRA Ok'S NAME: LIC s: D
`L ` J ` N/C CON]ROI.b
ISI ARCHITECT/ENGINEER: LIC NO: ADDIt HSS: ❑
7-4o �lloen►te sr S G', .
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) Bj�V ELECT I B MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECPRIGPERMIT- EEL
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing - JOB DESCRIPTION
Zzz with Section 7000)of Division 3 of the Business and Professions Code,and my licenses RESIDENTIAL'
won PERMIT ISSUANCE
F+,� fullfnveanrldfir t. SZ v ❑SFDWL ❑KITCHEN REMODEL
�U Licen Lic.# gppLIANCEs-RESIDENTIAL []ADDITION - ❑I'LIIMBING SUMER
Fz{xl Date Contractor
'/td❑ El MULTI-UNIT ❑STRUCTURAL
on y ` ARCHITECT'S DECLAR 1 PANELS
MODIFICATION
zOmz, ]understand my plans shall he usul us puMle records -
Oz- _ UP TO 200 AMPS - ❑INTERIOR El CHIMNEY REPAIR
W Liwnsed Professional 201-1000AMPS ,F,Frr IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I"AMPS ATH REMODEUREPAIR ❑DEMOI.I'fION
C I hereby afrnn that 1 am exempt foam the Gmnacmrs License Law for the
t4��y O L U following reason.(Section 7031.5,Business and Pmfessians Code:Any city or countySIGNS ELGC'IRICAL :1OTHER
I++3O vFJ which requires a permit to construct.chat,improve,demolish,or repair any swemre
2�wyd'
¢ prior to its issuance,also requires the applicant for such permit file a signed statement SPECIAL CIRCUIT/MISC. -
p+'g that he is licensed pursuant to the provisions of the Contmcters License Lha,(Chapter 9
W 00 (commencing with Section 7000)of Division 3ofthe Business and Professions Code)., TEMP.METER Olt POLE INS'f. COMMERCIAL;I
t1 L ea than he is exempt tbamGom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
WmN Seddon 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of
POWER DtiVICES ❑TENANT ❑FOODSERVICE
not more than five hundred dolly,($5011). I OVEMENT
FO01,as owner of the property,or my employers with wages as their sole compensation, SWIMMING POOL ELECT RIC
[�-++. a 11 dr the work,and the structure is not intended or offered for sole(SwJ044,Business
S4 m and Professions Code:The Cmduminr's License law does not apply to as.,act of OUTLETS-SWITCHES-FIXTURES
SS property who builds or jammers paincoq and who does such work himself or through
his own employees,provided that such improvements are not intended or offeed for NEW RESIDENTIAL ELECfR SQ FT.
IF sale.If.however the building of improvement is sold within one year of completion,the
- - .FT.FLOOR AREA $ISQ.FT.
rowner-builder will have the burden of proving that he did not build or improve for pm-
p acofsvla.)
I,as owner of the properly,am exclusively scrunching with licensed contractors In TOTAL:
construct tiro project(Sea 7044.Business and Professions Cri The Contractors Li-
cense[,use
i-mel.use does not apply to an owner of property who builds or improves thereon,andQTY. PLUMBINGPERMIT FEE
whocontracts
contracts for such projects with o contractors)licensed pursuant to the Contractors 1-
License law. PERMIF ISSUANCE
I am exempt under Sea .B&P C for this reason
Owner Dam ALTER-DRAIN&VENT-WATER(EA) -VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE '^^
I beach,affirm under petmlty of perjury one of the following declamation year 60
E] DRAINS vnd wlllmelnlninaCertirwhenfCtmsom to self-Insnrefor Wnrker9 Coepwr DRAINS-FLOOR,ROOF,AREA,CONI. STORIES TYPE CONSTRUCTION
action,as provided for by Section 3700 mf the Labor Code,for the per rearmacc of the
work for which this pored,is issued. FIXTURES-PER TRAP /�
[_]
I have and will maintain Worker's Compensation insurance,as required by Section /V
37M of the Labor Code,for the Carlos ounce of the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are: - /�.� ��
Carries Policy No.: GAS-GA.SYSTEM OVER 4(EA) K
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRGASFIINDUSTRL WASTE INT '
ERCEPTOR .#
(This section need not be,completed iflle permit is femme hundreddollae($10() _ :<a iF NUII•pINQ DIVISION I'EBS
of less.) CREASE TRAP PLANCI IECK FEE
I certllythat in the perfmmanceofihework for which,his permit is issued.],hall SEWER-SANITARY-STORM EA.200 Up.
not employ anycrsgn jt any manoer,rlo�o�iW"ubjew m the Workers'Cooper-
so.
[:NERGV FEE
Z
smion Laws ;OdF"'119fe•ulI ZO 1� WATER HEATER W/VENT/F.LECTR
Q ApplicantGRADING FEE
y NOTICE T AP LCA IL cru tanking this Calibrate of Exemption,you should WAFER SVSTEMITREATING
(~ hecnme subjectta the Worker's Compensation prwisiovisions of the Lulmr Code,you must 9011.5 FEE
forthwith comply with.such provisions or this permit shall ler deemed revoked. WM ER SERV ICH vv.
PAID i I--..- I .. '•-._.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT.
#7 ,`L, { Dut2 F'RdcdiI
I hereby amrm theubemiesued Seddon lending agency for the performance of - /�i t ,/._�-
��
(he work for which this penNtis issued(Seo.3097.Cis.C) �
{L Lender's Name 11'G IAI
U Lenders Address TOTAL, '-
�•n a . .. .: BIIILDI G FF:E �+ 2 1
[s I ramify that 1 I J this ppl'coeon vnd stria than the � f h mvuoa ,n
i..i y Goren,l agree to comply with 11 city and county o empire,a d state laws nolinin,to QTY - MECHANICAL PERMIT `' FEE' !
U Z building construction,std hereby mal rim represe naives of the city m enter upon the n" SEISN,IGFEE
�--i above-mentionul property for Inspection purprso. -
(We)agree m save,indemnity and keep hafmleds the City ofCall,.-against PERMIT ISSUANCE LLEQfRIQ1 CL—
linhilities,judgments,costs and expenses which may many way accrue against said City ALTER OR ADD TO MECH. PLUMBING PEE
in
consequence of the grinning of this permit.
APPLICAN UNDERSTANDS NO WILL COMPLY WITH ALL NON-POINT AIR IIANDLINO UNIT(TO 10,000 CFM)
MECHANICAL FEE
SOURCE � I .A S
AIRHANDLING UNIT(OVER IQ000CFM) CONSTRUCTION TAX,
Sierra( c nVCrnuecto air EXHAUST HOOD(W/DUCT) HORSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuturebuildingowupamt store rrhandleh...adous material HEATING UNIT(10 Io0.000 RTU)
as darned by the Cnpenum Municipal Code,Chapter 9.12,and the Health and Safety -
Code,Sectlon 25.532(a)". HEATING UNIT(OVER 100,000 BTI)) -
❑Yes E]No VENT'ILA'TION FAN(SINGLE RESID) PAID '-
Date Receipt#
Will the applicant or room bonding occupant use equipment or devices which
ore,h.zardme,air conmminants as darned by the Bay Are.Air Quality Management BOILER-COMP(3HP OR 11111,01111 BTU)
TO L:
tisnict7 BOILER-COMP(OVER 100,00d BTU)
Dyes E:1 No
AIR CONDITIONER
` I have recd the hazardous t w,155 requirements533under Chapter 6,95 of the Call- ISSUANCE DATE
fifforebuilds He h in Safety Code;e. one,
it.,i tarry responsibility
sp 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.In
.f,h n haven effluaahicasomcirfaciinfir.notify the occupant
of th ek prior miss.unce ofv Cenitic. of c jaancy. ^�{A--�7
tq�
t,tfthe gent Date TOTAL: ISSUED BY: / �/
OFFICE