31355 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 31355
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS /)^ l�"� SANI'T'ARY NO. APPLICATION SUBMTPI'AL DATE
Sq
OWNER'S ,. /,�//`(/ NE: CONTRA S AME: LI
r I NIC CONTROL
�{RCHITECgENGINEER: LIC NO: ADDRI S: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
o '�/ ❑ Consultant Fees Paid by Applicant(Initial) BLDG CL�E({� PLUMB MEC .
LICENSED CONTRACTOR'S DECLARATION QTELECTRIC PERMIT FEE ❑ / ElY.
I ncany oestrin Inas I am Bcca.d ender prnviain.,nr cnapter 9(calmne.cfng JOB DESCRIPTION
�DMZ ah Soahm 7(HXoo inn3ol he Bminenand r..fexxinm Code,radnty liceac is RESIDENTIAL'
00 wrfull force and cfl' t. PERMIT ISSUANCE
uF. '" -�.///, ❑SFDWL L1 KITCHEN REMODEL,
FQUU License m- G!/��Lic.X APPLIANCES-RESIDENTIAL [I ADDITION El PLUMBING RE-PIPE
F. nae TS DEl.f
ARCHITECTS UECLARATI(, ❑MULTI-UNIT ❑MODIFICATION ZO°fsZ IundcrsmnJ my plans shullMuseJ as pontic ranN. PANELS MODIFICATION
OZ.. UYT0200AM1'S ❑IN]HRIOR [_I CHIMNEY REPAIR
F•N•F hiccmcd l'rnlee:.innal21)1-1000AMPS IMPROVfiMFNT
IY C Q I herchy m(firha hER-BUILDER
mt Ie exempt from the Continuous
DECLARATI ' License Law for the OVER NXIC [IAMPS BATH REMODEI,REPAIR ❑DEMOLITION
xGOiU m following maxim. 703 LA Business aW Professions CWC Any city or county SIGNS ELECTRICAL ❑OTHER
ID 3 LL H which requires a permit to construct,alter,improve,demrlish,or repair any saucare
F�OQ pdorto its issuance.also requires the applicant forsuch perminofle a signed statement SPECIAL CIRCUI'1'/MISC - �,� w
S D thoth I' Jp so v th p fth C t f 1 1 (Chapter9
W 0 (arm g 41 S.ti 7(X)) ID' 3,,t,hc 13mone,,andP fice,sooCode)or I'17MP.METER OR POLE INST. f'OMMERCIAL'
a c c that be is exempt tnercfrom and the bass for me alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ao Sevami 0031.5 hyany a licwt fora 't suh'ec¢thee Ticanno a civil penalty of POWER DEVICES
=res pp Pena' / VF ❑TENANT ❑FOOD SERVICE
m more rhe five hundred J.Ilors(55(18).
IMPROVEMENT
Fl SWIMMING work.the pestructummyemntended mowadinsideirsole rompemaiess SWIMMING POOLELF:CIRIC
WCmwill Professions
Codcesa Contractor's
intended Law
an Business []OTHER
W
5 and Pndof h CoJC The Contr1h.n's L rid at Lnw such
not apply nr an owner of OIL LETS-$WITCHES-FIXTURES
propeny who holds or improves thcah i and whoimprovements
that,m n work deed o l'or enrou far
his own relplOYCON.Provided that such impmvemcnu arc not intended a orfered for NIiW RFSIDENTIAI.ELECfR SQ FT.
sale If.however.the nuilJing orimpmvcmem is sold wiNin one ycaof completion,the SQ.FT.FLOOR AREA LSQ.I'r.
ner-builder will have the burden of proving that he did not build in improve far pur-
pnu of sale.).
❑has owner of the propeny,am exdusivdy c.mmeting with licensed contractors to TOTAL:
<nn.amn rhe project f5ec.]1M4.Business and Professions Cede:)The Comrvcarrx Li-
eeLasvdoanmapplywaswithaonromosswhnhull pursuant
to the
Contra and QTY. PLUMBING PERMIT PL'E
who mommas for such projamv with a auntmemr(a)licensed pursuant w the Contractors
Llaersc Law' PERMIT ISSUANCE
I am exempt under Sec. .B&P C for this reason
•Owner Date ALTER-DRAIN&VENT-\V R VALUATION
WORKER'S COMPENSATION DECLARATION
FLOW PNOf[CI'.DE CE
1 twels,affnn under penalty nl perjury ono of the following declamllnnx'.
❑Ihuveand will imain a Certificate of Consent to,wlf-in,am for Worker',Camper- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPHCONSTRUCTION
anti..,a.provided Ibr by Section 37W.1 the Labor Code,for the permormce of the
w"k for which this permit is issued. FIXTURES-PER TRAP
I have and will maimain Workers Compensation Insurance,as required by Section
3000of .Ne LaborCode.fonhe perfonnmuccifrheworkfnr It hthisp rrs issued. GAS-EA.SYSTEM-I INC.40UTLETS OCC,GROUP APN
My Worke o re. i r s 'a cr d Policy{�u ,s L (y ��
Carrier Policy NO.: GAS-EA.SYS'I'I?M,OVIER4WA)
CIERTIPICATI?ll I?%I MM[ON FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCCTI'OR
BUILDING DIVISION FEES
(This accost need not beasmpleted if the pemtit is feature hundred dollars(SIM)
GBSETRA
or less.) FAI' PLANCHECK FEE
I certify that in be pedimmus,oOhe work for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 14.
not employ any person in any manner so as to become subjecno the Workers'Compal ENERGY FEE
zZ .croon Law,Of Cullromia.Date WATER HEATER W/VENT/ELECTR
Q Applicant GRADING FEE
NOTICE TO APPLICANT:If,after making this Cenificim of Exemption,you should WATER SYSTEM?BEATING
f-' > become suhjet m the Wwrker,Com,mido n provisions of the labor Cede,you most SOILS TLE
foehwithcomply with such proom msor this permitshill he deemed mvoked. WATER SERVICE
m �
z CONS)RUCTION LENDING AGENCY NEW RESIDENTIAL 1•LMB. SQ.FT. PAID Date Receipt 6
V O Ihercny affirm that there is:eonslmerion lending agency for the perrarrnance of
Ir mi
the work for whahthis pert is issued(Sec.3097,Civ.C.)
0 F" Lender's Name TOTAL:
Lender's Address - TOTAL:
I cenify that I have read this application and sate that the above information is BUILDING FEE
hcorrect.l agree to comply with all city and county ordinances and sate laws relaing to QTY. MECHANICAL PERMIT FEE
�.) ,Z building romuactina,and hereby lmthnnze repreumaives olthis equi emerugntfte SEISMIC FEET
mars-mentioned propeny for notoottion p"rp.sra.,:k PERMIT ISSUANCE
(We)ogre wsave,indemnify Ind keep honalax the City of Cupenlno against ET.IECI'RIC FEE
ludilides,judgmems,costs and expanses which may in any way accrue against said City ALTER OR ADD TO MECH.
incomequeacco(degrartingofthispermit. PLUMPING FEE
APPLICANT IdDERSTANDS AND WILL COMPLY WITH ALL ON-POINT AIR HANDLING UNIT ITO 10.(X0 CFM) MECHANICAL FEE
SOU IONS.
/ AIR HANDLING UNIT(OVER MOM CFM) CONSTRUCTIONTA%
&Sd5m,61Appf,cma/CoOh;w1o1 Dam EXHAUST IIOOD(W/DUCT) HOUSING MITIGATION FI?Ii
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicantor future building oecupvmaareor handle hmallom mmenal HEATING ON]T(1'O 1110.000 BTU)
a defined by the Capetian Municipal Code,Chapter 9.12,and the Health and Safety71 s -.S
Cede,Section 2553200/ HEATING UNIT(OVER 100.000897
❑Yes n PAID
�m, VIiNTILATION PAN(SINGLE RESIUI Date RceeiptN ./V
Will the applicant or I'utum building occupant use equipment or devices which
Um,havade.,air cora ommi x as dcliand by the Bay Area Air Quality Management BOILER-COMP OHP OR RX)TO(I13'1'U)
TOTAL:
Ucsmetl /
11 Yes BOILER-COME(OVER 108.(18 BTU)
/�IJo
i
1 have real the hwa bas materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER0 ISSUANCE DATE
fnmiO Heahh& 'dy Code.Sections 25505.25533 and 25534.1 understanding if the NEW RESIDENT[Al.MECH SQ.ET
nuilding dcrxl really haveatcnulll.Mat it"any rapnn,aahtym nmifylha wuEnot
nr the v ich mon he ester'prirnmiasam"O,in Ca at o
nth 'ttwag est
Data
TOTAL] ISSUED BY:
OEFICE.