31040 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF'CUPERTINO BUILDING-ELECTRICAL PERMIT NO 3q1Q
6Uu,)ING DIVISION APPLICATION/PERMIT' Pmc
I.Unm .NIECIIANICAII 3040
RUIL)IN(;PROJECT IDF,NTIFICAI'ION
BUILDING ADDRESS: �r/O� // /% SANITARY NO. APPLICATION SUBMITTAL DATI
OWNERS NAME: P NE' CJOIWRACfO N I LIC
N/C CONTROL#
ARCIF"aC ENGINEER: NO / AD R5SN.-//'�-
CONTACT: PHONE:; YW ✓iY✓fes .eiYMW, al (/M//'!/~/_ BUILDING PERMIT INFO
L�] Consultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ ❑
I hereby affirm that 1 am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
qaZ with Sectiou'I"hol'DivisionJoflhe Businc,md Pn ffsinn: c. nit liccnecix RESIDENTIAL:
F-W. in full force and effcat PERMIT ISSUANCE
aUUW' ❑SFD IT ❑KITCHENRE-PIREMODEL
License Cl Lic.p pppL1ANCES-HESIDEM'IAL ❑ADDITION ❑PLUMNING RHPIPE
Q L Dae Cnmmem,
HITECT'S DECLAR TIO ❑MULTI-UNIT ❑STRUCTURAL.
F--D'y PANELS
Z O'^Z I understand my plans shall be used as public records MODIFICATION
OZ=O UP TO 2W AMPS CI INTERIOR [I CHIMNEY REPAIR
Liecmxd Profescionol 201-Itk10AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
021.4 OVER 1000AMPS ❑BATH REMODEVREPAIR El DEMOLITION
C Q I hereby afBnn Na 1 am exempt from the Contractor's Liunse Lew for Ne
�S M We:Any city orcounty SIGNS ELECTRICAL [10 HER
U following reason.(Section 70)1.5,Business and Professions C
LLl a LL y which requires a permit m contact,alter,imm..rvc.Jcnwlleh,nr tepid,any nueture
E-LL'"t prior to its issuance,also requires She applicant for such permit to file asigned sum
teent SPECIAL CIRCUI'17MISC.
mmmvWvW��}
thea he is licensed pursuanun the pmvrsiomofthe Commemr's License Law(Chapmr9
CCp� (commencingwith Seenini70(NOof Division 3 ofthe Bu1mc11mdPfofesxionsCWe)o, TEMP.METER OR POLL INST COMMERCIAL
d e C thm he is exempt therefrom tmJ the basis for the alleged exempnon.Any violainn of ❑NEW BLDG/ADDITION ❑DEMOLITION
^y Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars Who).
IMPROVEMENT
SQ ❑1,as owner of the property,utry employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
{..� will do She work.and the structure is not intended or offered for%ale(See 70,14.Business El OTHER
6 3 m and Profemiom Cade:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,providcJ Shot such impnmemm�ts are not intended n offered for NEW RESIDEM IAL ELECTR SQ Fr.
ea1e.11 howeverthe building orimprovemem ismldwithinone yearofcompletion,theSQ.FE FLOOR AREA $/SQ.FT.
oisner-builder will have the bunicn of proving that he did not build or,mprove for Fur-
pose ofsale.). �,�`
C I,as owner of the pmpeny,am exclusively contracting with licensed nmhacmts m ox .
construct project(See.7(W,Business and Professions Cade:)The Conuannr's Li-
senseLawdoesnotapplytoanownerofpropertywhobattlesorimprovesthereonand QTY. PLUMBING PERMIT E
who cnnvaas for such prnaects with a comrnctur(.$)Iiccmed pursuant to the Comrnnor's
License In, PERMIT ISSUANCE
lam exempt under Sec. .B&P C for this mason
ALTIiR-DRAIN&VENT-WATER SEA) - yALUq'Tlpry
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affem under penalty of pdf Co one of the fallowing de Worker's
ns
•I] Ihave and will maintain by ection dans of ComentmCode.Forther Warkc,'eco of the
DRAINS-FLOUR,EDGE,AREA,COND. STORIES TYPE CONSTRUCTION
cation,as Provided forma Section A]IX)of the Luton CWe,for the perliammnce of the
r have
Nis ainta is issued. FIXTURES-VIiR TRAP
1 M1uve end will maintain Worker's Came of
n work
for w n as required by Section
3700 nfthc l,uM�r Coxlq Tia the performance of the work for which Nis per nit is iscnN, GAS-EA.SYSTF;w INC.40UTLETS OCC GROUP APN
My Worker n I I P ce ierandl'olicyn to
Cartier.-A Policy No.: GAS-EA.SYSTEM-OVER 4 RE Q
CERTIFICATE.OF (EMPTION MOM WORKERS'
COMPENSA'L'ION INSURANCE GRIiASFJINUl1STR1.WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need net he completed if the Sammi is for one hundred dollars 1$1 San GREASETRAP
or less.) PLANCHECK FEE
lactifytha'mthe le,tomman of the work In, hich,hi,petmitls issuoil* pn
[,bull SEWER-SANITARY-STORM EA.200 FI,
not employ any person in any Droner m as to became subject as the Warkers'Cmnn- ENERGY THE
0 ,Z cation Laws of California.Dam WATER HEATER WNENT/ELECTR GRADING FEE
z o Applicant
H NOTICE TO API'LICANI':HE after making this Certificatcof Excm.Oon.you should WATER SYS I'IMNREAI'ING
F > become subject to the Workers Compensation provisions of the Labor Code,you most SOILS FEE
Wforthwith comply with such provisinm or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LBNDINGAGLNCY NEW RISIUIiN'1'IAL PLMH. SQ.ET. PND
U ,z Date Receipts
V work
which his
that Ncre isxconsuee 30lending agency for the performance of
the work for which this permit is issued(Sec.Jo9],Civ.C.)
w � Lender's Name TOTAL:
L) Lcndces Addicts TOTAL:
04} BUILDING TLE
I ccnee that I have real this city
and county
Intrastate that the above information is
Vl bucca 1 agree to comply with all city and county nNtives IS and seas lows r upong m' QTY. MECHANICAL PERMIT FEE
V ,� building constmctinn,and hereby authnriecrcprcsenutivesul thiscitymemerupon Ne SIiISMICFEE
above-mentioned property far inspection purposes. PERMIT ISSUANCE
(We)agree h,save,indemnify and keep harmless the Ciry of Cupertino against ELECTRIC FEE
Iiabilitics,judgmenui,costsand expenses which may in any way accrue against said City ALT LR OR ADD TO MF;CH.
in consequence of the granting of this permit PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
MECHANICAL FEE
SOURCE.REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONS1'RUC'I'ION'TAX
Signature of Appli,warCentroor Dam EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
a
Will thepplicant or future building occupantstore urhandle hmallouvnme,adHEATING UNIT(TO HAN)0 BTU)
as define)by She Cupertino Municipal Code,Chapter 9.12,and She Health and Safety
Code.Sestina 15532(a)p HEATING UNIT(OVER I W,Ooo BTU)
El Yea FANu PAID
/ VGMI'ILATION FAN(SINGLE HESIU) Dae Receipt#
Will the applicant or future building occupant use equipment or devices which
emit hazardous air conamimams as defined by the Buy Area Air Quality Management BOILER-COMP PHP OR 100.000 RTU) TOTAL: 70.
DisWeR
El Yes /dry'�f J BOILER-COMP(OVER I00.000B'1'U)
I have read She ho...domnacriuls re u under ChaterM195of the Cali- AIR CONDITIONER ISSUANCE.DATE
quircmm� p
tomia cut &Suf ty CWe,Sections 25505,25533and 25534.1 undersand that if the NEW RESIDENTIAL MT:CH. SQ.TT 3 3 /-
tudidingdeesnot ndy have nW
ve a Second.that it is my resnsibihoym sonify th tncupont
(77
ofth mqu' the or toissuance ofa Cenificit en y.
Owne n agent am TOTAL: ISSUED BY:
OFFICE