31542 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY,. .r
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO 31542
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BUILDING DIVISION • APPLICATION/PERMIT PLUMBING-MECIIANICAL - K 1 ^4 L.
' BUILDING PROJECT IDENTIFICATION !J!11 L`JI
BUILDING ADDRESS: 1 �EN019L ^/ � � I I SANITARY NO. APPLICATION SUBMITTAL DATE
OWNS 'S AMG: PHONP' - CO RACTOR'S NAME: LIC NO: • -L Lt
733— 970/ n/" 2217 NIC CONTROLp
•ARCHITECTMINGINEER: - LIC NO: A ❑ .
2�i3 ! raa vE S,J. 9si
CONTACT. PHONE: BUILDING PERMIT INFO
';,� - .❑' Consultant Fees Paid by Applicant(Initial) BLDG .ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY Ii LECTRIC PERMIT FEE
I hereby affirm that I t licensed under provisions m
f Chapter 9(commencing
OB DESCRIPTION
O0O with Sectio.7(XV).fD .3.ftha Bust sand Pnderamne Codeandmy licensees PERMIT ISSUANCE RESIDENTIAL: x ,
F full force and eff F2Z 1^� ❑SFDWL ❑KITCHEN REMODEL
I Zw License lass Llc.k c�0 r APPLIANCES-RE.SIDEN`I'IAL
FZIu Datc--I�Conaac a9�C' OADDITION *Qn,UMBING RE-PIPE
FDy ARCHITECTS DECLARATION PANELS ' ` t ❑MULTI-UNIT' STRUC-MRAL
Z O n? I understand my plans shall be used m public worts - MODIFICATION
0 - UP TO 200 AMPS ❑INTERIOR 11 CHIMNEY REPAIR
���� Licensed Professional All-IOMIAMPS IMPROVEMENT
QYY OWNER-BUB.DER DECLARATION OVER 1100 AMPS
C w Q I hereby affirm mat I am exempt from the Contractors License Law for th< ❑BATH REMODEVREPAIR DEMOLITION -
k30.V following resin..ISection1031.5,Businessland Professions Code:A.,ely orcuuntySIGNS ELECTRICAL
- ❑OTHER
_W W which reyuirts a permit to construct,alter,improve,demolish,or repair any sometime
Irianou its t, mancealso xpmraa the applicant broach pc n it sged tntemcnt' SPECIAL.CIRCUIT/MISC. "
i+ that he'.licensed p nu nn thep t tad ftheC n mea License (Clatterera9
p0 (coir n n l tg vvithSection 700(biaMiAtion 3ofne Ini,imet,wid Profittrum,Code)in TEMP METER fill POI B INST �• "
14 e pf mat he a exempt themfmm and Ne basis f theIlegul axe pt A y v olutinn of ❑NEW BLDG/ADDITION ❑DEMOLITION
YpS, ts'
Section 7031.5 by any applicant for a Permit subjects the applicant t - I penalty of POWER DEVICES
so Mtn ❑TENANT " 1 ❑FOOD SERVICE
M t mum than five t h ndredprops dollars y employees
I,a:owner of the � IMPROVEMENT--
C ❑ property, from
fora ,(See compensation, SWIMMING POOL ELECTRIC
will native work,and the awcwm isnot intended oroffercA for salt(Sea 7044,Business ❑OTHER
3 and Profession.CuOe:The Commuc or's License Law does not apply to an owner of OUTLL+TS-SWITCH(?S-FIXTURE
S _ r
property who builds or improves thereon,and who does such work himultor through
his we employees,provided that such improvements ore not intended or offered for NEW RESIDENTIAL EL.ECfR SQ PT. -
' sale.If,however,the building or improvement is sold within one year ofcompletion,the `FL FLOORAREA VSQ,FT.
ner-builder will have the burden of proving that he did mat build or improve for pun- �L ����
you mule.). - }
❑1,m owner of the property,um exclusively connecting with licensed comments 10 TOTAL: /s !
construct the Project(See.1044,Business and Proes,iam Codc:)The Canwctara Li- CITY UJ-
close Law does not apply to an owner of property who builds or improves Ilarcon,and QTY. PLUMBING PERMIT, FEE LaUrCMIIIVU
who contracts for such projects with a contraction)licensed pursuant to the Contractors
License Law. 1,
❑I am extort under Sec. ,H&P C,(a,thisrcasm PERMIT ISSUANCEr _
OwnerData ALTER-DRAIN&VI!NT-WATER(EA) VALUATION. °• - ' , �,' I ,
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby mlirm under penalty of pe jury one of the following declaration:
.0 L have and will maintain a Certificate of Consenuo self-insum for Worker's Carrier- DRAINS-FLOOR.ROORAREAI CORD, STORIES' TYPECONSTRUCI'ION
sutian,as provided for by Section 37M of the Late,Code,for the performance of the - � )
work for which this pemtitisissued. s FIXTURES-PERTRAP. � "'t0
1 have and will maintain Workers Compensation Insurance,u required by Section
370C.Ohe Labor Cede,forthe perfotmaneeofinework farwhidt this permit is ismod. GAS-EA.SYSTE:M-IINC.4OUTLEfS '
My Worker p.'rtioa artier and Policy r OCC.GROUP APN
Comer. t� Alumnae Policy No,lT to 7ti7s GAS-EA.SYSTP.M.OVER 4(EA)
CERTIFICATE OFF EXEMPTION FROM WORKERS' (
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section aced nor becompleted if fi a pemtit I.bonne modest dollars($100) BUILDING DIVISION MRS
- GREASETRAP, PLANCHECKFEE - ..
certify that in the performance at the work for which this permit N issued,l shall SEWER-SANITARY-STORM EA.200 FT.
'7 not employ any person in any manner sous to Income subject to the Worker.{Compen- ENERGY FEE
cation Lawaol'California.Data t- ,. WA'fF.R 1113ATER WNI!N'T/ELECTR '
� Applicum - GRADING PEE
NOTICO'I'O APPLICANT.IL after making this a Cenioncmc of Exemption,,you should ,WATER SYSTEM/TREATING hccume subject subjeco the Workers Compensation provisions of the Labor Cade,you muss SONS FEE • i'
forthwith comply with such provisions or this Permit shall he deemed revoked WATER SERVICE
Q
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB,. SQ.FT. PAID
fJQ k for
rwhich thi thermic i issued(Sec.30KO..ding agency for the performance of Date Rtteiptp
ti the work for which this Permit is issued(sec.1091,Civ.CJ - -
O F' Landers Name TOTAL: -
Lenddn Address UJ TOTAL:
1 certifym
that 1 have read this application and state that the above infmmion is BUILDING FEE
..y cmorct.I.,me to comply with all cityand county oNinnnces and smte laws rtlating to QTY, MECHANICAL PERMIT FEE
-L> building connection,and herebyaumorire mpreuntativen of thio airy to enter upon the SEISMIC FEE
abuse-mentioned property for inspectio purpoue.. PERMIT ISSUANCIi
(We)agree It,u , em d keep hated the City of Cupeninn against ELECTRIC PEE
liabilities,nish,ee ,cost ones which nny weyaceno.'rost said City ALTERORADDTOMECIL
r in<nnscynew the the - - ' PLUMBING FEE
APPCIC UNI ,T n( C WI IALL NON-POINT AIR HANDLING UNIT ITD,III,(100 CFM) '
r U F,G' I S. MECHANICAL FEE
'AIR HANDLING UNIT(OVER IgLXXI CFM) CONSTRUCUONTAX `
g.ati treon ant ter _ //m EXHAUST HOOD(W/DUCE) HOUSING MITIGATION FF.E
A' DOU ERIALS DISCLOSURE
-I the.pplica.t m ilding accupranme or handle humdom material HRATING UNIT(TO 1(0000 BTU). -
v Jefi d by the Cupenino icipal C.
Chapter 9.12,and the Health and Safety
Cade,Section 35532001 ITfiTING UNIT(OVER 100,(1(10 BTU)
❑Yes ON. VENTILATION PAN(SINGLE RESID) PAID
Will the applicant nr form.building occupant use equipment or devices which Dam Receipt g
emit haaudaus air contammenH as defined by the Bay Arc.Air Quality Management BOILER-COMP QHP OR 100,(100 811fi -
District7' - TOTAL: - -
❑Yes ❑No - BOILER-COMP(OVER 100,000 BTU) -
I have mad the hamnhins materiels nx,irtments under Chapter 6.95 of the Cali. AIRCONDITLONER ' ISSUANCEU
Tamen❑cnith&So(ety CNe,Sections 255115,2.5533 and 25534.1 understand that if me NEW RI!SIDQNUAL MEC]L. SQ.FT.
building does oat aere.dy have.tenant,diet it Is my on,sonsibility to unity the occupant
ofthe mr,timments which must he met prior to issuance oto Ccrilicateof Occupancy.,
Owner or authorised agent Data TOTAL: ISSUED BY:
OFFICE