31326 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO' - BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION 'APPLICKrION/PERMrr PLUMBING-MECHANICAL;
BUILDING PROJECT IDENI'[FICA'I']ON
BUILDING ADURIESS: - - SANITARY NO. APPLICATIONSUBMITTALDAT
014kMER 00`W C?,
OWNER'S NAME: PHONE:" CONTRACTORS NAME: LIC NOi
t S NIC CONT'ROLa
N Z
777' of r20o vs a Pe/voDc�vc- s Fr ❑
�ARCHITF.CDENGINIiER: - LIC NO: ADDRESS: - - '
/ OSL 47 v
CONTACT: I �'rp PHONE: BUILDING PERMIT INFO
,1V-0-T✓, L-r�`O R LJ -978-6JO0 ❑ Consultant Fees Paid by Applicant(Initial). BLDG T PLUMB MECH
❑_ El ❑ .
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE s ,
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Woo) with S«tlon llXHq of DivisionlnOhe Rosiness nnJ Pndensinns Cole,and my licenni ie -
W PERMIT ISSUANCE-
9 1� L ease la end offices
<U~ License Class Q Lica GJYO B3 'FOWL [2 KITCHEN REMODEL
hGL Dam Co.".c a. /�- '� APPLIANCES-RESIDENTIAL ❑ADDITION O PLUMBING RE-PIPE
ARC[ifECES DECLARATION ❑MULTIUNIT ❑STRUCTURAL
'Dot PANELS
Z O m Z I understand my plans shall be coed as pohlie records MODIFICATION
p Z
40— UP TO 200 AMPS
Licensed Professional - ElINTERIOR ❑CHIMNEY REPAIR
201-1000AMPS IMP ENT.
OWNER-BUILDER DECLARATION
�_Y ' OVER 100DAMPti ATH REMODEUREPAIR:❑DEMOLITION
C Q 1 hereby affirm that 1 am exempt from the Contractors License Law for the
xd�aU following reason.(Section 7031.5.Business and Professions Cada:Any city or roomy SIGNS ELECTRICAL THER
uI'3 V,y which requires a permit to construct,alter,improve,demolish,or repair any nrucwre
FLL•Oa proeto t '.. I:orrq ' i1 app forsuch permit to fl signed SPECIAL CIRCUIT/MISC. r "
f
Zi he licensed p tt.uanthey ns of do,Counselors License la (Chapter9
0y (comm g th Section 7000)ofD am 3 of the Business and Profs ms Coi or' TEMP.METER OR POLE INST. COMMERCIAL:
d a c LL that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDI'TION ❑DEMOLITION
fi�ee,,ul�
Section 7031,5 by any applicam for a Permit subj« nVIC
tS the spPlieano a civil Penalty of POWER DEPS m []TENANT ❑FOOD SERVICE
^Z} not more than five hundred dal,u my e W I. - . OTHER EMF'\T '
�Q �Lo the work,the pestruc,onnyemglended witbwagesasalei(Sec.compemm�on. SWIMMING POOL ELECTRIC
f Cwill dothcwork,and the he Contractor',
License
offered farsale
1.an ..a,of - ❑GTHER
-
F
a 3$ and Professions Caic:The oyes thereon License taw d«s not apply m if owner of OUTLETS-SWITCHES-PI%TURIS
property who builds or improve thereon,and who does such mood himself or through �. !D
his own employees.provided that wch inapmvemmns are not intended or offered for NEW RESIDENTIAL ELECfR SQ IT
sale.If.however.the building or improvement issold within one year ofeempledon,the - SO.F] FLOOR AREA SISQ.PT.
owner-builder will have the burden of proving that he did not build or improve for put-
poseafode.). �. p 19915
1,as owner of the progeny,am exclusively enntntcung with licensed contractors tu To TA a/ -
omstmn the project(Sec.1044,Business anit I'rafesdons CoalThe Cantracm's Li-;
x law does•hm applyman owner of progeny who builds or impmres tncreon,and QTY. /� PLUMBING PERMIT FEE CIIY Ur (gUYCtAIII
who contracts for such projects with a commemgx)licensed pursuant m the Contractor's
License Law. - Sri,�Q
❑ lam exempt under Sec. ,B&PCforthisraon PERMIT IS E e
r A ;R-DRA1 NT 'ATER(EA) VALUATION
Owner •"• - I:
WORKER'S COMP17NSATION DECLARATION BA LO DR;
.DEVICE
I hereby affirm under Penalty of perjury ane of the following declinations:` SJ/
�Q l have and will maintain a Certificate orCosnenun self-mouse for Worker's Contact- 'DRAL . - ,ROFAREA,COND. STORIs TYPE CONSTRUCTION
sation,as provided for by Sectio 3100 ot'the labor Care,liar the parforniance of the �j
wmkforwhichthispermhisiaved. • FIXTURES-PE7
1 have and will maintain Worker's Compensation Insurance,as required by Section •• _ Y
9100 ofthe labor Code,for the performnx,of the work for whicM1 this permit is issued. GAS-EA.SYSTEM- N MITTS
OCC.GROUT' APN.
My Works Cmj'ensatianln V.n rand Pulicynut M1y O .. -
Catrier. rf'�'(�T-�_FUUaOe Policy No.: �`T�—/ ` GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATIEOFEXEMETION PROM WORKERS' -COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FRES
Chis motion need nut becomplmal if We pemtit is fm ane hundrcdJollars lSlWl _
nr less.l GREASE TRAP' PLANCHECK FEE
I cenify that in the parbousence ofthe work for which this permit is issued,l shall $EWER-SAN]TARY-STORM EA.200 FT.
not employ any person in any manner so as tu become subject to the Worker,'Comport- EN[RCY THE
snderAwsof Cnlifornmi Diie WATER HEiU'ER WNENT/ELECTR
Z Applicant "' - GRADINGFEE
M NOTICE TO APPLICANT,It,after making this Certificate of Exemption,you should WATER SYS'1'1?M/i'BEATING '
� ' hcmmc subject to the Workers Comµnsation pmvisiotss of the labor Cade,you must SOILS 12EE
W forthwith comply withsuch Provisions or this Permit shall be deemed revoked.
WATER SERVICE
a Q
CONS'1'RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FI'. PAID
'7 z I hereby affirm that them is a construction lending agency for the perfonnanmm' Date RecciptIt
L)� the work for wbichdo,permit is issued(See3091,Ci,C.) -
0 U Leader',Noma - "TOTAL: -
W Lender's Address s TUI'AL' - -
I cenify that I have read this application and state that the above information is BUILDING REE
-.W cored l agree to complywith all citland county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEF, _ /.
V Z bottomgcan,fraction,and beer,such ire representatives M this city to enterulxmdm SHISM IC FEE
above-marooned prtperty far inspection purposes. , . PERMIT ISSUANCE -
(We)agree to save.indemnify and keep harmless the City of Capsular,against ELECTRIC FLIT
Iiebilitics,judgments.ntnsmnd expenses which may in any way accomit,amt cid City ALTER OR ADD TO MSCI I. else]
in consequence of fl a gmnting.f this permit PLUMBING FEE
UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLINGUNIT(TO 10,10W CFM) MECHANICAL FEE
SOURCE,REGULATIONS,
AIR I IANDLING UNIT(OVER IB,M)t CFM) CONS'I'RUCHONTAX e
Signature of ApplicanVContractm Date EXHAUST HOLD GVMUCR HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havarlues tamarind IIEA'I'ING UNIT(TO II1f1,OW BTU)
os defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety,
Cede,Section 25532(x)? HEATING UNIT(OVER 100.0100 BTU)
[:1 Yr, El No - PAID
VENTILATION PAN(SINGLE RESID) Data RecciptN
WE the applicant or future building occupant use equipment or devices which
t hmmdoos air contaminants as defined by the Huy Area Air Quality Manugemeal BOILER-COMP(3HP OR 100.00 BTU)
•Disvict? TOTAL: c
El Yes []No BOILER-Comas(OVER I(10.IXA1 BT'U) ae_
I have read the hazardous materials maniminents under Chapter 6.95 ofthe Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505.25533 and 25534.I undemmnd that it the NEW RES IDE.NU IAL MITCH. SQ,IT.
building d«s which
ustn¢net prortit isua res ponsibiliDcam offythe«cupatn ( (/
of the uquimmems which nun he met prior to issuance oft Cenificae of Occupy«y.• ` •
Owner or antiterrorist agent Date TOTAL: ISSUED /)
OFFICE