S 0281 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 'BUILDING-ELECTRICAL PI7RMIT NO.
BUILDING DIVISION APPLICATIONIPF.RMIT PLUMBING-MKCIIANICAL O n O
B111.111,11 PROJECT IDR:YDFICATION G Q
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'I'S
-::?-Z Ctrl o DalesIJ0,4 �p
OWNER'S ME: PHONR: CON' ACfOR:S NAME: LIC NO'
/^ m/ /Vin /� !� O/ NIC CONfuOl.n
/Y ( /O C
ARCllll'ECf/f?NGINEF.R: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ Ih ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT- FEE
I hall nlBreathin 1 am licensed under pmvisions of Chapter 9 h,m n ame ng JOB DESCRIPTION
�Z with Section](Mp)ol'm
fDividon 3 ofthe Business unit (essions Cade,and my license is RESIDENTIAL:
yW p in I'IiRMIT ISSUANCE.
dull force unJ eRu�t ❑SI'DWL (D KITCHEN RP,MODEI.
pQ.ZU DmenseCavays— G--��—ItoIta4 mr �� APPI-IANCIS-RESIDENTIAL ❑ADDITION �PLUM6ING RE-PIPE:
.Cc, ' ARCHITECTS DECI TIO ❑MULTI-UNIT ❑STRUCTURAL.
I..,D N PANELS
Z O Vn Z I undemtand my plans shall be used m public records MODIFICATION
OZ CUPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
1=.�f{y hiwnscA Prnres.innul 201-1"AMPS IMPROVEMENT []SWIMMINGPOOLS
OWNER-BUILDER DECLARATION
OVER Im10AMPS ❑BATA REMODEIAtEPAiR ❑DEMOLITION
p 1 hereby.(diem shat 1 am exempt from the Cosions C s c:Any
Law fur ntt
x 31L FU- billowing reason(Section]OJLS.Badness and professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHF,R
which requires a permit to construct,alter,improve,demolish,or repair any structure
�� prior to its issuance,also reamers the applicant for such permit o file a signed sm@ment SPECIAL CIRCUFI'/MISC.
} that he is licensed pursuant mnhe gooeimi the Contractors License Low(Chapter 9
W^pC (commencing whb Section 701of Division J of the Business and Professions Code)or THNIP MIT ER OR POLI,I NSF. COMMERCIAL:
6 y� that he is exempt therefrom and the basis for rhe alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
i mT Section 7031.5 by any applicant for a prmitaubjects the applicant m a civil st yol POWER DEVICES ❑'TENANT ❑FOOD SERVICE
at,,marc rhmt five hundred dollars($5110).
� C ❑ c
has owner of the pmpenY•'rt my employee wish wages ns thei...Emnry:uation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do rhe wak,and the srruaune v ent intended or oRered for add(Sec.]IW,Itu.incs ❑OTHER
L m and Professions Cale:I'he Contractor's License Law does non apply to an owner of OUTLETS. -SWITCHES-F RES A
property who builds ar improves therein,and who daes.mch work himself as through
his own capitayces,provided thin such improvements arc not inderded or uttered far NEW BESIDE
N'fIAL F44 Q FT.
sale.IL however the bolding or improvemcm is sold within one yea ofcmndrase.the J SQ,FLF-OpQ AREA S/SQ.EF..
owner-builder will have the Force of proving that he did nor build or improve for put- • - 0, Y D V
pose crude.).
❑ I,as owner of the property,am exclusively contracting with licensed contractors to 4
1"
con.mrtmt rhe prnject(Sec.70,W.Rutinose and 11..tw,ons Coded The Combactor's Li-
cause law does not apply m an ownerofpropeny who builds or improves 0hemon,anA QTY. PLUMBING PERMIT
wha rrad acs for such an fens with a romracmr(s)licensed puruanno the Conwdon s
License Law. PERMIT ISSUANCE /•�f
❑ I ata exempt under Site .11&I'C for this moron
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dom
WORKERS COMPENSATION DECLARATION HACK FLOW PROTECT DEVICE
I herehy affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Gtmenno self-insure for Worker's Counter- DRAINS-FLOOR,ROOF,AREA,COED, STORIES TYPE,CONS'I'RUCI'ION
nminn,ns provided fur by Saation 3700 of the laMm Calc,far the ped pummel of the
work far which Ibis pernil is issued.. l'IX'TURES-PER TRAP
❑1 have and will maintain Workers Compensation Introduce,as required by Section
3700.1 the Labor CNe.fit,he perlorromweofrhe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUT' APN
My We err' C tPc rico .m re carrier and Policy samba �1m'
Carrier: Policy No.: A/LSL, ]CI(, 11100 (iAS-IiA.SYSTI?MAVI?R4(IiA)
CERFE, TE Ere
FROM WORKERS'
COMPENSATION INSURANCE. GREASMNDUSTRL WASTE INT ERCEPTOR
BUILDING DIVISION PL^RS
(this section need not he completed lithe permit is form"hundred Dollars is Hill) GREASE TRAP
or loss.) PLANCIIECK LEI?
I crafty thin in the perfannuncrnfthe oak for which this posit is issued.IshulI SEWER-SANITARY-STORM EA.200 FI'.
nm bout employ any person in any manner so as ecome subject In the Wada"Comper. ENERGY FEE
O ,$ air..Laws of California.Date WATER f11iAI'IiR N'/VENT/IA.EC
O Applicant 1 GRADING FEE
o-'7"i .7 NO'l ICI?TO APPLICANT.IL slier making this Cemidirme of Exemption,you should WATER SYSTIiA1/I'RIiAI'I NO SOILS FiiE
a , become.subject no the Worker's Compensation pmvisions of the labor Gude,you most
Irl forhwith comply with such provisions or this permit shall he duetted revoked, WATER SERVICE
a0
UO CONSIRUCTION LENDING AGENCY agency
NF.W RESIDENTIAL I'LM SQ,FII IND Darr AVE hereby ufGrtn pr than is a sad(See 30 lending agency Int the performance of
rhe wod,fur which This penult is issued(Sec.J(x)],Civ.CJ
lsndcrs Name OI'AI.:
O U Lenders Address 'I 'I
s� G I coolly that 1 have read this application and state that the above nomination is - BUILDING THE
fn correcr.I agree it)comply with all city and county ordinances and state laws relating to QTY. s MECHANICAL ERMIT FEE
U ,Z, M1nilding connfunction.add hereby authoriee representatives(if this city to enter rpm the SEISMIC PEI: :
al
`+ shove-mentioned property for nNatudion pro Tows' PERMIT ISSUANCE.
(We)agree it)save,indemnify and keep Lannless the City 0f Cuper inn against F,LEC'1'RIC FEE
Iiabilifies,judgments.casts and expenses which may in anyway accrue against said City ALTERORADDTOMECH.
in consequence of rhe granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL"COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 0010,80 CFM)
SOURCE REGULATIONS.
•,ar MECH ANICAL FEF.
7�a�� A I R HANDLING U Nil 111,00(0 CFM) CONSTRUCTION TAX
Si ms f4filicaducameartar Date EXHAUST 14WD DVMUC) HOUSING MITIGATION FEL
HAZARDOUS MATERIALS DISCLOSURE
Will n6enpplicam arfumre M1uiding oncupum gime,or handle Felonious material HHA'1'INC,UNIT(To 100.000 BTU)
as relined by the Caput Municipal Code.Chapter 9,12,and the Health and Safely
Code,Section 25532(s)? HHAI'ING UNIT(OVER 100,00 BTU)
❑Yrs E]No VENTILA'UON FAN(SINGLE RISID) PAID
Will then applicant or future building occupant use equipment nr devices which Date Receipt A
IIIIIINIIII Pp gn a yuiprQu BOILER-COMP f3HP OR 100,000 B'FU)
emit haatrJous air nmtamrnnmx as deOncJ by the Huy Arca Air Quality Mmn0ge0nem
I 'ITYI'AL:
Diintel? rs ❑Nn BOIL17R-COME(OVER 110,(00 BTU)
Ll YI hove mad the buzanlonx materials a under Chapter 6.95 of the Cali- AIR CONDII TONER ISSUANCE DATE
eynirc p
(omla gdoHealth ne Safely Code.Sermons 255115,3553)and 25534, understand ify the
thus if the NEW RESIDT:NTIN,MECH.
building does net currently have n mem,that o is my resof a Certificate
notify the ailment
of the rcquire0nemn which must be nKI prior rr issuance of o Ccnilicate of Occupancy.
Owner or aullofired agent Date 'roTAI.: ISSUED BY:
OFFICE