S 0764 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILIIING,ELECTRICAL PERMIT NO.
BUILDING DIVISION A PPLICATIONIPERMIT 1'LUMBINGCTIDEN I inc S 0764
BUILDING PIif)J IiC'1'IIIEN'1'IFICA'f1ON
(
SANITARY NO. AI'PLICA'1'ION SUI3M1'I"IAL UA'I'li
BUILDING ADDRESS:
r ISI , Yc:sRr--T Pt;Et- �T Co NS rstiblin 74,to 2—/9 —QJ
OWNER'S NAME: PL{OSP,: CONI' A 'OR:S NAME. hIC NO:
r Cu�� NIC CON'T'ROL M
11--1—f QCT/'ElC,`I�N/EI:R: ♦ 1 LICN.0 A PR'SS i
C213 T-G ! F
CONTACT: PHONE HUILDING PERMIT INFO
^_3 8q! ❑ Consultant Fees Paid by Applican (Initial) ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION ,O QTY ELECTRIC PERMIT FEE I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
ZWz with Section TXXP of Division Soft he Bmim,,and Plodollms Cnde,andmy license is RESIDENTIAL,
I'BIi MIT ISSUANCE
WW Licenlsf Clasen effect. Lic.M ❑SFDWL ❑KiTCHCN RIiMODEI.
U z� DateCnmmmr APPLIANCES-RESIDES IAL DDITION ❑PLUMBINGRIiPIPIi
fn¢y ❑MUI.TI.UNIT OSTRUCIURAL
ARCHITECTS DECLARATION PANELS
Z852 2 1 understand my plans shall b,used as public records MODIFICATION
OZ� UPT0200AMPS [I INTERIOR C1CHIMN17Y REPAIR
Licensed Prfas,imnal 3RL1000AMPS IMPROVEMENT (]SWIMMING POOLS
C OWNER-BUILDER DECLARATION OVER TWO AMPS ❑BATH REMODELIREPAIR ❑DEMOLITION
CtC
lag I hereby AM.,that I Am exempt from the Cnrnramnr's License Low for the
L�iyS5 L U following reason.(Section 703 L5.Business All Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHEk
m'30.F which requires a permit to construct.alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant forsuch permiuo file a signedstatement SPECIAL Cl RCUIT/M ISC.
;!lad, that he is licensed pursuant a the provisionsof the Cnmracmr'e License Law(Chopmr9
I a�p0 (commencing with Section 7010)of Division 3 of the Bruneas and Profusions Code)nr TI3MP.METIeR OR POI.Ii INST'.
IL y o Y that he is exempt R¢refrom and the basis for the alleged assumption,Any violation of ANEW B�I.DGfA�D IJ�I P h[ky1IEMOLITION
6417 4q• Section 70315 by any applicant fora femur mbpauk theupplicamma civil penalty if POWER DEVICES QTFNANT L]FODD SERVICE
L.,zY mamore di Ove hundred dollars($5(g). IMPROYP.1/titi7 _ ski
C Q ❑1,asownerof the properly,or my employees with wages as their sole compensation, SWIMMING POOL ELIiC'TRIC q
Y will do the work,and the structure isnot intended!ornRered formic Sec.Iflat Business MY
❑OTHER
IWi1"� unit Professions Code:The Contractors License Law,does not apply to an owner of OUTLETS-SWITCHES-FIXTURES t N" P I"
property who builds or Improves Noun,and who does such work himself or thorough — 11101 I(*his own employees,pmvidel that such improvements are not intended m nRered fur NEW RCSIDL'NTIAL ELECI'R SQ FI'.
Asia.If,however,the building or improvement is cold within one yearofcompletion,the SQ PT.FLOOR AREA (II� SISQ.(n'.
owner-builder will have the burden of proving that he did not build or improve for pur-
,so of sale.).
E)1,as owner of the property,am exclusively contracting with licensed contractors to 1"'
cnnswct the project(Sec.704,1.Business and Professions Code:)The Contractors Li
cense Lawdnes net apply man oviarafpropeny,wbobohN.r improves thereon.unit QTY. PLUMBING PERMIT TEF, �� 2
who comeacts for such pmiee6 with eliminations)licensed pursuant u:the Contractor's
License Law, PERMIT ISSUANCE
1a exempt under Sec. .B&P C for this teams
ALTER-DRAIN ffi VP.M'-WATIiR(EA) VALUATION
Owns Date MARUILDING
S
to urd R'S COMPENSATION UEC efollo in, HACK FLOW PROTECT.DEVICE L U U
1' rat under penalty mf perjury one of the fol lowing declarations:
s nainwina Cenihcate ofConsenun mlf-inmrcfmr Workers Cmmpen- DRAINS-FLOOR,RWP,AREA.COND. TYPE CONSTRUC'T'ION
sation,as pronded for by Section 37M of Ne Lubar Code,for the Performance of the
work for vi this permit is issued. FIXTURES-PER TRAP 1 have and will maintain Workers Compensation Insurance,A,required by Sectlnn
37lpof the Lor Cala,fmrtbe perfnrmanceufthe work for which this permit is ismed. GAS-EA.SYSTEMA INC.4 OUTLETS P APNI
My Workers Compensation Insurance carder And Policy number art:Carries Policy Na: GAS-EA,SYSTEM-OVEiRY(EA)CERI'I FICATE OF EXEMPTION FROM WORKERS' GREASNLIN DUSTRI.WASTE I NTERCF,PTOR
COMPENSATION INSURANCE DIVISION FEES
(This seclemmuldnot be completed ifsbe permit is forms,hunreddollars(SIOR GREiASETRAP
I certify thatiinthe performance ofthework forwhieh thispermit is Issued,(shall SEWER-SANITARY-STORM ITh 200 FT,
not employ any Person many mannerm asmLecome subject lothe Workers,Comprn. ENERGY FEE l
Oz sadon laws of California.Dam WATER HEATER WNP ELECTR GRADING FEE
Applicant - �Q — 14
G NOTICE TO APPLICANT:If,aIle making tun Certificate of Exemption,you shmdd WAI FR SYS'I'IiMTRUATING
bccomesubjectmthe Workers Cempensidon provisions of the Label Gale,you must SOILS FEE
forthwith comply with such provisions or this permit shall be deems revoked. WATER SERVICE
CONS'TRUCION LENDING AGENCY NEW RESIDENTIAL PLmB. SQ.14. PAID IF VV
Ibarehy affirm that that linear it.canswctien lending agency for the pernmene ol. m Receiptp
F the work far which this pennit is issued(Sec.3097,Civ.C.)
O U Lcralv0s Name TO L:
} {21 Leader',Address GC
1t I ecnify that)have read thi+appliwtion and state that the above informatina is BUILDING FE/ I�
rte. N correct.(agree to comply with all city and county ordinances and slue laws retatingm QTY. MECHANICAL PERMIT FEE
L) building construction,and hereby authorize representativesof this citym entarupon the SEISMIC IT:
above-ma sinned properly for impaction pur{s'c'. PERMIT ISSUANCE
(We)agree to save,Indemnify and keep harmleas the City 01 Cupenino ugain,t ELELTRI IEE
Iiohilitiea.judgmems,c...tsand expenses whichnmy many way Selma Againstmid City ALTER OR ADD TO MITCH. PLUMBI GFEE
in consequence Of the gmnling of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO ld"CFM) MECHA CAL FEF.
SOURCE REGULATIONS.
MA (\!k AIR HANDLING UNIT(OVER 10.000 CFM) CONS'I'RUCTI TAX
'ignawre of ApPlicmat"otmmor Date EXHAUST GOOD(WNUC17 HOUSING MITIGA'I'1 FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicunt or future hudding me.pam stare.handle hsenrdou,materiel HEATING UNIT TO IIXIJXy)if IU)
as defined by the Cupcnino Municipal Code,Chapter 9.12,an she Health and Safety
Code,Section 25531OR HEATING UNIT(OVER 100.0010 BTU)
F1 Yes E:1 No VENTILATION FAN(SINGLE RESID) PAID
Date Reccipl9
dldhe applicant or future building a:cupatn use equipment or devices which ROLLERCOMP(3HPOR 100,000BTU)air cnmaminants as def A.ned by the Bay AAir Quality Managem -
ent TOTAL.:
❑Yes 0N 1101LER-COMP(OVER 100,000 BTU)
I have read the hamtdous materials requimmena ander Chapter 6.95 of the Cali- AIR CONDITIONER $SUANCP DAT
Orion Health&Safety Cnde,Seminns 25505,255]1 A.]8534.I underswn that if the NEW RESIDENTIAL MF.CH, S FT. K/
buildingdoernotm,which
a moat primnixmyrcnpomiham usnotifytheoseepamt I 7
lithe rquaamenu which mux(he mu prior m issuance of u Cenificme of Occupancy.
Ownenmumhmizcdagunt Dale TOTAL: ISSUED BY:g.R
OFFICE