31273 APPLICANTTO TILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I I BUILDING-EIJ•:CTRICAL Pr:RMIT NO,
BUILDING DIVISION APPLICATION/PERMIT - PLUMBING-MECHANICAL 31273
BUILDING PR(IJEC'F unwrIFiCAvoll;
I BUILDINGADDRHSS: - SANITARY NO. APPLICATION SIJBMITI'AL DATE
og 1; Or 6
ityNW 9 NAME?: t Z4�e PHONi;I CONTRACTOR'S NAME:' LIC NO'.
`dC
4s� Fos- NIC 'ON1141
ARCHITECT/ENGINEER:, LIC NO: ADDRESS: ❑
v
CONTACT: PHONE: BUILDING PERMIT INFO
I ❑•Consultant Fees Paid b A (Initial). y Applicant pp ) BLDG P.LFiCTPLUMB MI?CH
❑ ❑' Cl. ❑
LICENSED metIamCON'IRACfOrproviCLARf Chapter
QTY. ELECTRIC PERMIT FIiE -
I hereby affirm Net 1 am fthe Bu under provisions offs Coder 9(commencing JOB DH$CRIPTION '
❑�Z wird Section 7000)ofDivision 3ofthe Business and Professions Cnde,Say,license is
�OO PERMIT ISSUANCE RESIDENTIAL:_
in full force and e
�k.UU License Ca _ _ Lie.# ��✓ ❑SPDWI, fUMBIN RE-PIPELE y<L Dote CommmorL APPLIANCES-RCSIDEN'TIAI. ❑ADDI770N PLUMBING RE-PIPE
Ali rECFS DECLARA ION PANELS ❑MULTI-UNIT ❑STRUCTURAI,
lum,,xlndmyplansshall be used aNpublic records ' MODIFICATION
OZ— UPT02W AMPS El INTERIOR ❑CHIMNEY REPAIR
^= Licensed Professional - 201-1000AMPS - IMPROVEMENT
A OWNER-BUILDER UECLARAi'ION
C I hereby amrm tam I am exempt notable Contractors License Low for the OVER 1000 AMPS ❑BATH REt�ODE.URF IR [I DEMOLITION
�y(❑L V following reason(Section 7031.5,'Business and Professions Code:Any city or county ❑OTHER � a
Yl a W F' whicM1 rcyuiies u permit m connmu,alter,improve,demolish,or re vucnuo SIGNS ELECTRICAL
repair any s
prior m its issuance,also requires the applicant fur such sentrinm linit'ig;ed statement SPI?CIALCIRCUIT/MISC,
y shot he is licensed pursuaauo the pmvisionsofthe Contractors license Live(Chapmr9 _
p0le mmeneing with Section 70001,11 Division I ofthe Hnvinow,and Pro&sslnm Codclor 'TEMP.METER OR POLE INET. t -
0. C that he is exempt therefrom and the trials for the street exemption.Any violmion of _ ❑NI? LDG/ADDITION' El DEMOLITION
aq5 a• Section 7031.5 by any applicant for o pelted subjects the applicant to civil penalty of POWER DEVICES
u+^rex TENANT ❑FOOD SERVICE
'Z y not more than Eve hundred dollars(5500). - IMPROVEMENT
QE]1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOLELECTRIL'
wdl du the work,and the stmcmre is not imendod oroRercd(or sale(Sec.]IW4,Busincu ❑OTHER
and Professions Code:The Committers License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pmpertywho hullds or Improves thereon,and who does such work himsel f or through
s' his own employees,provided that such imprnvemems ore not intended m offered for NEW RESIDENTIAL ELECTR SQ F. '
sale.IL however,the building or improvement is sold within one ywro(completion,the SQ.F.FLOOR AREA f/SQ.PT.
owner-hmilder will have the huNen of proving Net he did not build or improve for pnn y
❑1,m owner of the property,am exclusively contracting with licensed comment m TOTAL: i1ID
construct the project(Sec.7014,Business and R'ofession,Code:)The Contractor's L.i-
cense Low does not apply to an ow net of property who builds or improves thcreou,and QTY. PLUMBING PI7RMIT FEE o���
who contmcu for such pmjeets with o comeactobs)Iiecosed purannot to
License Law.
E] I am exempt under Seo. ,I1&P C for this reason PERMIT ISSUANCE 'yI
Owner Date
ALTER-DRAIN&VIRIT-WATER GDO Cpl(If y,ALUAT10N
_ - .
Wm underSCOMI'ENSATIon❑fife folio ing BACK PLOW PROTGCT DEVICE t
1hereby sffinn under penally teperjuryoneofthefollowing daaiereliam:
❑Ihave and will containetio.37nte of ComemtoCode,sto the Wnfkecar.of the
DRAINS-FLOOR,ROOFARIiA,COND. STORIES -TYPE.CONSTRUCTION
work,alimn,f nn hir h thi for by Section 3]00 of Oto huMr Gale,for the perronnnnw ol'the . .
wok lave and this permit is issued. FIXTURES—PERTRAP
❑I have our will maintain Workers Compensation Insurance, requiredrequiredt i P.A
Section _
J700af Ne Inbar Code.fnnhe pmfnrmee
enuf the work[m which
this permhia issued. GAS- .SYSTPMd INC.4(IUTLPTS OCC.GROUP ' APN
My Works' 1•ysey'�t1 exec cnrtier and Policy t��gMs1��P//RR
Carrier.Worker's
l�s^25 Pmi,Nn.:�/.. Z2 GAS-II.SYTHIM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE GREASFANDUSTRI.WASTE INTERCEPTOR BUILDING DIVISION FI?FS
Gbis section need not be completed if the permit is nature handout!dollars(S i 1X1)
or less.) GREASETRAP PL.ANCHECK FEE
I eerily Nut in the lrrformnnccoflhe work for which this pennit is issued,lshull SEWER-SANITARY-STORM HA.200 IT.
not employ any perm;in any manner so as m become subject the Workers'Cmmpen. - ENERGY PEP.
,Z Nation Laws of California.Date
z O Applicant WATER BEATER WNENTNLECTR GRADING HE
y NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEWTRRATING -
abecome subject o the Workers Compensation provisions of Ne L abi Code,you man SOILS FEE
W forthwith comply with such provisions lar his wounitshall he deenedrevoked WATER SERVICE ,
� zCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLACE. SQ.FT. PAID
1hemconstrictiondin
rfirri there iso constriction leng,may for the performance of Date Bisects al
The work for which this permit is issued(Sce.31197.Ci v.C.) - -
0 U Lenders Name TOTAL:
LkI r� Lenders Address TOTAL:1 certify that I have read this application and stem that the shove information is BUILDING PER
i.. V1 correct.I agree to comply with all city and county ordinances and sum laws reliongto QTY. MECHANICALPERMIT FEE
7 building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
done-mentioned progeny lir inspection purposes.
(We)agree to save,indemnify and keep harmless Ne City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE'
liabilities,judgments.cuisnnd expenses which may inxmy way viceme against said City ALTER OR ADD TO MECH.
in consequence og
f the ranmsi
ting of this pet. PLUMBING ME
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR 14ANDLING UNIT(TO IQIXq CFM) MECHANICAL FEE
SOURCE REGULATIONS. '
AIR HANDLING UNIT(OVER 10,900 CFM)
1. CONS'rRUCfIONTAX, t
SignammofApplic tit ntmaor Date EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Ne upplicam or forum building n'ucupam score or handle haxurdous mo¢riol HEATING UNIT(T0100,0100.B'ID - -
ns'defined byte Cupertino Municipal Code Chapter 9.i2,and the Health and Safety
Code,Section 25532m)7 HEATING UNIT(OVER I00,01p BTU)
F1 Yet, I p'VFN'I'ILATION PAN(SINGLE RES
ID) - PAID
. Date Receipt#
Will Ne applicant or future building by the n use ea Air u of devices which BOILER-COMP'(BHP OR 100,000 BTU)
emitict? s air comnmintima ax mal by 1M1e Bay Arca Air Quality Management TOTAL:
.
District?
C]Yes BOILER-COMP(OVER 100.0010 BTU)
AIR CONDUIONER
I base muddle It yard! us m I rcyuircmems under Chapter 195 of Ne Cali- - - ISSUANCE DATE
forma HwlN&S fry Cwle {ct 8505.25531 and 8514 1contendand that if the NEW RESIDENTIAL MECH. SQ.ET.
b4got urmntlyh t that t stay res 1 ryt t tify Ne occupant enbw 'h tb tet pct Cent(e f0 GagaOri dog t are TOTAL: I I ISSUED BY:
OFFICE