31200 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECFRICAL PERMITNO. J{^ ^L00
BUILDING DIVISION APPLICATIONIPERMIT PLU:IIBING-MECHANICAL.
BUILDING PROTECT IDENTIFICATION
BUILDING ADDRESS: L / SANITARY NO. APPLICATION SUBMITTAL DATE
0 � /1Gr6eR vie
'OWNFfxI'SNAME: PHONE: CONTRA )R'S NAMy - 1 NO:
r S /�( D NIC ONTROL N
ARCHf1ECT/E (NEER: - LIC NO: ADDRESS: ❑
er
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT' FEE
1 hereby tritium that 1 am licensed under previsions of Chapter 9(cammencing JOB DESCRIPTIO
0WZ with Section 700indDivision 3.fthe Hisinessand Prefexsians Crack,and mY license is RESIDENTIAL:
O_O PERMIT ISSUANCE
I.fall farce and effect.
all
I move Class Lie.» ❑SFDWL ❑KITCHEN REMODEL
Z{rl One Carousel., APPLIANCES-RESIDENTIAL []ADDITION MBING RE-PIPE
yd' ARCHITECT ❑
S DECLARATION MUI.TI-UNIT STR URAL
Z O<Z rsta
1 undend my plans shall he used as public records PANELS MODIFICATION
Oz%Jp UPT0200AMPS ❑INTERIOR [I CHIMNEY REPAIR
Licensed Professional' OWNER-HUII.DER DECLARATION 201-I000AMPS IMPROVEMENTL/
4 6 OVER PONT AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
�a 1 hereby i from that I um exempt from the Contractor's License Law for the
K aL U following reason.(Section 7031.5.Businus and Professions Cade:Any city or county SIGNS ELECTRICAL - []OTHER
uF1=C which requires a permit to construct,alterimprove,demolish,or repair any structure
prior o its issuance.also requion Be applicant for such peaniuo rite a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant no the provisions ofthe Commences License Law(Chapter 9
aq0 (commencing with Section 0000)of Division 3 ofnhe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom end the basis In,the ullegcd exemption.Any emotion of ❑NEW BLDG/ADDITION ❑DEMOLITION
use.• Section 1031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES
Is, tt ❑TENANT ❑FOOD SERVICE
Z}
out marc than five the pred roperty,
r yempl IMPROVEMENT
Q �Lothe week,the property, rmyemewith wages usthe(Sm.compensation. SWIMMING POOL ELECTRIC
will do the work,and the nmaure in not intended,Lima .Law do for at apply to Im Business []OTHER
ad
and Professions Cade:The Corwcnors Licenx Law does not apply to an owner of OUTLETS-SWITCHES-IlX'NRFS
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELE(7TR SQ FT.
sale.If,howevOcthe building or improvement is sold within one year.(completion,the .V-10d,AREA S/SQ.FT.
owner-builder will have Ne human of proving that he did not build or improve for pur- {JJ
puu i f ale.). TOTAL:
E] 1.as owner of the property,am exclusively contracting with licensed contractors to MAY m 6 '�
construct the project(Sec.1014usin
,Bess and Pmfesiondc:)
as CoThe Contractor's Li-
cense law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBI ER I FEE
who comment for such projects with a commnm(s)licensed pursuant to the Contractors YUr lzur t,( �,1
License Law. PERMIT ISSUANCE tTTl�lyU
❑1 am exempt under Sec. B&P C for this reason
•Owner Date ALTER-DRAIN&VENT-WATERIF VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby Munn under penulty of perjury one of the following declarations:
❑ I have and will maintain a Certificate ofCanunt to self-irsuu for Workds Compen- DRAINS-FLOOR.ROOF.AR EA,COND. STORIES TYPE CONSTRUCTION
union,as provided for by Section 3109 of the labor Code,for the performance of the
work for which this permit is issued FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Smioa
37W of Yl.Labor Cade.for th 'A.rm <ofnhe wads for which rBoix Fantail isicomd. GAS-IiA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Cartieerker t iu " ca lolcy No: %7wo0 • � GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICA``TEOF EXE PITON FROM WORKERS' GREASFIINDUSTRl WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This sea ion need not he completed ditto permit is furore hundred dollats(51W) GREASETRAP
or less:) PhANCHECK FEE
I certify that in the perfsumanceof Ne work for which this permit is issued,I shell SEWER-SANITARY-STORM EA.209 FT.
not employ any person in any manner so as m become subject no the Warken'Compen- ENERGY FEE
0 2 nation laws of California.Data WATER HGTER W/VENT/ELECTR
0 Applicant GRADING FEE
4 7
NOTICE TO APPLICANT.IL afmr making this Cenilicua of Exemption,you should WATER SYSI'EM/IREATING
a5 become subject to the Warkers Compensation provisions of the Labor Cale,you must SOILS FEE
DJ fothwith comply with such provisions.,this permitshall be deemed revoked. WATER SERVICE
0.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMN SQ.ET. PAID
V p l hereby affirm that there is a construction lending agency for the performance of Dam Rseeiptp
u. The work for which this permit is issued lose.3091,Civ.C.)
O Lenders Name TOTAL:
WLenders Address TOTAL:
I certify that I have read this application and pane that the above information is BUILDING FEE
VZ2 correct.l agree to comply with all city and county ordinances and smm laws relating to QTY. MECHANICAL PERMIT FEE
V Z building constrction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We).gimemsavet armfyandkiuTh.mIi,ote Citycf Cupeninuagainst ELECTRIC FEE
lia77bilides,judgmen s, ours dexpeasnwhi hmayinaryway.mmess,dr,tsaACity AI,TT:R OR ADD TO MECH.
in nuqucnm g Hing of this PLUMBING FEE
APPLICANT E 'TAN ILL COMPLY WIT]I ALL NON-POINT AIR HANDLING UNIT ITO 10,009 CFM) MECHANICAL FEE
SOUR ,C ,S.
AIR HANDLING UNIT(OVER 00,00l)CFM) CONSTRUCTION TAX
Si amre
HAZARDOUS
o(ApplicuDO IS DISCLOSURE
US Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZAROM
Will
yteCopanter future but gmcupaptstore r9,12,handle Health us and Safety HEATING UNIT(TO IW,OW BTU)
as de,Sed by the Cupertino Municipa 'ode,Chapter 9.12,send the Health trod Safety
Code,Section 25512(.)1HHATING UNIT(OVER IW.000 BTU) '
C]Yes 4 N PAID
VENTILATION FAN(SINGLE RES ID) Dam Receipta
Wrdsmll the ai,motont drfumre M1efineg by me
Are.
Air
mlity or Managemences whicht
BOILER-COMP(OHP OR 100.000 BTU)
emit h.zamoux air contaminants as defined by the Bey Aua Air Quality Management TOTAL:
DisWnl BOILER-COMP(OVER 100,,100ID U)
E]Yes 0<1
AIR CONDITIONER
I have read to hazaAous,reran mquimmenns uMcr Chapmr695 of the Celi- ISSUANCE DAT
fomia HUIN&Sa`I��y Cr/Y�_Fe.ouuyw 5505,255]3 re 25534.1 understand Nm if the NEW RFSIIIENTIAL MECII. SQ.FT.
building docs fru I has.Gfe nt ohm it
wrisibility to notify III, pare
of the fh mu �R� t eofa CenifiunGyfA p
Own .gem / Dae TOTAL ISSUED BY:
OFFICE