31322 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ECT
LERICAL PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MFCBANICAL '
BUILDING PROJECT IDKNTIFICXDON
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Coy
OWNERIS NAME: P E: C RACI'0 SNAM LIC NO:
/ —7 NIC CONTROLO
ARCHITECI'IENGINEER: IC NO: pp S: I 'p p ❑
CONTACT; PHONE: SU[ 11^ll^/ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
" LICENSEDCONTRACI'OR:S DECLARATION QTY. ELECTRIC PERMIT FEE
O.Z 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing )OB DESCRIPTION ..
ly with Smtimt7")of Division 3 of the Business and Profesdmu Cade,and my license is
FOO in full force and effect. PERMIT ISSUANCE
TIAI
�WZr License Class Lica DWL, ❑KITCHEN REMODEL
.Qu Dmc Convenor APPLIANCES-RESIDENTIAL. ❑ADDITION El PLUMBING RE-PIPE
py ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
�1••-.. PANELS Z O Za 1 understand my plans shall themed.;public rtnvJs MODIFICATION
OZ UP'10200 AMPS
^�
Licensed Professional - El INTERIOR ❑CHIMNEY REPAIR
OWNERBUILDER DECLARATION 301.1000 AMPS IM OVEMENT
I hereby affirm that 1 am exempt from the Cmnranices License Law for the OVER]"AMPS ATH REMODEUREPAIR ❑DEMOLITION
LL0- U following monsrm.(Section 7031.5,Business and Professions Cafe:Any city or county SIGNS ELECTRICAL ❑OTHER '—
a' which requims a permit to construct,alter,improve,demolish,or repair any structure
funcrro its issuance,also requires the applicant for such permit to file a signal atatemcm �.
vh SPECIAL CIRCDIT/MISC.
vWW11i tommensonghat be it redpursmnt mthe of Division
the Cn Businesme s
License Loons Code)(or
Cpl that he
xemit therefrom an du Division)o(me Business andon.Any violation
or TEMP.METER OR POLE INST. _ COMMERCIAL:
Sec he is 31.5 b therefrom and the basis it s be alleged applicant
to Anis viulmion of NEW BLDG/ADDRION ❑DEMOLITION
.n
{[• Section]1131.5 by any applicant for o permit objects the applicem to a civil penalty of POWER DEVICES
N ❑TENANT ❑FOOD SERVICE
p., not more than five hundred dollars(8500).
Fq=6 I,as owner of in rt,orm employees with wo es as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT '
^��^2q..' ❑ ProPe Y Y6 Tense
doth Professions
Ce e:The Communes
License ow does not apply to an Business - OTHER
tai and Professions ilde:The ronwnoos License Law does not apply s if owner of OUTLETS-SWITCHES-FIXTURES
6 3^ property who builds or improves thereon,and who fines such work
te himself or red for
his own employeese provided that soca improvements me not intended or offered for NEW RESIDENTIAL ELECTR SQ PI'.
salewin(hmwever,will hbuil he made.imparmansen
issoldhewithin one yc or improven,me
pm- /S 00 REA LSQ.FT.
owner-builder will have the burden of proving that he did oat build orimprove far par- s
Imes of sole.).'
❑1,in owner of ct Smpeny,am exclusively contracting with licensed contractors to TOTAL:
construct La thedoes
net (3a9W4,Business off nti Professions Ca r imprc C,thereon.Li- /b
cense Lowdoesr such plymad ith aofprapeny whcusead sorimt Loth Cculnu,ues QTY. PLUMBING PERMIT FEE
who contracts for such projens with ecmnaacmr(s)licensed pursuant to Cnntranors "
Liccrtu Law' PERMIT ISSUANCE
❑1 am exempt under Sec. ,B&P C for this reason
Owner - Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
F5�—
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE (Jv
1 hereby affirmote under penalty of perjury one of the following Workers Co
❑Ihave andwill for byneCion 37 to of the Labour
oadc,for
rthe Workersce of to DRAINS-FLOOR,HOOP,AREA,COND.
mromn,u provided for by Section 3]00 of the Lebor CUJe,for the performance of she STORIES TYPE CONSTRUCTION
w I for which this pemtit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance.as required by Section
37 ufthe Labor Code,for the performance ofthe wok for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS .00C.GROUP APN
Joy W CourZkST/Tln�o�luAl instant
palcypalcy NiaT /3f'� GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF,ASOINDUSTRLWASTE INTERCEPTOR
B 11, GDIVISION FEES
(This onerous not not hecompleted Blue Permit is formic hundred dollars(SIM) GREASETRAP
ter less.) PLANCHE
Ic iffy
minsheperfm ranceofthe wmkfor which this permit is issued,IshalI SEWER-SANITARY-STORM FA.200 Ff.
not empl tiny tsnn in tiny m iter so as m he ]na uhj�cno the W ( open- ENERGY F ,
W it
z notion sof o 'e.Date SO \ V l.y -
'7�O Applicem eN WATER HEATER WNENT/ELEC R GRADEWf ter.LUI+C„TIN
q NOTICE TO APPLICANT:If,a mg sr nea this Cenificete of Exemption,you should WATER SYSTEM/IREATING --
F” hemaresubject m NC Worker's nmpensation provisions of the labor Cafe,you must SOIfSFEE'-
{ail forthwith comply with such provisions or this permit shall be domed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDLNTIAI.PCMB. SQ.FT. PAID
U I for
thi Char themisaed(Secu 0lending agency for she performance of Date Reccipra
GL f•+ the wart far which this permit is issued(Sec.709],civ.CJ
Q,` Lenders Nome TOTAL:
44L Lendersdress AdTOTAL01
fy�s y 1 certify Nm 1 have read this application and note thm the shove information is Is BUILDING PI:E
i-i Vl context.l agree to comply wish all city and corny ordinancesand onto,laws rcladng to QTY. MECHANICAL PERMIT "FEE
V building convection,and hereby authorize repmsenmtivea ofthis city to enter upon the SEISMIC FEE g
above-mentioned progeny for impowden fampuses' PERMIT ISSUANCE(We)agree manse.indemnify end keep harmless the City of Cupenimo against ELECTRIC FEE
Iiebilities.judgmems,costs and expenses which may in any way accrue against said City ALTERORADDTOMECH.
nc qucmeofthegcomingofthispermit, PLUMBING FEE 3-
LIANTUNDE NUS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
HOUR REGULATI NS. MLCHANICAI.FEE
,0-1 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signamrc of ApplicarmConoacmr Date EXHAUST HOOD(WOUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE '
Will the applicanmr(at..building uccupamiame mhandle harmi material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupeniea Municipal Cede,Chapter 9,12,and the Health tend Safely
Code.Section 255320)] HEATING UNIT(OVER 100,001 BTU)
❑Yes ON. VENTILATION FAN(SINGLE RFSID) PAID
Date Raeipra
Will she applicant or future building occupant use equipment or devices which
•emi[hamNminont ss
ous air conmdefiW nby the Bay Area Air QualityBOILER-COMP QHP OR IORDM BTU)
Quality Management TOTAL' Q
Disvin4
❑Yes C]No BOILER-COME(OVER 104000 BTU)
I have read the hazardous rwburials requircments under Chapter 6.95 of NAIR CONDITIONERe Cali- ISSUANCE DATE
forma g does&Safety Cale,Sections 25 en i 25537 and 35534,I Ianitytunderstand that if the NEW RESIDENTIAL MECH. SQ.FT.
building not currently hove a tenant,shat itis 53 rend 255 4.1 Inanity she mcupum G
of the requirements which most on met prior to issuance of a Certificate of Occupancy.
Owner or emhoriuJ agent Dote TOTAL: ISSUED Y.
OFFICE