29363 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION PP CATION/PERMIT PLUMBING-MECHANICAL n C
BUILDING PROJECT IDENTIFICATION J v
euapwc Aooness SANITARY NO, APPLICATION SUBMITTAL DATE
1 /
V�a$an rnurino C' ePno �lan Alt' o�o'� / _/`' Q�
UWNF,B',i N ME:�I�
PHO t I L CONTRACTOR'S NA�MaL''. O p'O/ N/C CONTROL p
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACTPHONE:
- BUILDING PERMIT INFO
et,C�O ❑ Consultant Fees Paid by Applicant(Initial) BLDG , ELECT PLUMB MUCH
r e 985' x,, - X �
.I. but I CONTRACTOR'S DE ers of CON QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
I hcrcby affirm that 1 em licensed under provision.of Chapter H(commencing
CZ with Section 7000)of Division 3 of the Business and Professions Crile,and my license is PERMIT ISSUANCE- RESIDENTIAL.
full force anti effect.
�U��J License Class Contractor
❑SFDWL ' ❑KITCHEPLUMBINREMODEL
Ful Date Commmar APPLIANCES-RESIDENTIAL ❑ADDITION. ❑PLUMBING RE-PIPE
[yI+?y ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O r5 Zn. I understand my plans shall be used as public recalls MODIFICATION
OZ"Q uPTo 211(IAMPS El INTERIOR E]CHIMNEY REPAIR
LVA � Licensed Pmfessi...I 201-1000AMPS IMPROVEMENT,
(Li •.1 OWNER-BUILDER DECLARATION !� n ^�
6 I hcrcby off that 1 am exempt from the Contractor's License Law or-rhe OVER 101m AMPS ❑BATH REMODEUREPAIR DEMOLTTION
ip�j5,O 6 U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECfRICAL ❑OTHER
which requires.permit ra construct,alter,improve,demolish,or repair any stmnure
pramor its issuance,also requires the npplicam farmch permit 1.fileasignedsmlamem SPECIAL CIRCUIT/MISC. • PR '
p; that he is licensed personal to the provisions ofthe Contractor's License Law(Chapter 9 s I
iQ (commencing with Section 7000)or Division 3 ofthe Business and Professions Code)or TEMP,METER OR POLE(NST. COMMERCIAL,
that he is exempt therefroand the basis for e alleged exemption.Any violation of ❑NEW BLDG/ADDITI0
m m
N _i]l)lnLITION
ro
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
not more than fivehundreit dollars(55110). IMPROVEMENT
Q 0I,as.wner.fthepropeny.in my employees with wages.,their sole compensation. SWIMMING POOL ELECTRIC
G will do thew.rk,and the structure is not imendedoroRered for sale(Seo.7044,Business ❑OTHER
3 m and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pmpeny who builds nr improves thereon,and who does Inch work himself in through
his own employees,provided that such improvements are not intended or.tTered for NEW RESIDENTIAL ELECTR SQ FT.
aide.If,however,the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA / �8/SQ.FT.
oaeof
owner-builder will have rho human of proving that he did nm build or improve for pun- IS-7�7�• A T77
psalt). 4
❑I,as owner of the property,am exclusively contracting with licensed contractors r. TOTAL:
construct the Project(Sec.701 ,Bhr,mass end Pmfavocar,Coder The Contruc res Li-
cense Law does not apply to an owner of property who builds or improve&Turner,and QTY, PLUMBING PERMIT FEE 39y 7/y/�flr
who cinmacts for#uch projects with a contortions)licensed pursuanuo the Comments 7
+ License Law. PERMIT ISSUANCE
Fl am exempt under Sec. B&P C for this reason _
Owner pate ALTER-DRAIN&VENT-WATER(EA)' ALUATION
WORKER'S COMPENSATION DECLARAnON , BACK FLOW PROTECT.DEVICE se 194 6 0 7.
I hereby affirm under penalty of perjuryone of the following declarations
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND.
satiun,as provided for by Section 3700 of the latimr Cade,for the performance of the STORIES TYPE CONSTRUCTION
work far which this pconnu ,issued. FIXTURES-PER TRAP
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Cade,for the performance of the work for which�this permit is issued. GAS-EA.SYSTEM-I INC 4 OUTLETS OCC.GROUP APN
My Worker's .mpen,li a ane mevalcy NaYCarrier:lic n�Yl /]/Q oyo� GAS-EA.SYSTEM-OVER4(EA)
CERTIF CATE OF EX. ION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need net he completed ifrhepermit is forme hundred dollars(SI)u
or less.) CREASE TRAP .�
PLANCHECK FEE
I certify that in the performance oftbe work forwhich this permit is issued,I shall SEWER SANITARY-STORM EA.2110 FT
mol employ any person in any tumor .y=s lr�caRgkyl'Q the Workel%Compen- BNERGY FEE
Z ancien Laws of Calif Date n f! 7-r17
zO Applicant ytV/ p..e WATER HEATER WNENT/ELECTR GRADING FEE
NOTICE TO NT.If,after making this Certificate of Exemption,you should WATER SYSTEMOMEATING
abecome subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
W forthwith comply with such provio.mor,his permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING
ngAGENCY
agency NEW RESIDENTIAL PEND. SQ,FT. PAID
L) Q I for by affirm which this
isisued( ec.30lendingagency for the performance of _ Date Receipt# _
w U
the work for which this permit is issued(Sec 3099,Civ.G)
Q U Lenders Name TOTAL:
Lander"Address TOTAL:
a 'I certify than 1 have reatl Nis application and state that the above information is BUILDING FEE
i.r U) comet.I agree to comply with all city and county ordinances read state laws rclaring to QTY. MECHANICAL PERMIT FEE , po
V 4 building construction,and hereby authorize representatives of this city to enter open the SEISMIC FEE 7
ahnve-mentioned property for inspection purposes.
(We).gree m save,indemnify and keep harmless the City of Corcoran againPERMIT ISSUANCE[ ELECTRIC FEE 71r,
liabilities,judgments,costs and expenses which may in any way accrueagainet said City ALTER OR ADD TO MECH. PLUMBING FEE /
I.emommo a of the granting or this permit,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLNON-POINTAIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE /7Sry
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX 66r
Signature of Applicant/Contmcmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will rhe applicant or future building rccupant store or handle hasamous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Crile.Section 25532(a)1 r I(EATING UNIT(OVER 100,000 BTU)
❑Yes . ❑No VENTILATION FAN(SINGLE RFSID) PAID ,
Dam Receipt#
Will the applicant or future building occupant use equipment or devices which- BOILER-COMP(3HP OR I W,OW BTU) r
emit hazardous err contaminants as defined by the Buy Area Air Quality Management 'TOTAL: //J
Council !
E]Yen �No BOILER-COME(OVER 100,000 BTU)
,
I have mad the hastrdots materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
f.mia Health&Safety Cade,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.IT. -
buildingdces or curtently have atenanr,that it is my rospori ratify the occupant
of the re mems wh' she met prior to issuance nfa Genii tet to .
OK,or.orhorimd agent +Date 17 TOTAL: ISSUED BY:
OFFICE