31123 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 31123_
�1I q1 L n�
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
,0 76P
s _
OWNER'S P ONE: CONT CI'( ApME: LI NO:
- r s � J 11 / N/C CONTROL 0
•ARCH( /ENGINEER: IC NO: ADDRESS: b J ❑
CONTACT: PHONE: BUILDING PERMIT INFO
Q~e ❑ Consultant Fuca Paid b Applicant Initial
s Y PP (Initial) BLDG ELECT PLUMB MECH
0 ❑ ❑ ❑ ❑
LICENSED CONTRACTOR' ]#IELARAI(ON QTY ELECTRIC PERMIT FEE
1 herehy alDnn mat I am licensed under provision,of Chalser 9(mmmcreing LOB DESCRIPTION
QggZO with Section 7000)of Divisimm 3ofthe Business and Prnfecans Gale,and my license is RESIDENTIAL:
F n full immoral effect. PERMHISSUANCC
�UU License Class Lic.M ❑SFDWL ❑KI HENRF.MODEL
Hzw Date Comeaanr APPLIANCES-RESIDENTIAL ❑ADDITION MBING RE-PIPE
p,pm ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O y Z I understand my plans shall be used as public records MODIFICATION
OZ�O UPT03M AMPS ❑INTERIOR ❑CHIMNEY REPAIR
g"R Licensed Professional - 201-100BAMPS IMPROVEMENT
a a� OWNER-BUILDER m Ce Conte ON OVER IOW AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
1 hereby.(Seta that I tan exempt from the Canvases Code:License Law for the
5nd' a U following mason.(Section 7031.5.Bu slows and improve.
de io demolish,
avAny city m county ❑OTHER
fy 3 F SIGNS IiLIiCfRICAI.
=O which rets issu n Permit re construct,ellen improve,demolish,Orearepair any smcwrc
m
but
he
issuance,also requires the applicant for such Counamtinniileusignedmuterrem SPECIAL CIRCUE17MISC.
Q� Item he is licensed pnnuemrolhe provisions of the Cnnwemrs license U. Chamer9
C (r'nmmencing with 9eclinn]IN)IB mfDivision3m[the Businaa one Professions Cnde)nr TEM('.ME,117R Olt MILE INST, COMMERCIAL,
t1 y o C that he is exempt Ihemban and the basis for the alleged exemption.Any vinlrtwn of El NEW BLDG/ADDITION ❑DEMOLITION
kXl Y• Section 70315 by any applicant fora Tremor subjects the applicant to u civil penalty of POWER DEVICES
�Zynot morethan live hundred dollars(SSM). El TENANT ❑FOOD SERVICE
0131,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
d. will do the work,and the structure is not intended or offered for sale(Sec.96/4,Business ❑OTHER
Land Professions CAR The Contractors License Low does not apply ns an owner of OUTLET - WITCHES-FIXTURES
-. property who Wild,or improves thms m.And who does such work himself or through
his own employees,provided that such improvements art not intended or offered for NEW REVaNTIAL ELECTR SQ FT.
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $ISQ.FT.
owner builder will have the burden of proving that he did not build or improve for put- 5 r
prseofsele.). ,
L,m owner of The property,am exclusively contracting with licensed comments to TOTAL:
onswct the project(Sec.9614,Business and Profesions Code:)The Conwaors Li--
mice Law does not apply to an owner of proItsmy who builds or improves thereon,and QTY. M GP: IT FEE MAR 21 RECn
who contracts for such po jecrs with a comamods)licensed pursuant the Contractors
License Law. PLRMIT ISSUA I:
1 ant escort under Sec. N&P C for his reason Lit
ALTER-TRAIN&VENT 'WATER(EA) . IV
Owner Done a V 1 VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of Perjury one of the following declarations:
❑ I have and will maintain aCenifcate of Consenuo self-iumre file Worker's Compen- DRAINS-FLUOR.ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
nation,as provided for by Section 3000 of the Labor Cars.for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation huumnce,as required by Section
W odds,LrWr Code,for the perfoanunce the workfor whichmhispertnitism.ml, GAS-EA.SYSTEM- INC.4 OUTLETS OCC.GROUP APN
My Work .o pen and Polis,
Cartier: olicy No.. GAS-G.SYSTEM-OVER 4(EA)
CERTIFICATE B M ION FROM OR f:RS'
CO ENSATION INSURANCE GREASUINDUSTRLWASTE INTERCEPTOR BUILDING DIVISION FEES
CILis.senion need not be completed iftbe permit is for tme hundreddollats($100) li
or less,) GREASETRAP PLANCHECK FEE s
Loy any Person
int he Performance the as to
which this permit isissued,Ishall SEWER-SANITARY-STORM FA.200 FT.
not employ troy person In any manner so es n he<ama�thjoc Wnrke 'Compen- ENERGY FEE
lotion Luw Iif u
y� O Applicant` e 1. WATER IICATER W/VENT/ELF,CTR
G ti NOTICE' AI'I .C T.Iltlafter m�ktn this Ceniriewc of linea tion,you s null GRADINGFEE
WATFiR SYSTEM/fREATING
a Income subject y the Worker's Compensation provisions of the created
Cole,you must SOILS FEE
� forthwith comply with such provisions of permit MJcemal invoked. WATER SERVICE
�z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ PAID
L)Q (hereby affirm that thea is a construction lending agency for performance of Date Receipt
l-' the work for which this permit is issued(Sm.3099.Civ,C.)
0Under's Name TOTAL:
W Lebteri Address TOTAL:
y 1 certify that 1 have read this application and stale that the above information is BUILDING FEE
h correct.l agree to comply with all city and county ordinances and slate laws mlating to QTY MECHANICAL PERMIT FEE
L) Z Wildingcunsiucrion,and hereby authorize reptesentativesofthis city to anmrupon the SEISMIC FEE
issues,mentioned progeny for inspection puEwses. PERMIT ISSUANCE
(We)agree m save,indemes
nify and keep harmless the City of Cupertino egaial ELECTRIC FEE
Iiahilities,judgmenn.coats and expenses which may in Any wary accrue against said City ALTER OR AIDTO MECH.
raegoence mit
of the grunting ofLis per . PLUMBING FEE
APPLICANTIJND13RS LANDS AND WILL COMPLY WITH ALL ON-POINT AIR HANDLING IINITGO II,IJMCFM)
R•T,J1UI,pTy)NS. ) MECHANICAL FEE
ALL////y�/ Q�f+ c � Cy�� AIR HANDLING 11MT(OVER IO.OW CFM) CONSTRUCTION TAX
Signa Appl comt/Comacnr a s7 Dame EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
Willthe Applicata or tenure building oecupant former handle hazanations..mhal GRATING UNIT(TO IM."BTU)
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532001 HEATING UNIT(OVER 1011100 BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building oacupem use equipmeta or devices which Date Receipt a
emm
ia hallous air comaminants a defined by the Bay Arca Air Quality Management BOILER-COMP DHP OR 100.000 BTU)
Diann? TOTAL: air
-1 Yes CO]No BOILER-COMP(OVER I00,0011 BTU)
1 have inad the hazudous materialsAIR CONDITIONER
requiremmns anter Chopmr fi95 of the C li- ISSUANCE.DATE
front Henhh&Safely Code,Sections 255115,25533 and 25534,1 undo land that i he NEW RESIDENTIAL MECH. SQ.FT.
buil ' rmadyhaveun Lth�t it is my rcspnnsibilil Ion fy theme pant
ct Eriawksuanccoface; c ff0 u
Osraror Ihar em ue TOTAL: ISSUED BY:
OFFICE