31183 ? APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINTPEN ONLY
. CITY OF CUPIERTINO ,-BUILDING-ELECTRICAL WPERMIT NO.
BUILDING DIVISION APPLICATIONIPIERMITPLUMBING-MECHANICAL - 31183
BUILDING PRfI,II?CI'IDENTIFICATION
BUILDING ADDRESS: I 0_ fN o ���� SANITARY NO. APPLICATION SUBMITTAL DATI
OWNER'S NAM r � ; HONE, 1A
��/ r ONT rf�ORS � /q q L- WC C NTRO It
ForARCHHECUnNGINIMR: + LICNO: f MA ),Y;SS: A�/IvlC 'Nat
SS/�6 ❑
CONTACT: PHONE: '� BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ . ❑ kin .. ❑
LICENSED D CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
G a Z1 thereby affr n that I n licensed under provisions of Chapter 9(crm rteing ' JOB DESCRIPTION
�0Z Sectionwith7009)of Division/i of the Business and Imfirssmns Ca'oodd`e1undmylcen.cis PERMIT ISSUANCE
Wr mfullf Icff i 6 Lic.4 4q.13 • - _s SFDWL ❑KITCHEN REMODEL
,aUU Lce'so Class
F-4w Dam a Cmanu J�V ABf k 4 APPLIANCES-RP.SIDF.NTIAL• ❑ADDITION ❑PLUMBING RH PIPH
��a' ANCHlTECISDECLARATION� '�� ❑MULTI-UNIT v ❑STRUCI'URAI.
p..;prn a PANELS
ZO > lunderstund my pin. hall he umA us public records J MODIFICATION
O Z- : UPT0 2 W AMPS
F=�C ❑INTERIOR [I CHIMNEY REPAIR
Tal Licensed Professional 211LIOWAMPS IMPROVEMENT
Sy t S J� OW I am exempt
from
Contractor'.
onti ON OVER 10MAMPS. ❑ ATH REMODEUREPAIR ❑DEMOLITION
yy PC Ic 1 herMy,(firm that 1 am exempt from the Cessions Ci s e:Any c Law for the
)d 3 a F following reason,(Section]1I11.S.Business end Professions Cade:Any city m county SIGNS ELECTRICAL'' �TN.)
u411 u.y which its irts n permit to cno.flieral¢q improve,h permit
file.
mpair any suucmre �� r-r— N?-
0 r
;LLg patheissiemsedpurm quires'hansbis an,far.oftheauchpertniuLices Law(Chaptert SPECIALCIRCUITMISC.
�} thmheincingsedpuramunothe provisiomnf the a Bmacmrs Licersehw(CTapter') S��
is.L (bar he is exempt
Sereirs. aD of Divisions the al aged eminpl Pm Any Code)m TEMP.METER OR PoLE INST.
a a e that he is exempt Nertfmm anJ the b,xia for We alleged exemption.Any vmaterial ❑NEW BLDG/ADDITION ❑DEMOLITION
xro Smwion]03L5 by any appliaem ford pcm'it subjcea Ne applicannoti civil penahy of POWER DEVICES,
ly�r/t ❑TENANT - ❑FOODSERVICE
FZY na more than five hundred dollars(SSW). IMPROVEMENT
p=Q ❑ I,,s owner of the pmpeny,or my employees with wages ax their sole compensation, SWIMMING POOLELE IC - _
will do me work,and the stmclnre is not intended oroffdrcA bustle(See.]M4,Business ❑OTHER
W ig m end Profession.Cole:The Commnors License,Law'does not apply to on owner of OUTLETS-SWITCHES I 4U;CES
a"3'� property who builds or improves thereon,and who does such work himself or through - - _
his own employees,provided thasuare But, ch improvements anot intended or oVffered nor NEW RESIDENTIAL EL fR SQ FT.
sale.If.however,lire building nriatinumment is sold within one yearn cobnpletion,the SQ:Ff.FLOOR AREA VSQ.Fr
owns,-builler will have the lumenof proving 114,he did not build or innPan,e for par. ,
ems ofsale.),
❑ 1,us owner of the mo,ay,am exclusively emanating with licensed v ntmclna In TOTA1
.
construct the ,.jet[Ner.7144,Business and Professions Code:)*1 he Conrarlou s Li-,
cerisem Lmv docs napply to on owner of properly who builds or improves lhemon,und QTY, PLUMBING PERM FI:
who contmms ba such projeme
cts will',conwmr(O faeased pumuem m m
the Comemr's
La .ate
License w. '- PERMIT ISSUANCE V
❑I am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER BEA). VALUATION Owner Dae
WORKER'S COMPENSATION DECLARATION BACK ROW PROTECT.DEVICE
1 hereby affirm under Certify of e perjury one of the following declarations:
❑Ihave end will far by eCemifi7W ofConcentthe
to ode.for for Worker'sce of the
DRAINS-BOOR.ROORAREA.CON0. STORIES ' TYPE CONSTRUCTION
ntinn,r providedcthis
far by Section 3700 of the Labor CMe,for wire perfommntt of the
wJPk for which wills Cantu is issued. FIXTURES-PER TRAP
37 I have and will W maintain.frWorkers Compensation ofn ion Insurance,which
h requi'W by .suiun -
3](Mlnf'heln�tT,,r .ode.funhFperformence of Ne work fmwhich wills lis'smed, GAS-EA.SYSTEM-]INC.40UTLETS OCC.GROUP APN
MY Wur n,1o%aylon luf emierand Polic�i�ylir`er{{nai _
Cartier: OOOsss l < Policy No.. v GAS-RA.SYSTEM-OVER 4(E,O
CCRTIPICATEO v%EMPDON FROM WORKERS'
COMPENSATION INSURANCEGREASU_INDUSTRL WASTE,INTERCEPTOR
- (Thisscaion need nm beconrplctedBNe Permit is forms'hunduatollurs(SHp) - - BUILDING UfVISION I•I3W
or least GREASE I'RAP PLANCHECK FEE
lemdyllati til p f 'o nfthewnrk for whwh'h spermi's vual lshjll SI.WER SANITARY-STORM EA.200 fT.
notcrPly yp ni uy iso as to becomemblect m the Workers Compcn- - ENERGYFFE --•�
Z wumn Liw u I C I'f rni [).to
C)O A,pI cum - WATER HEATER WNENT/fsLECTR g GRADING FP
r
on NOTICE TO APPLICANT:IL after making this Cemlfica'e of Exemption,you should WATER SYSTEMfTREATING
en - -
1-' become subject to the Worker's Compensator provisions of the Labor Care,you FE
must SOILS E
Q (mnwit
hh comply with xun
ch provisions permit shall be deemed res.kcd. WATER SERVICE t
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLAIN SQ,FT. PAID
L)0I hereby affirm that there is,construction lending agency forthe Performance of Dam
the work far which this permit is issued(Sec.3047,Civ.C.) t
i-" Lender's NameTOTAL:
1<nsters AJdrtes - ETOTA!-
Its 1 terrifydrat I hvemad'his,pplicaion and Sate drawrhe aboveinformation is BUILDING FEE
VI corrcct.IagrecmchmPiy with all airy anJ rnunry rNinmrces and stem laws retailing to QTY. MECHANICALPERMI !rFE
U z building conswetion,and hereby authorize rcpmsenafves of this city to enter upon Ne SEISM IC FEE
mbove-memimad property far impaudim purposes. PERMIT ISSUANCE
ELECTRIC FEE
(WO agree in save,indemnify just keep hamline e City of Cupertino against
liabilities,judgmena,costs and expenses which may in any way accrue against mid Cry AI-TER OR ADD TO MECH. O
in ousequcnce of the startingrmit. PLUMBINGFEE of this pe
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO BLOW CFM) MECHANICAL FEE
SOURCE REGULATIONS.
.,I. I AIR HANDLING UNIT(OVER 10,007 CFM) CONSTRUCTION TA%
Sigmnure of Applic:mVComruaor - Date EXHAUST HOOD(W/DUCT) HOf1SING MITIGATION FEE '
HAZARDOUS MATERIALS DISCLOSURE
Will the mplicrm or future building ocwupjnt erore or handle hazamdoue material I IHA'Z'ING UNIT(DO 100,000 BTI]) - -
'us defined by the Cudcmioo Mmump l Code,Couple,9.12,and the Health and Sur - , '
Code.Section 25532(x)? _ _ HEATING UNII'(OVER IW,W0 BTU) -
❑Ycs �J No' v - VENTILATION FAN(SINGLE RESID) PAID '
I Date ReceiptR
Will the applicant or future building tmcuprat use equipment or devices which,.• BOILER DHPOR IW,000 BTU)emir hazardous air contaminants as defined by the Bay Area Air Quality Management - TOTAL:is
District?
❑Ycs f�ts'o BOILER-COMP(OVER I00,0010 BTU) -
I have octal the haarrall materials uimencnts under Chapter 6.95 of the Cali.
AIRCONDITIONER
req ap ISSUANCE DATE
fn t I &safety G S.ions 8 85)7 and 8534.1 urdcrsraml No'if rhe NEW RESIDENTIAL MECH. SQ.FT. I/%
of
star ecurrcnd ave,m .r aisuance ,bi Ytp no o..Y.
of rhe me ono iiau,nm of C fi// unc Y.
Owner or amhrnted agent Dam TOTAL: ISSUED BY: - O
OFFICE