31436 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 314
OBUILDING PROJECT IDENTIFICATION
BD BUILDING ADDRESS: ^ 1^ SANITARY NO. APPLICATION SUBMETAL DATE
1n IVU IV
OWNER'S NAM ' !� E: COQiTONAME: �
OWloIrrs �S 3--v/
NIC CONTROL p
kCHITF.CE/IiNGINF. R: LIC NO: ADORF;SS: 5.5-C�-,3"'-` ❑
CON PALM PHONE: LLr! W BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ �C $
LICENSED CONTRACTOR r provi mcof CON QTY ELECTRIC PERMIT FEE
I hereby Mfr mm I am ftheBd Mader ddPoorlanx of chapter 9(rwmmenang JOB DESCRIPTION
O�Z with Sation]fIW)ofDivision3 of the Business and Pvdesxiara CtNe.and my license is
�W p in PERMIT ISSUANCE RESIDENTIAL:
FCUH full for�ce9 anFd�ef-fa'(` LA�,.1.-t.3yp� ❑SFDWI. ❑KITCHPN REMODEL
NGi Dale` — b Conuac �1 �f APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUM181NG RE-PIPE
FOy ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z p m Z I undersand my plans shall M used oz public records MODIFICATION
OZ�Im UYT02W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed Professional 201-1000AMPS IMPROVEMENT
G �"I OWNER-BUILDER DECLARATION
CC p� OVER 1000AMPS - El BATH REMODF i EMOI
I hereby reaso .(Oro o n I 1 5exempt tram the Comms Co License Law for the
Ixy 3 F following reason(Seaton]Ol LS,Business and Pntfessinns Cale:Any city an county SIGNS FLECI'RICA], ❑OTHER
y which requires a permit to comtiva,after,impmvc,dchmllsh,or hapmr any structure
F_,u,Oa
prior o its issuance,also requites the applicant hmxuch permin,,file aelgnedxmmmea SPECIALCIRCUIT/MISC.
that he is licensed pursuant to the provisions ofthc Contractor's License law(Chapter9 I
W�00 (commencing with Section 7")of Divisian 3 ofthe Nosiness and Professions CMe)er 'EFMR MITER OR POLE INST. COMMERCIAL:
a a e C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�w Semon]031.5 by any applicant for o permit subjects the applicant o a civil penalty of POWER DEVICES ❑TEtNANT ❑FOOD SERVICE
t mom than flit hundred dollar(5500).
E-
?Q ❑ as owner of the propor my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
L "ry
f Ft] DOTTER
will do the w.,k...d theswcmre is not inm.dedor-offered forsale(Sm.70sW Business
Y� m and Professions Chile:The Conuacmr's License law rates not apply to an owner of OUTLETS-SWITCHES-FIXTURES
a�'- pronely who builds or improves thrown,and who does such work himself or through
his own employees,provided that such impxwemcnts arc net intended or offered for NEN'RESIDENTIAL ELECTR S FE.
sale.If.however.the building or improvement is sold within one year of completion,the SQ.FT FLOOR AREA S/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
Inam train.).
I,as owner oro
f the property,am exclusively carimennto)
with licensed contractors t 'TO'fAl.:
wasted the project(Sec.7044,Business and I'ntl'ussinns Craft:)The Comnscox.Li- 8� 8
seam Law rues not apply on an ow,ner of nmpcny Who builds or improves thereon,and QTY. PLUMBING PERMIT FL'L
who ctmtmns Rn soh projects with a contractions)lacnmcl pursuant tome Camt-ni aw i
License]..a. PERMIT ISSUANCE FYI
I. exempt under Sec. ,B&P C for this reason 1�9 V J
Owner Date ALTER-DRAIN&VENT-WATER IEA) / �� Ur VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE i6 Uf-CfIIIIYV
I hereby affirm under penalty of perjury rote of the follawimg declarations: 71
I have and will maintain a Cerificateof Commnuaxolf-imumforwwrkees Compcn- DRAINS-FLUOR.ROOF AREA,COND. STORIES TYPECON'STRUCTLON
sation,as provideal for by Section 37W of the Labor Cale,for the performance of the
r which this permit is issued. FIXTURES-PER TRAP
wort hove and will maintain Worker's ComP"nwtom Inwmmce,m required by Section
3700of the Luton Cale,for the peraharmarc of the work for which this permit is issued. GAS-EA.SYSTEM-I INC 4 OUT LETS OCC.GROUP APN
My Works�ls tion lesions cp,� a and Policy nu W g'
Currier: fW IM"ln�lEA�/"IPoIIcy No,:RT yr g3OQ GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION DRUM WORKERS'
COMPENSATION INSURANCEGRIiASI%INDUS'1'RL WASTE INTHRCIiPI ON
BUILDING DIVISION FEES
(TM1lx section inertia becamplemJifthe permft is lbranc hundred dollars S100) GREASE TRAP
nr PfANCHECK FEE
less.)
I certify that in the performance ofthc wink Re which this permit is issued,l shall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner m ae.s
s to brol mubject to the W'ortum'Camper- ENERGY FEE
O Z satin.taws of California.Dae WATER HEATER WNEM/ELECI'R GRADING FEE
z O APPlia.t
.Na NOTICE TO APPLICANT.If,after making this Cer ificac of Exemption,you should WATER SYSTEMITREATING SOILS FEE
a , become subject to the Workers Compensation provisions of the Labor Cade,you must
for Both comply aith such provisions an this permit shall be,deemed revoked. WATER SERVICE
z 0
CONSTRUCTION LENDING AGENCY NEW ftfSIDENTIAL PLMB. gU.FT PAID
U C) I hereby affirm that there is a construction lending agency for the performance of Don
u R citing
El. F-' r
the work for which this vnit is issued(Sec,3(19].Co,CJ
Lender',Nano TOTpL:
U IFNICfa AMrc's I'Ol'AL:
tlU1LDING 'f
f-+ 1«rify that I have"crud this appliailan and none tom the above information is
Val connect.l agree to comply with all city and county ordioaoce.s and.awe laws relating to, QTY. MECHANICAL PERMIT FEE
U � buildingcon.straction,and hereby authorize mprescnmtives of this city o enter alpha the SEISMIC FIiF:
aMrvumemioned prapcny far inspection furryh"'. FERMI'T ISSUANCE
(We)ugme 1.save indemnify and keep harmless the City of Cupertino against ELECTRIC FEF.
liabiliticsjudgments.ensu and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
a. nsequcmx of the emoting of this permit. PLUMBING FEE
APPLICANT UNDERS NDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO.WOCFM)
MECHANICAL PIiC
SOURCE RF�ULATI S. ��-I���
a�// J AIR HANDLING UNIT(OVER to."CFM) CONSTRUCTION TAX
..
Sigw�! A tityApplicardContractor Date EXHAUST HOOD(W/DUCT, HOUSINGMITIGATION F i
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicamorfuture building occun.ntsemor handle hazwdous material HEATING UNIT(TO 100.000 BTU)
no,cleaned by the Cupesino Municipal Cale,Chapter 9.12,and the Health and Safety
Conde,Sectio 25532(01 1117NI']NO UNIT(OVER 100,000 BTU)
O Y. ❑Na PAID
VI?MTILAP[ON FAN(SINGLE RESID) Dam Receipt M
Will the applicant or future building occupant use equipment or devices which
'mit baardom air contaminants as defined by the Bay Area Air Quality Management HOILI:R-COMP(MHP OR 1 W,000 BI U) TOTAL:
Diadma.
s 0Yee ON. BOILER-COME(OVER 100,000 BTU)
I have read the hamNous materialsrequire tx umler Chapter&95 of the Cat- AIR CONDTIONER ISSUANCE DATE,
forma Healthre Safety Coda.a a bound.new
i 25533mad
nsibil I to notsmnd and if the NEW RESIDENTIAL MECH. SQ.fT.
building does nm currently have a tenant,that it is my rtsrymsihility m notify the acupot
of the«quimmemtx which most be met plat to issuance of a Certificate of Ocau soncy.
Owner or autholzed age", Date TOTAL: ISSUED BY:
OFFICE