S 0300 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY ^K
CITY OF CUPERTINO BUILDING-ELECTRICAL. FCJM1IT NO OJOO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING,-MECHANICAL J
BUILDING PROJECT IIIEN'1'IFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITIAh DATI
//8/ VL"LvR95#1A E C7--
OWNERS NAME: /• 171,11?: CONTRACTOR'S NAME: LIC NO',
0g6
,fifirp /ENGINEER: LIC N(J: DD "S: I--]
CONTACT: PHONE: NUILDING PERMIT INFO
w+1V F" PX-- 3-719- 6.2 a 0 ❑ Consultant Fees Paid by Applicant(Initial) BLDG HLECT PLU MECH
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT PEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOR DESCRIPTION
"Z with Section]0Bo)of Division 3oflhc Business and Professions Code.and my license is RESIDENTIAL
�I— in full force and afeer. PERMIT ISSUANCIi
U 11--.. License Cl ass Lia# �7 vo B3 ❑SPDWL [I KITCHEN RI3MODIH.
< U APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGR ,1'IPE
FZj Date TSD
V1G ANC411TF.CT'S DECLARATIONCan 4 ❑MULTI-UNIT ❑ST'RUCfURAI.
F D y
ZOZ IundenwnJ my plans shall he used as public recordsPANELSMODIFICATION
OZ O up TO 200 AMPS ❑ CRIOR ❑CHIMNEY REPAIR
Ueensed Prafessianal 201.10,10AMPS PROVEMENT ❑SWIMMING POOLS
OWNER-BUILDER DECLARATION Contractor's
OVER IgMAMPS IODH •PAIR ❑DEMOLITION
I hereby LS,xt that I nm exempt from the CSSI.A, oat License Law for fuc
O U which log reason.(Section]onsan Badness trod improve,
de to demolish.
Cale:Any city nr county SIGNS IihP.CTRICAI.
a W which require n permit reconstruct.alma impmva demolish,rn repair any srmmum
0 thatheor to slicesed.ts smance,alsote to daccurviues the icantfor such permr',Limt to File n La.(ed Cammem SPECIAL.CIRCUIT/MISC.
y (commencing with
pSectio7 the provisiomof Ne Cnnuacmrz License LawsCode) >
W�A O (cat he is xempt therefrom
and of basis for afthe ageBusiness xempt Professionslation or TEMP.METER Olt POLE INST.
Sec io is exempt Therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION El DEMOLITION
^4N' Secrian]B3L5 by any aPPllcum for apennh subjects the apPlicununacivil penalty til POWER DEVICES ❑TENANT FOOD SERVICE
F+y k•
Out more than five hundraddollurs($500f IMPROVEMENT
fZIn1,Astiwnet of the proptny.or my employees with wages AS heir sure compensation, SWIMMING POOL ELECTRIC
will do the work,and thestructure is not intended or olTered fsrsalt(See 70414,Business a ❑OTHER
at and Professions Code:The Contractors License Law does not apply to an owner Of J OUTLia'S-SWITCI IHS-FIXTUR
�'3.. propery who builds or improvesthereon,and who does such work himself or through
his own cnSPluyce5,poi That Such in funveomnte are oat intended or offered tin NEW RESIDENTIAL HI.IiCTR
Sale.If,however.the building or improvement is stilt]within one yearal"copletioq the SQ FL..FLOOR AREA $/SQ.FT.
er-huilder will have The burden of proving that he did not build or improve for ated.
C] C! 6 put-
pace of sg /I�
1,as owner of Ne property,am exclusively contracting oes cting with licensed ImmartIt (YT {/
constma the project(Sec.]M4,Business and Professions Code) n
The Conrmors Li- CRY
cense Lawdoes nm Apply Toun owner ofprops0y who builds or improves Ia at,unJ QTY., PLUMBING PERMIT 9 FE UF �UPEHTIN
who connects for such projects with a conlmcoons)licensed pursuant the Contractors U
License Law, PERMIT ISSUANCE
❑I ran exempt under Sec. ,B&P C Dim This mueam
ALTER-DRAIN&VENT-WATER(I?A7 VALUATION
Owner Dale
I? Wm K HEunder SCOMPELearn,mi DE Ce RNTIONfollmsing BACK PLOW PROTECT.DEVICE
a v andei w of maintain
a penally Of e of
ent of the fnsumfor do analives ns,
have and will for bySetion 37W of the Labor
Code,for the
Workers Comp the DItA1N5-FLOOR.ROOT",AREA,COND, STORIES 9'YPE CONSTRUCTION
..,k f r provided for mi Ss issued.
3TW of The LnWr Code,for the performance of the
work forwhich this maintain Worker's
issued. FIXT'URF_S-PER TRAP
❑ 1 have And will maintain Wofkerx CaACC of flirt Insurance,as required by Section
3]tNl of the Lobar Code,fnnhe performance of the work for which this permit is issnnl, GAS-EA.SYSTEM-I INC.4OUTLETS OCC.GN(IIJP APN
My Workc's Co Iron Inatmnce trod Polley nL nh•r orf G
I F �A/ l "At icy No,:!T� — `a GAS-BA SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF.ASFIINDUSTRI,WASTE INTERCI:PTOR
BUILDING DIVISION PEF_S
Otis cationneed or be completed dire Permit is home hundred dollars(SIM) GRIIASHTRAP
or less.) 1'LANCHECK Il'eE
I cenily that in the perfnrnanccofma work Ar whidi his pennit is issued, SEWER-SANITARY-STORM EA.Nat FT.
oat employ any person in any manner so as to bmame nuhjecl to the Workers'Coral oto- ENERGY FEE
z sarion Laws of California.Date WA'I'HE HEATER WNENT/ELECTR
z O Applicant GRADING FTiE
wNa NOTICE TO APPLICANT.If,After making this Cerrificare of Hitentrown.you should WATER SYSTEAI/1'R13ATING
become subject m the Werke,Compensation roo,kinns of The Labor Cale,you most SOILS FEE
Wtr forthwith cmnply with such provisions or this Pronit shall be detained revoked. WATER SERVICE
LL Ca
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM& SQ.FT PAID
41)0 l hereby anion that is a concoction lending agency for the Performance of Date Receipt#
rhe work far which this pemnir is Issued(Sea.301 Civ.C.)
Lender's Mom TO r'.
U Lender's Address ']OTAL:
I teddy that 1 have read this applicmion and xlate that the above information is BUILDING FEE
aFs0 correct.I agree to comply with all city and county Ordinances and state laws reining to QTY. MECHANICAL PERMIT FEE
C.) z building concoction,and hereby anhoria,mpmscntatives Ofthis city income upon the SEISMIC FEE
" above-metnioned proptny,for inspection purposes. PERMIT ISSUANCE
(We)npree re sms N
me.indemnify and keep himerese City of Cors inn against f:l.pCrRIC FEE
Iiabilities,judgmems.c.osand expenses whicbnmy in any wmymente Astin"said City At,]17R OR ADD TO MECIi.
in consequence of the gaming At this permit. PhIJMBING Plili
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CPM)
SOURCE REGULATIONS. MECHANICAL PI:.
NJ
AIR HANDLING UNIT(OVER IBM)CFM) CONSTRUCTION TAX
Signature of APplicam(Conwder Data EXHAUST HOOD(W/DIJCn HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the Applicant or future building oceepam sm.a or handle harmlouvmarerial HEATI NO UNIT(TO 100,00 BTU)
as defined by the Curer ina Municipal Code,Chapter 9.12,and the Health and Surety
Code,Section 25532(a)? HEATING UNIT(OVER 100.000 BTU)
❑Yrs ❑No VENTI LATION FAN IS I NGLE RESHA PAID
Data Receipt#
Will the applicant or hmure building by the B use equip-Add.Ar Qu or devices which BOILHR-COMP OHPOR 100.(1(1(1 BTU)
dons air coniaminams As def nwJ by the Puy Arca Air Quality Manugenmm 'I'(J'TAl:
Ois.•`•(�
Yes ❑No BOILER-COMP(OVER 100,0.11 BTU)
❑ -
I have mad the hmeNous materials equireniene,under Chapter 6.95 of the Car. AIR CONDITIONER ISSUANCE DATE
famim HeAldt&Safety Coda,Sections 255115,25533 and25534.I understand dua d the NEW RESIDENTIAL MITCH, SQ.IT.
buildingdtice men0y have a tenant,that it is my responsibility m notify thmwxv[ann
of the tryuir ¢ow hich onto be net prionO's e of n Cenific:ne of Occuryncy.
7
Owneror nmd agent me TOTAL: ISSUED BY:
OFFICE