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S 2822 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL Q n O BUILDING PROJECT IDF.MPIF'ICA'PIDS N G o 22 BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE X6671 �,�� vie A.. Y- _g OWO'SNAMEC_h A'o PHONE:- �� CONTE£O NAME: % ,Sass K NIC CONTROI.iI RESS ARCHITECT/ENGINEER: LIC NO: 1A p�'� u� r� A- 'Sr 'I • E_]CONTACT: PHONE: _ll/ U L BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MECH ❑ ❑ Z�__ ❑ LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE 1 hereby emrm met 1.,It ficoned under prtwi,ima,of Chapter 9 Nommeneing JOB DESCRIPTION �AZ'Z with Smtion7g1I1)of Divlsion3oaths Bu.inr_as and Pndessinns Cade,nn mylicenw:is RESIDENTIAL: 0 0 PERMIT ISSUANCE atF in full tone and effeaA-�� a S ❑SFDWL ❑KITCHEN REMODEL F ((JJ License Clan_-/ OO a Lao.# Wti Dam Ll—y_V�—/ Convuctnr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE ARCHITECI"S DECLARATI N ❑MULTI-UNIT L1 STRUCTURAL Z8WPANELS -4 1 understand my plans shall he used a,puhh opemds MODIFICATION OZ4D¢� UP TO 2W AMPS ❑INTERIOR El CHIMNEY REPAIR Q��..1 Lleensed Profes,ional - 201-1000AMPS IMPROVEMENT (]SWIMMING POOLS �•�.•..III OWNER-BUILDER DECLARATION {i?y5� OVER 1000 AMPS ❑BATH REMODEVREPAIR El DEMOLITION ptgyy 6 1 hereby nation that 1 am exempt from the Contractors License Law for the W'3 a U f.11awing reason.(Section 7031.5,Business and professions Code: city or county SIGNS ELECTRICAL ❑OTHER A a y which tactics,a permit t.u,nstmm,most,Impmva demotion,or repair any sot A/ y tf 0y6 111.111 its iasuanee,also requires the applicant for such permit o file a signed statement SPECT AT.Cl RCUIT/M ISC. That he is licensed pursuant to the promslom of the Contractors License Law(Chapter 9, d'S (commencing with Section lOIX)of Division 3 at the Business and professions Craft)or TEMP.METER OR POLE INST. COMMERCIAL' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION a..to soction7031.5 by any applicant for a ryrmitsubject,the applicant m act,it penallyul POWER DEVICES ❑TENANT ❑FOOD SERVICE not more than five hundred dollars l$500). IMPROVEMENT it., Oad 1, .wm ner of the property,or my employees with wages as their sole copns eation, SWIMMING POOL ELECTRIC C F.O will dome work.radmestruomre is far sale(Sea 74114,Bodo,, ❑OTHP,R and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES property who milds or improves thereon,and It.does such worso imsml nr through 1XL his own employees,provided that such improvements are not lomaded or.Imrcd for NEW RESIDENTIAL ELECTS SQ Ff. side.If,however the bulldiegor imps wart is old within one year of completion ,the SQ.FT.FLOOR AREA $/SQ.FT. or-builder will haw the burden of proving that he did not huild n1 improve for par- Pu a of sale.). ❑ 1,as owner of the property,am exclusively correcting with licensed contractors to TOTAL ceramic,the project(Sec.7044,Business and Professions Cade:)The Conmac.rx Li- 71 / ecnse Law daesnot apply to anownerofpropoty who builds or improves thereof,and QTY. „PLUMBING PERMIT FEE' who contracts for such projects with v automobilist licanscd pursuant little,Connector's License Law. PERMIT ISSUANCE. ❑I am esemptunder Sea ,B&P Cfar thisrwson Owner Data ALTER-DRAIN&VENT-WATER CA) VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 1 herehy affirm under penalty ofperjary ane of the following dedamdenr El DRAINS-FLOOR.ROOF.AREA,GOND. STORIES TYPE CONSTRUCTION store,as provided for by Section 3700 of the Labor Code,for performance of me work for which This permitwissued. FIXTURES-PERTRAP by 3700 have und will maintain Wnrker6 mome offhi stock ckfar which h required l ISection / ;, 3700 of the Labor Code,for the performance of the work fur which this pGlllit is is,ucd. GAS-EA.SYSTEM-]IN�[4 UTLETOCG GROUP APN �Wor rs C�m ensmion in,umnu��rriupund conyT eJ ,(�� CAS- BA.SYSTEM-OVE a LA) ar: CERTIpICATE a EXEMPT ION FROM WORKERS' COMPENSATION INSURANCE GREASUPIDUSTRL WA.iE-MTE9 s r RAT (This,count nein not he completed If the permit is for ono hundred dollars(SEE) BUILDING DIVISION FEES or less.) GREASE TRAP ANCIIF.CK FEE I certify that in the performance ofthe work for which this permit is issued,(shall SEWER-SANITARY-S HA 203 FT. not employ any person in any manner so as a become subject m the Worker,'Comperr B TERGY PEE Z sation Laws of California.Date WATER HEATER W/VEN --- Z Applicant GRADING FEE VJ NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMR'REATING SOILS PEE {Yi become subject to the Workers Compensation provisions of the Labor Code,you must LT1 fanhwith comply with-ch provisions onhis paurna,hell he deemed revoked. WATER SERVICE a � CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PUSH. SQ.IT. PAID I hereby affirm thanan, here isootmction lending agency fonhc Performancen f Dom pt# V the work for whicM1mi,permit is issued(Sec.3097,Civ.G) I� {L F' Lender's Name t©V TOTAL Leader Address - L �� Fye I certify that l have read this application and state that the above Information is BUILDING PE comeo.lagrezmtxomply with all airy and wunq uNinvnces and,mm laws rcmtmgto QTV MECHANICAL PERMIT FE& V z building construction,and hereby authorize repoesentarves onhis city to enter upon The SEISMICFEE above-mentioned property for inspection purpoes. PERMIT ISSUANCE (We)agme m eve,Indonmtry and keep harmlesx me Clout Caperton against ELECTRIC FEE imachlex,judgmems,costs and expenses which may in any woyaccme agiami,nid City ALTER OR ADD TO MUCH, consequencein of Ire granting of this permit PLUMBING FE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINTAR HANDLING UNIT(TO 10,MOCPM) SOURCE REGULATIONS. MECHANICAL FF, AIR HANDLING UNIT(OVER I0.000 CFM) CONSTRUC'DONTA Sign era of Appleant/Contmemr Data EXHAUST HOOD(W/DUCT) HOUSING MI9'IGATION FEE HAZARDOUS MATERIALS DISC USE Wriffieappliamn ar future thaddingwcuPunl,mreo,handle mind.us material HEATING UNIT r(To 100,000 BTU) as defined by the Cupedino Municipal Code.Chapter 9.12,and the Health and Safety Cale,Seaton 25532(n)l' HEATING UNIT(OVER 100,000 BTU) ❑Yes No VENTILATION PAN(SINGLE RESID) PAID Data Receipt IT Will the air coumintanuor ebuilding occupantuseArea Air Qualitment or y ,nageas int BOILER-COMP(3HPOR IGH000131U) emit Hazardous air coneminams vs defined by the Bey Arca Air Quality Management O 4 O Dimdo7 BOILER-COMP(OVER lBOA0 BTU) El Yes No AIR CONDITIONER 1 have read theh ode,Sections material,requirements under Chapter Understand of the Cull- IS$llANCE DAT�r foods gdoes&tSafetycroc Code,Sectionst,that,25533and 25534.1 unotify thtomif the NEW RESIDENTIAL MECH, SQ.FC l/..O Y building docs not currently have u move,that ll Is my responsibility to notify dneoccupant — pancy. n th ruryircmema which mus mm Ohormissmnce Dfa CenidcmealOccupnncy. .:.� Ownr or authorized agent Late TOTAL: ISSUEDBY: �Q OFFICE