S 3241 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING-ELECTRICALMECHANICAL P'' 'T"" 3241
BUILDING DIVISION APPLICATION/PERMIT rl.unTmrvc-MEcuNNlcnl.
BUILDING PROJECT IDENTIFICATION
BUILT)) AD)k SANITARY NO. APPLICATION SUBMITTAL DATE
l I rd Gt. fi
OW '$NAM(: PH NE. C RACfOR'S NA LIC NO:
? NIC CONTROI.K
(IM hm
AR HTTEC7rT GINEER LIC NO: S 1:11\ CONTACT: - PHONE: 7 BUILDING PERMIT INFO
❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECT' PLUMB MECH
Wands �Tn 037-91Bd � ❑ L2-- 1:1
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm thm li
It.,1 aconsed under provisions of Cheater 9lcommencing JOB DESCRIPTION
pa,OW wiOSxcImn700T.fDlvido 3ofthe Business and Nofcsi s Code.andmyliceneeis RESIDENTIAL'
x_100 PERMIT ISSUANCE
infullhniwi,, effect. ❑SFDWL ❑KITCHEN REMODEL
TUU Licenxc Class Co.(.
Ly!.r�.my7p APPLIANCES-RESIDENTIAL []ADDITION 71 PLUMBING RE-PIPE
F�W Dam C,nlmctor�.ay—Ka
rn a ❑MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION
Z p y K I undersand my plans shall he used ax public records PANELS MODIFICATION
N UPT0200AMPS
OZ C1 INTERIOR CHIMNEY REPAIR
W Licensed Professional 201-III00AMPS IMPROVEMENT C]SWIMMING POOLS
Y -4 OWNER-BUILDER DECLARATION OVER I"AMPS &TATH REMODEVRF;PAIR ❑DEMOLITION
C I hereby a1Drn thus 1 in exempt Gum the Comrucmr's Licence Law Ibr the
a O y V following reason,(Section 7031.5,Ilminehs and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
'R)t O� which myui e,a permit to construct,cher,improve,dectim sh.or repair any smetti.
rotor o its issuance,at,..,.iresthe applicant for suchpemed 1.file asigncd smmmert SPECIAL CIRCUFUMISC. CA
} that he is licensed pursuant m the provisions of 0e Contractors License Law(Chapter 9
� Professions
p(C0 (commencing with Section Division of the Business and P,Code) TEMMETER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑ EW BLDG/ADDITION ❑DEMOLITION
iC ro W Section 7031.5 by any applicant for o permit subjems the applicant to a civil penalty of POWER DEVICES :Np ❑FOOD SERVICE
..y not more than five hundred dollars 155 W). I ' EMENT
f5C ❑ I,as owner of the TFOTT ,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC ❑0TH
F+ will Jo the work,tmd the shaman is not imemirdao6bmd far auto(See 7044,Business
Tal-It and Professions Code:the Contractors License Law does nm apply to an Owner of OUTLETS-SWITCHES_FIXTURES
3 property who builds or improves thereon,and who d«s such work himulf or through Val
his own employees,provided that such improvement.are not infeasible,offered for NEW RESIDITNT1AL ELEC:R SQ FT.
sale.If,however.the building or improvement is sold within one yearofcompletian,the .Q.FT.FLOOR AREA S/SQ.IT.
nerbuilder will have the burden of proving that he i id not hat Idea ., foo par-
pew"I'l 1eJ.
E] 1,us owner of the property,am exclusively contracting with licensed contmemta To TOTAL:
construct the project(Sec.7014,Business and Professions Code:)",COnwctors Li-
cemi,Law does not apply to an owner ofpropcny who builds Or improves thereon.and QTY. PLUMBING PERMIT ME
o m
whnwas far such ma
Projects with a concle,D)liceto licensed Pursuant the Conra
tctors
License taw. PERMIT ISSUANCE.
❑lam exempt under Sec. \&P C forthis recon
ALTER-DRAIN&VENT-WATER(PAT VAL ATION
Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PRCr I'.DEVICE
1 hereby al mea easier penalty of perjury one of the following declarations:
❑(have and ides]forty Section 7M of the Laor sare,Rato, Workersce upcu-of'he IIRNNS-FLOOR.ROOF,ARIiA.COND. - TYPE CONSTRUCTION
radon,as provided fof by Section Jlfq of the Labor Cade.for the perinmtrnce of the �\
ork for which this permit is issued FIXTURES-PER TRAP
have and will maintain Worker's Compensation Inmmnce,ns required by Section
7 ofthe labor Code,for the performance ofthe work for which this pemtit is issued GAS-EA.tiYSTEM-I INC.40U'TLF.TS OCC GROUP APN
C Worker' Can
ami Insu acarrier Pand y Policy GAS-EA.SYSTEM OVER 4(EA)
ac
CERTIF PT.ION FROM W K+H s.!AN @ s 1999 dJ
COMPENSATION INSURANCE GREASOINDUSTRI.WASTE INTERCEPTOR pU1LDING DOI ION FEES
Unik Onion need not W completed d flet permit is Tonins hundmddollars(S Ilk) GREASE TRAP
or less.) PLANCHECK[TEE
Icortifythtin The performance ofthe work for which thispermil isissued,l shall SIiWEk-SANITARY-STORM EA.NN114.
not employ any person in any manner so as to became subject to the Workers'Compen-
Z suction Lowsof Gdifornia,Date WATER HEATER W/VENT/&.ECTR
z 0 Applicant GRAVING FEfi
t. nN-t NOTICE TO APPLICANT:IL after making this Cor iff,am of Exemption,you should WATER SYSTEM71'REATING SOILS FEE
abecome subject to the Worker's Cmnpensation previsions of the Labor Code,you must
t� forthwith comply with such provisions or this permit shall be deemed revoked. WATER SHIN ICE
0
p' CONSTRUCTION LENDING AGENCY NEW RESIDENTIALI'LMB. SQ.FIl PAID Date Receiptp
U 0 thereby offimvhatthere is a construction lenJi ng agency tin the peduarmo¢e of
Us F the work far which thi.a permit is issued(See3097.Ci¢C.) If TOTAL:
O U Lender's Name •LOT
Lender's Address
U
y I certify that I have read this application and state that the some infomtmion is BUILDING IT
sF.s y correct.l agree to comply with all city and county Ordinances and state lows rtlmingto QTY. MECHANICAL PERMIT FEE O
SEISMIC FENJ
V;y building mmimdinn,and hereby nulhorlu mpresentatives of his city to enter upon the
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC A:
(We)agree to save,indemnify and keep hamtless The City of Cupertino against
liabilities,judgments,costs and expenses which may in any way arrow,against said City AUIPR OR ADD TO MECH. IHOUSING
( O
in consequence of the granting of this permit.APPLICANTUNDF.RSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITfTO 10,0X0 CPM)SOU EREGUfATIONSAIk HANIl1.ING UNIT(OVFiR IhgN)CI>M) AX
Signature ofApplicanUCorthowar Te EXHAUST HOOD(W/DUCT) ION FEE
- HAZARDOUS MATERIALS DISCLOSURE
Will The applicant or future building occupant store or handle haeaMoa,malenal HEATING U N IT(17)1 W,1NMT B 1'U)
_ as defined by the Cupcnino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section M532bo? —/ HEATING UNIT(OVER E00,(pp BTU)
n 0Ye. Li VENT'l1.ATION FAN(SINGLE RI PAT])
Doc Receipt N
Will The applicant or future building occupant use equipment or devices which BOILER-COMP GHPOR 101.0X1 BTU)
emit Section
dour air contaminants as defined by the Nay Arca Air Qmdi(y Management
District? I
BOILER-COMP(OVER 100,000 BTU)
❑Yea obis
I have read The hawk, mn.l: comments under Chapter M1.95 of The Cali- AIRCONVITIONF.R ' ISSUANCE GATF�S
learn Health&So od )5,25533 and 255W.1 understand thus if The NEW RESIDENTIAL MECH. SQ.ITT.
nuilJinB doss nTly a tlt iT is ter respominil)y to ratify the wcupant / l9
oftheregnim awhic m nor i....a,, as}tgYYutysljkgy1,one,'
/ �(y
Ownct�ul�uJ age u � Date TOTAL: ISSUED BY:
OFFICE