31257APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECT RICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL'
BUILDING PROJECT IDENTIFICATION
PERMrr No,
31 /57
1 L V
BUILDINGADDRESS :
SANITARY NO.
APPLICAOON SUBMDTALDATE
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C(1 DRS NAME 6h Vli/NO
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RCf1ITECf/ENGINEER: LIC NO:
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CONTACT: - PHONE:
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❑ Consutlanl Fees Paid By Applicant (Initial)NO
BUILDING PERMIT INFO
ELI❑'�CT PLIIpIB MO 1
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LICteD CORACTOR'S DECLARATION
ENSS/E1NT
I I ... eby affirm Ilial L am seemed ander provhmna ar CTarmr 9 (tam.merw,.
with Section mXXBof Division lot the Bndmevsand Prnfeasioma Ctde.aodmy license is
t lull force end effect.
License Clans Lie.
[),It-(nnmmmr
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RERIDFNTIAL'
- ❑SFDWL CKfIC11IiN REAIODEI.
❑ADDITION 0111.UMRING RE. PIPIT
El MULTI UNIT CSODIFICATI.
MODIFICATION
❑INTERIOR 0CHIMNEY REPAIR
IMPROVEMENT
PERMIT ISSUANCE
APPLIANCILS-RESIDENTIAL.
ARCIID17cr$ GpcCARxnON
Inndemwid myplans Shan he used as puhlicoremds
PANELS
UPT02NTAMPS
Licensed Professional
20I-10NIAMPS
Y
C
it,:4O
OWNER BUILDER DECLARATION
I hereby saint that I am exempt from the Contractors License Law for the
following reason. (Section 7031S. Business and Profession Cale: Any city or county
which requires a proton to construct. ulcer, improve, demolish, or repair any structure
O BATH REMODEUREPAIR 0DEMOLITION
❑OTHER
OVER IIxxIAMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUIT/M ISC.
prior to its issuance, also requires the applicant for such permit to file a siguedsmrnicat
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6 p, Q a
4X1 4.Scout,
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that he is licensed pursuant to the provisima of the Cnmractar's License Law (Chapter 9
(commencing with Section Was)) of Division 3 of the Business and Professions Code)or
tem he is exempt therefrom and the basis far the alleged eiteranion. Any vinlmion of
7031 it by any applicant for n pennil subjects the applicant in civil penally of
nm roma than Ovc hundred dollars f 900).
01. us owner of the pmpeny, nr my employees with wages os their sole compensvlion,
wnlldnlhewmk, and the structure isnot inreadedurctkered forsade(Sec. 10/4 Business
and Professions Coale: The Contractors License Law does no apply to an owner of
who hnihh or improves thereon, unit who does Hach work himself or through
TEMP. METER OR TOLE INS' It
COMMERCIAL,
❑ NEW BI,OG/ADDITION El DEMOLITION
❑TENANT 0 FOOD SERVICE
IMPROVEMENT
El OTHER
POWER DEVICES
SWIMMING POOL ELECT RIC
OUTLETS -SWITCHES-FIXTURES
property
his own employees. IF vidrd that such improvement, orc sol intended or offered far
sale, If. however. the building at improvement is sold within one year ofmmplelion, the
NI?W RESIDENTIAL ELECTR SQ FT.
SQ. IR FLOOR AREA SISQ. F.
sur -builds will have the burden ar proving that he did not build or improve !m par-
on,afalal
❑ I, n owner of the pntpeny, em esdusivdy cnmmdtng wtdl licensed contractor, to
p A I D
TUrnl.:
onswn the project (Sec. 7044. Basin,,, and I4oBaamms Cadeq The Contractors Li.
wac eLawdorsnotapply,,uvownerofpmpenywhobuild.,orimprovesthorns,and
n contracts for such projects rim a rnalmnmr(a) licensed pursuant to the Contmnri s
QTY. PLUMBING PERMIT FEE
OOT' 7 1996
PERMIT ISSUANCE.
Lio,me Law.. -
0 l am eeempl under Sec .B&P C for this reason
ACfER- DRAIN A VEN f -WATER FA)
- )N
.net Data
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
')
Ihereby of na under rrnahy of perjury one Ml he following dew! ... arms:
STORIES
TY PE CONS I RECTION
I have and will maintain a Cenilicvle of Consent to self -insure for Worker's Cout
onion, as provided for by Section 370X) of the Lahat Code, for the performance of the
DRAINS- FLOOR, ROOF. AREA, COND.
work for which this peril is issued.
FIXTURES - PER 1'RAI'
F1 hoc and will maintain Worker's Compensation Insurance, as required by Section
37N) (if the Labor Cale for the perfnmmnce of the work for which this permit is issued.
/ CAS - EA. SYSTEM -I INC.4OUTLETS
OCC. GROUP
MIN
My Worker's Cnmpensntion Insurance carrier and Policy number arc:
Carrier: Policy Nn :
GAS - EA. SYSTEM -OVER 4 (EA)
GREASr•IINUUS'1'RI. WASTE INrEkCEPTOR
CER'FIFICATEOPF,XEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
TBtissection need out be conadetart Hire permit is human hundred dollar,(M0B7
m less.l
GREASG tRAP
PLANCHECK FEE
O Z
y 12
(fjt
I certify that in the perfmomiceof the work fur which this permit is I ... ed. I hat]
not employ any person in any manner so as to become subject to the WorkersCompen.
amimu Isws of California. Date
Applicant
SEWER -SANITARY- STORM EA. 2011 IT.
ENERGY FEE
WATER HEATER WNENT/F.LECTR
GRADING PEE
NOTICE TO APPLICANT: IL alter making this Certificate of Exemption. you should
become subject to the Worker's Cmnprnnntinn poisnions of the Labor Cale. You nom
WATER SYSTEM,7REA'1'INf,
SOBS THE
WAI ER SERVICE
a
mnhwilh vnmply with such rraskinna o.this permit shall he Aceanal rcvnkrsl.
Q
z
U O
4L
RUWi
}Lot
CONS'IRIA IIONLENDINOAGFNCY
1henbyaf Orn lhm there is.conewamnn
ion leading agmey fur the perGnce of
the work for whine leis lcnnit is issued (See 3097, Civ. C.)
Lender'., Na
PAID
NEWRRSIDENTLALII-M11. SQ. IT.
Pam krcriptp
IOIAL:
ntc
Lender's Address
TAT -.
BUILDING FTE
I certify that I have reed this application and state that the above information is
correct Istate u,enmply with .11 city mal county indinmato ..,it state law, relating to
building construction, and hereby authorize represenmlivea of this city to enter upon the
ahuve-mentioned property for inspection Fanatics.' `
(WO agree m save, indemnify and keep harmless the City of Cupertino against
QTY. MECHANICAL PERMIT FEE
SEISMIC FTai
F. V)
U
PERMIT ISSUANCE
ELECTRIC FEF.
ALTER OR ADD TO MECIL
Iivhilin,,,judgmenls, cams and asp... es which they in any way secure mgvinstsald City
in consequence of the granting of this permit.
PLUMBING FEE
AIR HANDLING UNIT(TO It1,Np CFM)
MECIIANTCALFEF.
APPLICANIU S1 )SA WILL COMPLY WITH ALL NON POINT
SOURCE RF �)
AIR HANDLING UNTI OVER 11MOCITO
CONSTRUCT ION TAX
/�.-7Y/
V b
¢&+kms
Sigmrmrc of Al MComrnctm Data
EXHAUST Dool)IW/DLII
HOUSING MGHGAf10N FEE
DAZARDOUS MATERIALS DISCLOSURE
IIExrl NG UNIT LTO 1WLW10 BTU)
Will the applicnm nr future building cap., store or handle huzallom mamrinl
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Cade. Seniun 2t532(to?Yea
HEATING UNIT (OVER UNITED BTU)
VENTILATION PAN (SINGLE RCSID)
DD It
0 / `
PAID pant Racipl p
Will the applinmt m future building occupant use equipment m devices such
emit hazardous air vommuinnm, as defined by the Bay Area Air Quality Mnuugemeat
BOILER -COMP (JHP OR IW,190 BTU)
TOTAL
Dialdcc
❑Yes 11
BOILER - COMP(OVF.R IIXI,INX)8111)
AIR CONDITIONER
ISSUANCE DATE
I have read the natation, materials unpiremera under Charge, 6.95 m lee Cali-
NEW RESIDENTIAL MECH. SQ. FT
fomin Ilealm A Safety Cade. Seelion., 25505, 25533 orad 25534.1 undemland that if the
building dae,nol ��eptly hu al'11; 6that i0 is my responsibility m notify the occupant,
}}}}}����aaaaaf��
of Ili• rn aim I r t I to issuance of a Cenincer�-0Xf (k
I �aF95
pe(y�m t( 1° cm �Q ` / - / Oryas
TOTAL:
ISSUED BY:z
Owners mnlma letal agent Una
OFFICE