31271 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF,CUPERTINO - BUILDING-ELECTRICAL PERIUNO. /� .t /�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �I•( 1 /, / 1
BUIIDINGPRO]BCT IDENTIFICATION ..LLL ..a.
BUILDING ADDRESS; - SANITARY NO APPLICATION SUBMITTAL DATE
OWN SNAME: PHONE: ON'IR CTOR'$NAME' LIC NO
t•-UC1. j '7 V �I . �a S N/C CONTROL#
ARCHITECT BNGI EER: LIC NU: ADD ESS: - ,❑ '
v s5" 24 ✓�`
CONTACT PHONE ^i BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PI PAID MECH
.. , ❑ ❑ ❑
LICENSED CONTRd under SDEConsof hap QTY ELECTRIC PERMIT FEE
I hereby affirm that I am lite B.under provisions of Chapter 9(commencing
JOB DESCRIPTION
Z with Secdon7W0)of Division3pf the Busivess auJ Profeeslons Colla,mW mylicensa le PERMIT RESIDENTIAL
F O full force and eff (0 -
TGZ `V ❑SFDWL [:j KITCHEN REMODEL
6 U� Donen. xs Lic.#
hdh� Done Commmor b APPLIANCES-RESIDENTIAL - ❑ADDITION a(- UMBMG RE-PIPE
ARCHITECT'S DECLARA ON PANELS ❑MULTI-UNIT TURAL
p,O r° I undersmnd my plans shrill be used az public records -'z 13
Oq UPM 200 AMPS MODIFICATION
C Lmensed Pmfessipnm . ❑INTERIOR: ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-1I00AMPS IMPROVEMENT
I hereby affirm that I um OVER 1000 AMPS y exempt from the Contractor's License Law far the Q BATH RHMODBVRHPAIR El DEMOLITION
following mason.( i 7031,5.B d .:' Cale A y'ty
F�OEv'1
which eq; Permit t carousel,all❑ improve,Wf demolish,I' rrep structure ni cture re SIGNS ELECTRICAL - ❑OTHER
< prion 't c al. mines thef hpermit t fleasigned.ma n
me
that he 1 .licensed a u th p ' row fth C I ULicense Law(ChapW9 SPECIAL CIRCUIT/MISC.
X11, pouninamr.,withy ti 'IOW) fD' rani fth Business adP f ions Code)Or - TEMP METER OR POLE INS r r COMM R IA
4 W m C that he is exempt therefrom and the basis En the alleged exemption.Any violation of - ❑NEW BLDG/ApDIT10N [I DEMOLITION
Section 7031.5 by any apylicaut for a permit subjects the applicant to a civil penaltyof POWER DEVICES -
y tmarc than five hundred dollars($500). ❑TENANT r ❑FOOD SERVICE
O ❑1asnwnerofahepmpeny,ormyempinyces with wages vs their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the s2cture is not intended proffered for sale(See7n4T Business El OTHER
and Pmfeasioos Cade.The Contractor's License Law does not ripply In an Owner of OUTLETS-SWITCHES-FIXTURES
u' property who builds or improves thereon,and who does such work himself or through _
his own employees,provided that such improvements Ore not intended or offered for NEW RESIDENTIAL ELECTR SQ BF -.
-
sale. r.however the building or imprevemena is sold within one year ofcomphOinm the -IQ PI'.uFLOORARHA §/$Q.fT.
-builder will have the burden of proving that he did not build or improve fprpur- i -
pose of mala).
❑ 1,vs owner of the property,am exclusively cmu acda,with Ileensul wntiveanrs m TOTAL:
construct the proJem(Sea 7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to on owuerpf pmpeny who builds or improver,thereon,and QTY. PLUMBING PERMIT FEE Y W
who concocts for such projects with a contractor(s)licensed pursuunt to the Commemr's
'Licoariv exe PERMITISSUANCE-
.. ❑ I am exempt under Sec. - '' � ,B&P C far this reason � 1�
Owner DateALTER-DRAIN B,VENT-WATER(EA) VALUATION
'•
WORKERS COM of SKI]ONdearyon DECLARATION BACK FLOW PROTECT.DEVICE 7� h Lurtfr/I/yv
I hcicby affirm under penalty of perjury one of the followingdeclarations: G
❑ Ihave and will maintain or Ceniliwte of CFnsenuosalf-immn,fnr Worker's Cnmpen- DRAINS-FLOOR,ROOF,AREA,COND. - -
soccum,as provided for by Sectio 3700 of the Lab.,Cade,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued, I FIXTURES-PER TRAP i -
El I have and willmaintain Worker's Cimps fn Insurance.as required by Section
37M of tic La(��Qp Code,for ntIh Performance fah workIO which this permit is issued: GAS-EA.SYSTEM-I INC.4 OUTLETS t
MY Wo ke 17 G came d PollY d'r') n - t OCC.GROUP APN
Cartle. Policy No.: - (� GAS EA.SYSTEM-OVER 4(EA)
CERTIPICA'IEO EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTEINTERCEPTOR
(This section need nut be cnmplwal if the permit is forpnc hundred dollam(k 100), BUILDING DIVISION FEES
or lean.) GREASE TRAP -
Icertifythatinthe performance of the work for which his 'PLANCHECK PEE
P the W.kesued,ahall - SANITARY-
not employ anypersoniaany mannersnusmbecome subjecttotheWorkers'Cpmpem SEWER- STORM EA.200 FT. - -
,`� Armon Laws of California.Date ENERGY PEE
y�y O
Applicant ' . WATER HEATER W/VENT/ELECTR
- A 11 NOTICE TO APPLICANT.If.a Her making this Coming..le of Exemption,you.whonW GRADING PEE
a ? become subject m the Worker's Compensation prow irnts of the Labor Code, WATER SYSTEMO BEATING
forthwith"imply with Inch you must SOILS FEE.
� A pywV pmviainnx.,this permit shall he deemed revokwl. WATER SERVICE •
�z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR SQ.FT, PAID "
L) O, l hereby affirm that there is a construction lending agency for the performance of Dam Receipt#
w Ne work for which this permit is issued ge.e.3097,Civ.CJ i
O Lender's Name -
'Lmder'sAddreas' - i TOTAL:
1 certify that I have rend this application and same that rico above infsrriihtion Is TOTAL; BUILDING FEE
Uh condor 1 agree er Comply hero all city and county etQtIvQ,of and roam laws relating to QTY. MECHANICAL PERMIT FEE
� huildiugcnnsaucdnn.and I.,on authorize represenmtivps of Nis city menmr upon the SEISMIC FEE
above-(We)a m property for emnify an purpose. -
(We)agmemcavaindemnify and
Q,hicp harmless me CityofCupenino ad City PERMIT ISSUANCE ELECTRIC FEE _
inconsequent of the coarsing Rhes permit. ALTER in any way accrue against said City ALTER OR ADD TO MECH.
consequence UNDErantingRSTANDS
ScolsDWIL PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) '
• -'SOURCE REGULATIONS. MECHANICAL FEE •
' AIR HANDLING UNIT(OVER I O,UW CPM)
CONSTRUCTION'fAX
Signature ofAppbceR - Data EXHAUST HOOD(W/pUCT)
HAZARDOUS
1'
HAZARDODO US MATERIALS DISCLOSURE - - HOUSING MITIGATION FEE
Will the teCupentor finure huil"Ide.Chamsm.1Or bangle Hent hazardous Safety HEATING UNIT(TO 1!10,000 BTU) _
as defined io the Cupenino Muntupal ride,Chapati 9.12,and the Hculth rind Safety
Code,Section 25532(nTI HEATING UNIT(GVHR i 00,000 BTU)
Yet,
VENTILATION FAN(SINGLE RES ED PAID
Will the pplicam.1 f lm building Occupant use equipment or devices which
Date 'Receipt#
emit laremilmn, I, xtra6n tae road by the Bay Area Air Quality Management BOILER=COME ONE OR 100,000 BT U) ,
District' TOTAL:
F7 Yet, - BOILER-COME(OVER 100,000 BTU) - -
t I have read the hazardous uwteatils matommems nader Chapter fi 95 of the Cali- AIR CONDITIONER
Terms Had, Safely Gida S ciions 25505,25533 and 25534.1 ondetsmna that if the - ISSUANCE DATE
buildht he current m amnvmtnhmit' spcaribilhy m notify the occupant NEW RESIDENTIAL MECH. SQ.FI'.
of IrunenLc'w ' theme i t a ceof.C n'
aro rmth ze ag Date TOTAL: ,
ISSUED BY:
OFFICE