99110082 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY / ", i 1 V Q O L,
R
YOF CUPERTINO BUILDING-ELP:LTRICAL PERMITNO.
UILDING DIVISION APPLICATION/PF,RMIT PLUMBIN;-MECHNICAL
1NILUING PR(1JN:CI'II3F.NTIEICATIONDING ADOR95S. SANITARYNO. APPLICATIONSUI3MII'I'AI.DATB
6d / Vh1.Co N .6
O NER'Sp! PHOMI: C NT CfOR'S N ME: a I C NO:
1/ NIC CONTROL N
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HIT('UENGIN :R: �. LICN ADDRESS; ❑ O O
CONTACT.�fN PHO 6UILDING PERMIT INFO
6 ❑
Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLO a MO i
LICENSEDCON'I'RACfOR'S ULCLARATION l (JTY. F'hECTRIC PERMIT FEE,
1 hereby aninu mut I am licensed under provki is of Charam 9(commencing JOB DESCRIPTION
05Zm5ec,i.n]tX0),IDivisinn7ollbe Business and mPo.adons Co ,un mylicenm is RESIDENTIAL,
�+IOp x, PERMIT ISSUANCE
F W n full force and effect '�+ GAA 4,0
❑SFDWL ❑KITCHEN REMODEL
QUU LiccnxaF,i Cents pppLIANCES-RESIDENTIAL ❑ADDITION ❑PLUA1BING RE-PIPE
y Q L Date T'S DECLARATION
F.,Dm ARCHRECTS DCCLA Aconic PANELS ❑MULThUNIT ❑MODH`iSTRUCTURAL
z p w Z B unJer,wnJ my plain,hall mused.,puM1lic records MODIPICA'TION
.JZ- UP TO 200 AMPS [11 INTERIOR ❑CHIMNEY REPAIR
F-,_n!:a —
W Licensed Professional 201-1 WOAMYS IMPROVEMENT []SWIMMING POOLS
< OWNER-BUILDER DECLARATION 11)
x� -1 OVER RXOAMPS ❑BATH REMODEI/REPAIR [I DEMOLITION
Q 1 hereby affirm that 1 am esempt from the Ca berema's License Law handle
following must(Section'1031.5,Rusioas and Professions Cade:Any city lir county SIGNS ELECTRICAL (]OTHER
I+1'31�y which mcmar,a permit m Coname.liber,improve,demalixn,m repair any shaclare
oeg "introit,lxanuncc,aka rcyuims,he upplicam forxuehp I,,fila n,ignCd.dntcment SPECIAL CIRCUITIMISC. /
f y�Y that he is licensed pursuant o,the provisions of the Contractor's License Live Ulp,er
WCL 2O (commencing with Section?000)of Division 3 of me Business and Professions Codgo P. COMMERCIAL ,
ME , that he is exempt therefrom and the basis for the alleged eremptian.Any violation o ❑NEW BLDG/ADDITION ❑DEMOLITION
X^u' Section 7031,5 by any applicant for apemdt subjects the applicant toacivil penalryo
'^y t more than rive hundred dollars($5ary. .L.}MPROV ❑FOODSERVICE
HZY as OTFI17 IMPROVEMENT
< wi Los he worolthe property,or Cmployeed,n alkhedbesdei(See 70,14,BCat.,,s SW 1 'and.OELECT RIC�'='0 will Jn the w�rk.mW,hastmmurc is lint imendcd.r.I'I'Cndfnr sato(Sec.](H4,Business ❑QTIIIiR
F
tial w_ and Professions G+dc:The Cnntrunnr's License Law Jacs not apply u)an owner of OU S Zg*'
M 3 property who builds or improve,thereon.and who dues such work himself m through
his own employees,provided thatinch improvements am not intended m offered for E I
sale.If,hon'even the building.,improvement icxld within runt year.f Iamdeitn. SQ.14.FLOOR AREA $/SV.IT.
owner-bmlder will have the harden of proving that he did not build lir Improve for p
File of vale.).
Ej 1,ascot the propony,nn,exclusively contfoctin,with licensed Con tact
.nswct the projov(Sec.]000,Business and Professions Codcp)Bre Contractor's Li-
censeBawdest not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMITFEE
who contmctx for such projects with a commctor s)licensed pursuant to the Contractor's
Licence law. PERMIT ISSUANCE
tum em In under SCC. .B&P C fin,bis reason
ALTER WATER TEA) VALUATION
D er Date 7a ��8
WORKERS COMPENSATION DECLARATION BACK PLOW PROTEGE DEv
I hereby affirm under penalty of perjury one of the following declaration.
,]Ihave and will..fail.aCe"frcme of Conttnuoolf-io,ure for Worker's Co.,.- DRAINS-FLOOR,ROOF 'A,GOND. STORIES TYPE CONSTRUCTION
ration,as provided for by Section 3900 of the Labor Code,to,the pcdum,ana of the /-
wt tk for which this lemad is issued, FIXTURES-PER TRAP V
B have and will maintain Workers Comprnxallon hourunce.as required by Section
ofthe talar Cede,for the performance of the work for which this Permit is issued GAS-EA.SYS TEM-1 INC.4 OUTLET OCC.GROUP AI'N
My WorkN'��/'y&tjT er and Policy ���///
CarriccJ�.l[I I/sek/lice calif Policy No: 173164- GAS-EA.SYSTEM-OVER4 EA) � 310.� .��
CERTIFICATE OF ESEMPIION FROM WORKERS' GREASPIINDU$TRL WASTE INfBRCEPfO
COhIPENSAI'[ON INSURANCE BUILDING DIVISION FEES
fli,icxec,lonneed notbe...tnplcleddthCpannit is f..nme hundred dollars($I had GREASE I'RAI'
or less.) PLANCHIiCK BIi9
lCmify that in the perfommancembe work ba.fich this encit is i....d.l shall SEWER-SANITARY-S'BIHM EA.2100 Ff.
not mummCandlish-employ any Person in any r so as to becamsubject to the Workers'Candlish- ENERGY FEE
Z .in.Law.,of California,Date WATER HEATER WNF:NT/ELECIR
Z2 Applicant GRADING FEE:.
NOTICE IU APPLICANT:It,after narking this CenlEcam of Exemption,you.should WATER SYSTEM IREATINC,
(✓ ? become sohjtta m the Worker,Cnmpcnsmmn pnrvlxinnx of In.Labor Cn It,you must SOILS 191E
funhwith,r iply with seen provisions a,this permit shall liedeemed revoked WATER SERVICE �Y��' '
0. PAID f\
U z CONSI'RUCTION LENDING AGENCY NEW RESIDENTIAL PI-MIL SQ.FT, f/1 Usebe Racipt x
U Ol hereby affirm that there is a construction lending agency for the performance of (l tl /� IT
the work tin which this permit is issued(Sec 307,Civ.C.) 'U) �a TOTAL. I 1
O ULender',Nmne , n
Isndcr',AJdm,, IOTALMG
: /' II
"ti y I Cor iy that B have read This application and state that the above information is BUI SP
F' 0 coned.B agree to comply with all city and county ordinances and stme laws refiningto QTY, MECHANICAL PERMIT FEE II
U z building Conswction,and hereby amnion representatives ofthis City to enter upon the SEI£MIC IT'S
id mearectioned property h,r inspection puryr,xs. P[RMI'T ISSUANCE
(We,,agree tool,, and keep faultless the Cry of Cupcnino against ELECTRIC LIFE
liabilities,pd,hNnta,co,¢and es,tnx,which tray intmy way avatesgainxt mid City ALI'17R OR A OUT 0 MCC I I.
in asequence of the granting of this permit. PLUMBING hlili
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO I0.000CFM) MECHANICAL FEE _a
SOURCE It tLAT10!g.
1liWUmc f AIR HANDLING UNIT(OVF,R10.000CFMI CONSTRUCTION TAX
'i,e turenl pplicanU unne,na EXHAUST HOLD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicantlir future building occupar,stem.,handle haaandous material HEATING UNIT(10 U(Di XI BTU)
m defined by the Cupcnino Municipal Code.Chapter 9.12,and the Health and Safety
CWc lisclio.25532m)? HEATING UNIT(OVER BOB(XX)BTU)
�}LtYcs ❑.Sb PAID
/, VE [LAI FAN(SINGLE RESID) Date Receiptp
Will be app,Cm,o,flame haddhog occo can,use Cquipnical o,device,which
LE t
emit hie hairs moos air Commanmn,as dhi..ed by the Bay Arca Air Quality Management 1301LBR-COMP(3Hp OH 10U,IX1U I3TU)
TOTAId` L.
cs nNa BOILER-COMP(OVER 100.1%X1 BTU)
I have real the Infractions materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE�
Ibmio HCahh&Safety Gale,Sectio,25505.25533 and 25534.1 understand that Than NEW RPSIDEN'TIAL MECH. SQ.FT. �J
hadingdmm�ut Indy hu towel,thin it isnty rcnpomi 'llty e.....lily dtmccopam � L
In
rat ..rent n ice n, yyyne,pdm to „ounce a'0 er fear Ov,.p rcy.
ukwhelcaauthon edagent I'vl 6 Duro TOTAL: ISSUED BY:
OFFICE