31173 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICALS PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 31173
BUILDING PRO.IFICI'IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
LIr�AqVLiarf —
OW ER'S NA E: PHONE: CONTRACTOR'S NAME: LIC NO: N/C CONTROos L a8' Yo68 E- 5Teve^5Lrxt:c 1 Karts s I.is o 5
ARCHITECfIENGINEER: LIC NO: ADTRESS:Y110ADAIGARA Be o�nond
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG/- ELECT PLUMB_ MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE NrJ�/ rL-zSt/ rL��-nI/' L��Y/
OO w; I hereby affirm that I um licensed under provisions of Chaptar 9(commencing JOB DESCRIPTION
N Seen.7000)af Division 3ofthe Ihomessand Professions Codgandoylicenve is PERMIT ISSUANCE
in full force and effca.
� MIAL
Uf� License Class _ Lic.p 45�o A S - FDWL KITCHEN REMODEL
u� Dam Commctm APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
�' 17 ARCHITECT'S DE
C1_ARATION PANELS • ❑MULU-UNIT ❑STRUCTURAL
Z O M Z I understand my plans shall be used m public«curds MODIFICATION
OZ- UPTO 200 AMPS r]INTERIOR El CHIMNEY REPAIR
F'r Wilq"- Licensed Professional
OWNER-BUILDER DECLARATION 20I-1000AMPS IMPROVEMENT
4 Y 2�...,.....1l)1111
Fyye W 6 I hereby affirm that I am exempt from the Contractors License Law for the OVER Iqp AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
p(34 U following rcawn.(Section 7031.5.Business and Professions Code:Any city or countySIGNS ELECTRICAL ❑OTHER
YY1IµO which require a penrdt to construe,alter,improve,demolish,or rtPan any munum
prior to its issuance.itka requires,theapplirma for such pe unit to file.olinedsmfement SPECIAL CIRCUITIMISC.
that he is licensed pursuant to Ne provisions of Ne Cmnataor's License law(Chapter 9
p0 (commencing with Section 7")ofl)ivision 3 ofthe Business and Professions Code)or. TEMP.METER OR POLE INST COMMERCIAL
6`o
that he is exempt therefrom and the basis for the alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by tiny applicant for a permit subjects the applicant m a civil Penalty of POWER D13VICES
m not more Nan five hundred dollars($500).
❑TENANT ❑FOODSERVICE
Q I,as owner of the norm employees with wn es as their sole con cmad11n, SWI MMING POOL ELECT RIC IMPROVEMENT
❑ property, Yg P
will do Newoik.ands:no
inronded or offered!does et apply to an owner
❑OTHER
t13� and Professions Cade:The Conwcmrs License law does net apply to an owner of 3 OUTLEfS-SWITCH -FIXTURES
property who builds or improves Nemo,and who does such work himself or through
his own employees,provided that such improvements are not intended or offend for NEW RESIDE .ELECTR SQ FT.
sale.If,however.the building or improvement is sold within one year of LOmPle1111nthC SQ.FT.FLOOR AREA 5/SQ.FT.
owner-builder will have the burden of proving that he did not build 1110 improve for pur-
pose of sale.).
❑1,as owner of the property,can exclusively contracting with licensed commctors 10 OTA 2-
consumer the project Sec.7644,Business end Professions Cmleq The Convector I.I. (J
cenm law does not apply to sn owner of property who builds or improves thereon,and QTY. PLUMBC MI FEE
tt _
who contracts for such projects with a contrmctona)licensed pursuant the Contractors
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&P C fur this maven
Owns,
'ALTER-DRAIN&VENT-WATER(
Dam VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTEGE DEVICE .a
Ihereby idiom under penalty ofperjury one of the following decimations: C((2-0 (J d O
❑ I have and will maintain aCenificale of Consent to self-insure for Workers Cmmpen- DRAINS-FLOOR,ROOF,AREA,COND. - STORIES TYPECONSTRUCDON
cation,as provided for by Section Pon of the Labor Code,for the performance of the
work for which Nim permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation loommet'as required by Section
3700.4 the labor Code,for the performance ofthe work for which Nia permit is issued I GAS-EA.SYSTEM-1 INC,4 OUTLETS ACC GROUP APN
My Wmkers Corpensadon Insurance canner and Policy number arc:
Camcr. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPEANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section needno becumpleted ifthe permit is far one hundrM dollars TH00)
or less.) OREASE TRAP PLANCHECK FEE
I conify that inthe perfs.enfthe work fnrwhich this pe is issued.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manners a%In and fi6ien e e rken'Compen- ENERGY FEE
Z satins Laws Vi ' Date ' WATER HEATER W/VENT/ELECTR
0 ApPlicent D m✓L GRADING FEE
y .NOTICE TO APPLICANT:If,after making this Ce Bcate of .to paten,you should WATER SYSTEM/TREATING
thermos,subject m the Workers Compensation pros limns of rM1 a a Code,you must SOILS PEE
W forthwith comply with such provisions onM1ia pmmir shall be dee revoked. WATER SERVICE
Q
CONSTRUCcIONLENDING AGENCY NEW RESIDENTIAL PLMB. SQ,PT. PAID
V 0 Ihemby effimr that there ismconstruction lending agency fonhe performance of __6-_m7 RcceiptN
U. r. the work for which this permit is issued(See.309],Civ.C.)
0 1"t Lenders Name TOTAL: Z f
WLender's Address - TOTAL:YT
a I amity that 1 have read this application and state that the have infnrnmtion is BUILDING FEE a 00
N s.le Iagree to comply with At city and county mcbrtancow and state laws miming to QTry, MECHANICAL PERMIT FEE
V building romanticism,and hereby milmnee representatives of this city m rotor uponthe SEISMIC FEE
above-mentioned property for inspection purposes.
(We) a.to save.indemnify and keep harmless Ne City ofCu cain.against PERMIT ISSUANCE J V ELECTRIC FEE a Z,y
PLUMBING FEE
liabilities,judgments,costs unit expenses which may in any way aerme against said City AITF.RORADDTOMECL Q
in consequence of the granting of this permit. F
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT AIR HANDLING UNIT(TO 10.000CFSUrt1
SOURCE REGULATIONS, MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of ApplicandCuntruemr Dam EXHAUST HOOD(W/DUCIf 00 -HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE J
Will the applicant or future building mcupant store or handle hazardous material HEATING UNIT(TO IOBgID BTU)
as defined by the C,conim Municipal Cede,Chapter 9.12,and the Health and Safety
Code,Section 25532(11)? HHATING UNIT(OVER 100.000 BTU)
❑Yes E]No PAID
VENTILATION PAN(SINGLE RPSID) Date Receipt a
Will the applicmn or forum building occupant tax equipment or devices which --
emit hazallous air contaminants as defined by the Bay Amu Air Quality Management 'BO[LERarCOMP(3HP OR IOO,000 BTU) O
DintioO AL
❑Yes E]No A BOILER-COMP(OVER 100,000 BTU)
I have read zarmm
the hadous crials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
home Health&Safety Code.Sections 25505.25533 end 25534.1 undcrstatd Nat if dm NEW RESIDENTIAL MECH. SQ.FT. �/
building does not nnrently have a tenant,that it is my responsibility m notify the occupant ,1 .- ��4 /
mf the requirements which must he met poor to issuance of.Certificate of Occupancy. V [
Owner or authorized agent - Date TOTAL:q / ISSUED BY:
OFFICE