31217 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAh 31217
BUILDING PROJECT IDENTIFICATION
BUILDIN A DRP_SS: SANITARY NO. APPLICATION SUBMITTAL DATE
0 Ap
OWNHN:SNAMS`IT, PLO E: ON'WAC'TOR'S ME�' LIC NOIV/ U . NIC CONTROL#
LHITELT/FNGINIiGR: LIC NO: At L
L
CONTACT: PHONE BUILDING PERMIT(NPO
�' �� _ a Consultant Fees Paid by Applicant(Initial) _ B LC LU MUCH
LICENSED CONTRACTOR'S IiCLARAI[ON 'r QTY. ELECTRIC PERMIT FEF. It
I hereby affnn used 1 am licatsed under provisions of Chapter 9(commencing JOB DESCRIPTION
O 46� wilh Section 7")of Division 3 of the Business and Professions Cule.andm license isy PERMIT ISSUANCERECIDFNTIAL:
llfame andttc"p �, �' n O f ❑�FDWL ❑KITCHEN REMODEL.nse ass V LCoal O J APPLIANCES-RESIDENTIALPp't/Conmuc g { 4• AUDITION ❑PLUMBING RE-PIPE
ARCIII'ITCT'S DECLARATION PANELS' - ❑MULTI-UNIT El STRUCTURAL
Z O v�Z 1 undemand my plans skull In,used a public retards MODIFICATION
OZ—ZI UP TO 200 AMPS F1 INTERIOR [I CHIMNEY REPAIR
1=o,i1"j Licensed Professional - 201-IJW AMPg IMPROVEMENT
a - OWNF,R.HUIIDF.R DECLARATION OVER 11101AMP5 ❑BATH REMODEUREPAIR El DEMOLITION
I hereby off nn that l am exempt from the Contraemr's License Law lin the
36 U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS P.LECTRICAL ❑OTHE
LL which inquires a permit toconstruct.alter,improve,demolish,or repair any swnure hl
=�0 prior to itsiemince,iii.requites the applicant for such penamm fictioned atatemcnt SPECIAL CIRCUITIMISC.
cis ts.< that heis licenxdputsoata to depnwmerrsof the Commences License Law(Chapter 9
❑❑DO (emonteming with Section700mof DiAtion 3of the Bnsinessand 11 resslone Code)or TEMP MEI ER OR POLE INST, nem
a tY that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑N I DI/µ/n ❑DEMOLITION
{v Section 7031.5 by any applicant for a permit subjams the vppBcant m v civil penalty of POWER DEVICES •'�V
w al$d'FI4AO ❑FOOD SERVICE
} mmom than five hundred dollars(ssw). eye�h��{
fit wi Lmhe work.the pmpeny,mmycmntendes withwagesaale(Sec. 044. iaiacsv SWIMMING POOL ELECTRIC NIj
will dothewons anti ilia The cture Comisnotemendedn vilcred Law does
notl apply
an owner
❑OTIINk 61
1 and Professions Code:ho es.mention.
License w Laws such
not apply s if owner of OUTLIiTS-SWITCHI3S-FIXTURES
r property who builts m improve Ikota i and who Joe such wink himself or through
his own employer,provided used such improvements are not emanated or o0eret far NEW RFSIUENTIAL IiLELTR SQ FT.
ado If.however,the building or improvement is sold widen one yam.f completion �1 SQ.FT.FLOOR AREA SISQ.FT,
cr-hmider will hovethe burdenof prnving I hal hedid not huil'I or improve for pur- I / 'Ly111.
pose of sale.). Lr
1,as owner of the profanity,am exclusively contracting with licensed contractees to k
conswn me project(Sec.7014,Business and Professions Cwle:)Me Connector's Li-
cense low does nm apply manow.m.1'property who huilds or improves thereon.and QTY, PLUMBING PERMIT FEE U`
who unnhuns for each prujuis wish n oomrador(s)licensed pummmun the Cnmrnnnr's
License Law. PERMITISSUANCE
❑ I am exempt under Sec. ,B A,P C for this mann
Owner
ALTER-DRAIN A,VHNT-WATER(EA) VALUATION
Dee
WORKER'S COMPENSA9dON DECLARATION BACK FLOW PROTECT DEVICE
I hereby affnn under penalty a(perjury one nI do following Jcdamtinns:
I have and will maintain a Cenificate of Consent usself-insure for Worker's Compen- DRAINS-FLOOR,RUDE.AREA.C STORIES TYPE CONSTRUCTION
section,as provided for by Section 3700 of the Labor Code,for tete performance,of the
ark for which this pernia is issued FIXTURES-PER TRAP
❑1"live unit sell art rain Worker',Compensation Lawrence,as required by Section
3700ofthe Labor Cole,forthe Forbearance afthe work furwhich thispermic is issued. GAS-HA.SYSTEM-1 INC,4 OUTLETS OCC GROU' APN
My WorketCymgc Ter me UvArrte and Policy No.:number ort: GAS-PA.SYSTEM.OVER 4(FA)
Currier. 11 NN[E CC f V J)
CER'I'IPICCO OF EXEMPTION FROM WORKERS'
COMPENSATION opernuANCR GREASEIINUUSTkI.WASTE INTERCEPTOR ,Il G DIVISION PL'HS
(This section ncW not hernmplmeJ if the permit is for one hunJrca dollars(SlfNl) GREASE9RAP
critics.) PLANCI :C � E
(certify the inche peAonnancanfde work fnwhich this pennitis iasucdlshall SEWER-SANITARY-STORM EA.2W Fr.
not employ any person in any manner sec a m become subject m tlm Workers'Crnnpen- ENERGY FEE �r
Oz section Lnwsaf Cul i foein.Data WATER flEAMR W/VFN'NELECTIt
Z Applicata GRADING FF,
rade NOTICE TO APPLICANT.ILaMr making this Ceniftcme of Exemption,you should WATER SYS'I'EMaREAI'ING
a > become subject to the Worker's Compensation musicians,of the Lather Code,you most SOILS FEE
Ikl forthwith comply with such provisions or this permushall he deemW revoked, WATER SERVICE
Q
'J�. CONSTRUCTION LENDING AGENCY NEW NLtSllll?NTIAL PLMB. SQ.PI'. PAID
U 0 (hereby nation,that them is v construction lending agency for the per(omance of
Data can p
U. H the work for which this periotic is issued(Sew.31197,Cil C.)
O U Lenders NameTOTAL:
Centers Address
I certify mvt 1 have read the.application unit scam that the olwve inl'ormminn is BUILDING FEE,\,in /a
V) correct.l agree m comply wish all city and county ordinances and state laws mincing m QTY. MECHANICAL PERMIT FEE
CJ Z building construction,and hereby authorize representatives of this city to enter upon the SEISMICIT:TT
above-mentioned prolixity for inspection purposes.
(We)agree m save,inds, fard keep hannleas the City of Copeman against PERMIT ISSUANCE, ELECTRIC E'l 0
liabililics.judgrnems,cos..andexpenscswhicIt may in an way vccme against eiJ City
n comacatence of de gendng of this permit. ALTER OR ADD TO MECH, PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL, it ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)SOURCC NEGUI.ATION'. MECHANICAL FEE
-'f /1 AIR HANDLING LINE OVER IO,000CPM) CONSTRUCTION'T X
or
Signamrco ApplicantlConaacttel PXHAUS HOOD(WIDUCI) HOUSING MITIGAT .E
HA9ARDOUS MATERIALS DISCLOSURE?
Will the applicant or Tatum building occupant store or handle hazardous material HEATING UNIT(TO IM.WO BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and de Health and Safety
Cole,Section 255321o17BEATING UNIT(OVER MOW BTU) -
❑Ya ❑No VENTILATION PAN(SINGLE BESIDE PAID
1. Data RecciA-
District?
Willman applicantorfurore building occupantaxeea AllnQuor deviceswhich BOILER-COMP(3HP OR 100,000 BTU) 'st humrdous air cnneminnms:ndcftied sy the Ilny Aren Air Quality Managmnent TOTAL
0y. ❑Nn BOILER-COMP(OVER IM."BTU(
/
J (hove reel the hazardous mmerivls reyuiremnns under Chapter 6.95 of use Culi- AIR CONDITIONER - - ISSUANCE DATE
fomin I licalth A Barelyre Cote,Section 25505,25539 eant]sp 25534,1 Inde end men I[the NEW RESIDENTIAL MICII. SQ.FT.
building toes not currently hove a Roos that itis 53 responsibility ria notify she hat if t e
of she requirements which most he at prior to ivamc of a Certificate of Occupancy.
Owner or authorized.,art Data ISSUED BY:
OFFICE