S 1353 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL)ING-ELV.CrRICAL Pitt .
BUILDING DIVISION APPLICNI'lON/PERMITPLUMBING-MECHANICAL 1353
BUILDING PROJECP IDEN'rIPICATBTN
BUILDING ADDRESS: SANITARY NO. N'PLICAIION SUBMI'I'1'AL IJAI'I
OWM1'IiR'.' G: 'I
It CON' RA "NAa �J, LIC NO.
�f NICILL
CUM1 BOLA
ARCHITEC'VENGINTER: LIC NI I: At) FSS: ❑
h
CONTACT: I1110NII: _ BUILDING PERMIT INFO
qq ❑ Consultant Fees Paid by Applicant(Initial) BLDG PLECI' 'LU ILL
A O ❑ ❑ ❑
LICENSIiDCD 1.ACI'OR'SI ?I.ARATIUN QTY ELECTRIC PERMIT FEE
1 hereby alErm that I am licensed under paresi....ae nl cualnkr I(cmmmeneing JOI3 DESCRI I TION
C'YZ with Section 7ga)of Division 3 ofuhc Busincrs and l'mfinelom Cdc.and my becoscm RESIDENTIAL].:
u:OC, in I'IiRMITISSUANCE
F a,— full force and effect. 0SFDWL 11 KQCHEN REMODEL
aUU License Class Lica APPLIANCES-RESIDENTIAL ❑AEDITION Uh1HING RIiPIPIi
l-Zw Dxa Carl ruclnr
rn6d Oh1U1.TIUNIT OS UCTURAI.
cinARCHITECT'S DECLARAI'[ON
Z O H Z 1 understand my plans shall be mcOm public records PANELS MOD119CA1'ION
OZNC UPTO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed l'micv,ioced 201-101)DAMPS IMPROVEMENT O SWISRIING POOLS
5 Q 1 hereby affirm IhwNtat I am exempt fromLDER theC mtmlaur's License haw for the OVER 1000AMPS C1 BATH RIiMOUIiIBTa'AIR ElDIiMOLITION
3 El OTHER
following reason.(Section 31.5.Business and Profersiom Code:Any city or counly SIGNS ELECTRICAL
F wi71
I- which requires a permit to Construct,alter,improve,demolish,or repair any aructare
primum its lmoanee.aho requires the applicant for such permitm file a signed saament SPECIAL CIRCULUIL SC.
any that he is licensed pursuant to the previsions at the Contractor's Liecme Law(Chapter 9
m��0 (commencing with Section 700)of Division J of the liminess and P'rofmsinna Code)or TEMP.METER OR POLE LISTS14 COMMERCIAL:
a.a C ]hat he is exempt therefrom and the basis for the alleged exemptiou.Any violation of ❑NEW BLDG/ADDITION ❑DIiMO1,ITION
W m Section 7031.5 b Permit eab'eme the applicant mm a civil leaaB f POWER DIiVICF_S
y any applicant for ) Yo' ]TENANT Fool)SERVICE
not more than five hundred dollar(5500). IMPROVEMENT
=O ❑ I,mownerorthe propea,,comeoldoyees with wages as theirsole conniemation. SWIMMING POOL ELECTRIC
�F.m will do the work,and the sumeoure is not iatendedarofemJ farsele(See 7014.❑minae OOTHIiR
L'3 and Pngisouns Code:The Contractors License Law does not apply In ret owner nI OUI LETS-SWITCHES-FIXTUR
prupeny who builds or improves thereon,and who dxs such work hlnmsclf or through
his awn vi-qu,n ue,providM]hat such Impmvcmcnte are not intended or official Int NEW RESIDENTIAL ELECZR P.
sale If,however the building or impnwenantkwdd with'mnne ycarurvorpir ion.the SQ.1-1.[:LOOK AREA EISQ.14.
u-bmWer Is l have the hooka provingal' that he did not build or loprn a for par
pure of sale). v TOTAL:
❑ 1,us owner of the property,am exdmlvely conimelamg with licensed contruco s m
mulct the project(See 7044,Palms,,Land Preterm.....Crdr:) he ComniOnre Li-
saLawdoes lmotapply(it ano-mrol'prope'rty who builds or mprovea demon,and (YI-Y. PLUMBING PERMIT PEE
whomnwclyficmin prop,a,w llh a anmriamr(s)Ikcmal pnrsua I ,,the COmtuaturs
Liar"Law. P ERMI'IISSUANCE
(] Iummmnplunde,See .It M P C Iia In,moon
ALI']It-DRAIN k VENT-WATER(EA) VALUATION
OvL Umc
WORKER'S COMI'ENSA'I'ION UECI.AI NITON BACK FLOW PRGTEC'I'.DEVICE Ili 11„ n
1 hereby affirJcr pf p
m nnenally oerjury ono of the billowing declurntlors:
I have and will maintain eCerificmeofC... edursdl'dmuref..Worker's Comgnm- DRAINS-PLOOR,ROOK AREA.COND. STORIES ,I:YPECONS'TRUCTION
samn,as provided Gu by Section 3701 Ill he LnMa Code,for due pcdinn acre ul the
I orfir d
ki pennit is ru< .JIIXTUR1iS-PERTRAY
w
I have and will maintain Workers Colmpem:llhnl I'mmanec,us recoiled by Sermon
3700of the Labor Club,Ili,the P:thanan,rof he work l in which this permit isisuacd, GAS-Hat.SYSTEM-I INC.4 OU'LLETS OCC.GROUP AI Op
My Wnr ' , ear m Im,ura c" 1 folic GAS-EA.SYSTEM-OVER 4(EA) G. OO
Carrier. Policy ILL �NSpE
'ERT ICATIi( 'B?XEMPIION FROMK)RKERS
1 COMIIPNSAI'ION INSURANCE GRIiASF%INIIUSTRL WASTE INTERCEPTOR BUIIAJ f1 WV151(2 1':I'S' A T m
(This section need not he annplclN 11 the pcnnil is lbnme hundred Jollam(81(X11 GREASE TRAP 1'/ '
ar less.) PLANCHECK ITH J. N
I certify that inlbc pcdoureaccoflhc wnrk msmL h
for which this permit is <d, a11 SEWER-SANITARY-5'TORM EA.2fq IT
not employ any person in any manner so acme bee o..w,rd ro m the W..kers Co opera ENERGY FEB
Z zainn laws of CtliOmmix.Dale ILL HEATER W/VENT/ELECTR
z0 Applicant GRADING THE
z Is ICE TO APPLICANT.IL after making this Cenilicae of Exemption,yen should WATER SYSTEMI TREATING
become subtest tO the Worker's Cr viva otion pmviaom of the IaMa Crdc,you must SOILS PER
CX D.1 lirnhw'ith comply with zacb pmswereor this permit shall he devoted resulted. WATER SERVICE
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI-MB. SQ.FT. ]`AID Dae Receipt p
V 0 I hereby aRrm that hem is a amstrction Lending agency for the pc f0 mmNC of
I1 F., the work for which this permit is issucd(Sec.31107,Civ.C.)
TUI'A L:
U LendetTOTAL:
a Name
{Z1 Lender's Andress
G 1 certify that 1 have read this application and swe that the above information is BUILDING PIiG
N comet.l agree toamnply with all city and county onimnecs and stale laws adding to QTY MECHANICAL PERMIT FEE SEISMIC FEB:
I.) z building crmtration.and hereby authentic mprevenlativmofitak city memer upon the
ala,re-mentioned property bar impcaion purVwx%. PERMH'ISSUANCE ELECI'RIC FEE
(lye)agree to wve,indemnify and keep hamdeu the Cary of Cupenin,against
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTERORADDTOMECH, PLUMBING FEE
III asequence 01 the granting of this permit.
API'LICA 'UNDERSTANDS AND WILT,COMPL4/n
NT AIR IIANpLING UNIT(TO 10,310 CPA) MECHANICAL ITE
'P .'ULA'1'11
AIR HANDLING UNIT(OVER 10.1100 CFM) CONSTRUCTION TAX
Signa cal.pp an✓Cantr 1 tc EXHAUST HOOD(W/DUCT) HOUSING MI HGAI ION FILE
HAZARDOUS MATERIALS DISCLOSURE
Winds,a'bcau or future buildnglccr:parts more or handle holaNnuv Material HEATING ON IT ITO HXk000 BTU)
as de ined by the Cripenino Maicipd Crdc,Chapter 9.12,and the[Icahn and Safety
Crdc.Srctinn 255320x)7 HEATING UNIT(OVER 100,0 0 BTU)
❑Ycr 0 N VENTI IATION FAN(SINGLE REST D) PAID
Dam Hacipt p
�IWiIre Ih<applicant I,,(marc huilding m,o pmet me equipment or devices which coal
BTU)
emit bae:udnm at,cnnw circuits ae Jetined by the Bay Arca Air Quaaity Mawgarem BOILER-COMP(JHPOR IW,
TOTAL:
Dieuict'1 BOIIAR-COMP(OVER 1100,000BTU)
❑Yes 0 N
Ileuhaverwd the latennbntyirena
....aciulern . aunder
r Chapter(n95 of the Cali. AIR CONDI'I'1 ONER ISSUANCE DAIE
fumin hh IS Safety Coda Sections 25505,2.5.533 rind 25534,1 on l,mr: I Lha if the NEW RI'.SIDPiN HAI,MITCH, SQ.Pr.
building deer net critically have it ananl,Ih d it Is my 111 mmoblfuy um amity the n"a'sna
ot')Ie equiTenmem which ram be o0pdn11,ie11omre Ill;I Ccnaficme ol'Ocnlpency.
Outer,or allhari,d agent Dule TOTAL: ISSUED BY:
OFFICE