99110121 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL E M
.. -BUILDING DIVISION APPIACATION/PERNIIT PLUMBING-MECHANICAL
BUILDING PROJECT IDEN'TIFICAT'ION
BUILDING ADDRESS: �j SANITARY N2 APPLICATION SUBMUpTTTAL DATE
�..L7 _ '( ? —(
OWNER'S NAME PHONE. CONTRACTOR, NAME: LIC NO:
oz,
IQ N/C CONTROLN
HCHITECIENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE 6UILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECIH
1:1STI+ ❑ JV
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby afErm that 1 am licensed ander provisions of chapter q Eman+eneing JOB DESCRIPTION
WOO with Section]aMpnl Divisier 3 afore nosiness and PrefessionsCMe.andery licenuis 1 RESIDENTIAL:
X00 \ PERMITFSSUANCE
sc W F in full f�rcel force and k'{(e �I a I t ❑SFDWL ❑KITCHEN REMODEL
4,ZU I,icensc ).iota 9MC.0% APPLIANCES-RESIDEN [A]. []ADDITION [I PLUMBING RE-PIPIT
y6u1 Oute Cnmmcmr,
'=)� , ARCHITI;CI'S DECLARATION PANELS ❑MULTI-UYII' ❑STRUCTURAL
Z O to Z I understand my plans shall be used as public records MODIFICATION
O Z.ND UP 10200 AMPS ❑INTERIOR El CHIMNEY REPAIR
FCL; Licensed Professional 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
�yqJ OWNER-BUILDER DECLARATIONOVERIfXX1AMY5 BATH REM sf/REPAIR ❑DEiMOUTION
G OOC I hereby affirm that 1 am eac;opl frn;n the Cnntmaar's Liecree Law for the OTHER r_�L{�G�
k a c. following reason.(Section 9031.5,Burmor and Promotions Code:Any city unmtY SIGNS BLECfRICAL
lar' IL y which requires a permit to consWeh alter,improve,demolish or repair any structure y
0 prior to its issuance,also requires the applicant for such pent itto file a signed statement SPECIAL CIRCUIT/MISC. —1 A GYD.D Je.rD ,
En, that he is licensed pars....tome proviomm.nhe Contmcmr's license Law(Chapter 9
cia=<n
(commencing with Section➢)0p)of Division 3ofthe Business and Professions Cale)is, TEMP.METER OR POLE INSTOMPA
a a p Mthat he is exempt therefrom and the basis for the alleged exemption.Any violation of - 0 NEW BLDG/ADDITION [IDEMOLITION
ul I vi Section"1031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES 0TENANT [D FOOD SERVICE
nal mere the live h:mdsed dollars 05500.
IMPROVEMI?N'I'
d Wiko the Work,
pmpeny.remyen+nloyas witfferedirale(See 04cl.Bsiness SWIMMING POOLELI!CTRIC
p=.O will do the work,anJthe structure is not intended ornRercdlitr sale(SecAUYi.Business ❑OTHER
m
ty and Professions Code:The Contractor's License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
6 3 pmpeny who builds ar improves thereon,and who does such tints ded or or ehm.gh
his own employers.the
provided the,such mens is monks am not intended or offered for NEW RESIDENTIAL ELECfR 'Q
sale.If,hanvever,the building or improvement is sold within one ycarof completion,the SQ.FT.FLOOR AREA SISQ.FT.
huild.r will have[lie burden ofproving that he did not build or improve for mu-
,,,,a
u-
P,,u -tic it sale.)
0 1,as owner of the property,an exclusively contracting with licensed contractors n+ TOTAL:
on.muct the pn.jca(Se,.7(d34,Business and Professions CMe:)The Com....in s Li-
censelawdoesno.apply to an owner of pmpeny who builds or improves thcmm.and QTY. PLUMBING PF,RA71T FEE
who contracts for such prejec¢with a eommctor(.$)licensed pursuant o the Contractor's
License Law. PERMIT ISSUANCE
I am exempt under Sec. ,B&P C for is meson
ALTER-DRAIN&VENT'-WKI ER BEA) VALUATION
Owner D;.c
WORKER'S COMPHNSAI'ION DECLARATION BACK FLOW PROTECT DEVICE
1 hereby affirm under penally of perjury one of the following declarations:
,] I have and will maintain a Certificate of Consent to self-mme for Worker's Compete. If DRAINS-FLOOR.RODRAR+ .GOND. STORIES TYPE CONSTRUCTION
when.as provided for by Section 3]0)of.he Ldw,Cods,for the performance of the ,
qwork for which this Permit is issued FIXTURES-PCR TRAP
9 1 have and will maintain Worker's Compensation Insurance,as required by Section
91X)ofthc lal.m Code,for the perianince urthe work for which this p�i:Cial, OAS-EA.SYSTEM-I NC.JOUI'LETS OCC.GROUP �b APN
MyWlJ�X Cdonryry.Rkon lnnuruna carrier and Policy nundue,i •:
Cameiyai l�kZ'1!\C Policy Nn.:k0�T GAS-EA.SYSTEM-OVERO(BA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR I
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not If completed ifthe Permit is forone hundred dollars(SIM) GREASETRAP
,it less.) PLANCHCCK PER
I ccnilythat In thepMoneence ofthe work for which thiapermiI is issued,l shall SEWHR-SANITARY-S,,RM EA.2W L-C
an,employ any pct. ,in any manner se,ri n,bacume subject n+dm Workers'Cnn:pan ENERGY FEE
Q ,Z sa.ian laws of Caliloraia.Data WAIER HEATER WNENTNLECI'R GRADING FEF.
Z 0 Applicant
= NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should WATER SYSTEM/TREATING
h > became subject h)the Worker's Compensation provisions of the{alror Code,you mus. SOILS FEE
Wforthwith comply with such provisions or this Permit shall he deemed revoked. WATER SERVICE
Q
a' CONS"fRI1C'TION LI?NDINO AGENCY NEW RESIDENTIAL PLMN. SQ.FT, PAID
+7 z Dom Reccipta
VO II whiff this panel i isuamsestctiunlcnding agency forthe peHurmm�ce of
F' the work Ira which this Permit is issue)(Sm.3099.Cie.CJ r'
D. Iandcr's Name I /n1 pi�`l�''�=a'+
Landers Address TOTAL. 0 DING FE5 u hI
I certify that I have mad this application and some that the above information is I U�
correct.1 agree.+comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FE
U z huilding construction,and hereby untlmrim representatives oflhis city mentor upon the 1 F E
abov-nm +edpro,saty lin inspection pumase PERMIT ISSUANCE
e (We)agree to save.indemnify and keep formless the City of Ca,omo against 0m, F 2L
Iiabilities.judgmenta,costs and expenses which may in anyway accrue against said City ALTER OR ADD'TO SUCH.
in conmquamm of the granting suffix permit PLUMBING FEC
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) Y.
MECHANICAL FEE
S(U E REGULATIONS
s�r� CsO AIR HANDLING UNIT(OVER Io,IX)O CFM) CONSTRUCTION TAX
1]TL.) \7
Signature of Appbcam/Commcmr Dim1?%HAUNT FLOOD(W/DUCT) HOUSING MITIGAI ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building accepted store or handle harztdnu.s material HEATING UNIT(TO 100,000 BTU)
m deRoed by the C.pcnino Municipal Calc,Chapmr 9.12,and the heal@ unJ Sofmy
CMe,Smion 25532(a)T HEATING UNIT(OVER 101,0110 PTU)
❑Yes ( VENTILATION FAN(SINGLE RESID) PAID
Dam Receiptp
00 W'11rd the air co oat tar fomrc haidefined by the Be,use ea Air o or devices Moch
emend
mit hvmNuux air cantaminnna as Jef neJ by the BArea Air Queliry Mumgnnnn BOILER-COMP(3HP OR I00,00 BTU) rN )AI
Dwtrct? 11011.17R-COMP(OVER 100,000 BTU)
0 Yes
AIR CONDITIONER
1 have¢:ul.he havaNamz materiae mu requirecnunder Chapter 695 of the Cali- ISSUANCE DATE
fomia Health&Safey CMe.Sections 25505,25533 and 25514.1 understand the,.if the NEW RESIDENTIAL MECIL SQ.Ff. /1
1m gJasnetcnrrentlyhnveamount.Ihulitismymsimnsihilitynrnotifythcacvpunl
m
+' requlret 'itswhich lnnw bumet Pdnrtn ew.na uI.Ccrtili ,,,mfO"o, n •
Owner or alnh+�d%���Y "s_�Am"'- TOTAL: ISSUED BY:
OFFICE