31414 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL PI!RMIf NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
31
BUILDING PROJEUF IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'PI'AT.UNIT
v4f. ' 2e
OWNER:SNAME:}/�I ) of PHONE CONN�TRACT'/OER'S NAME: LIC NO:
A NS169/` %s-7 -7887 �+.g."as' Lir �a677.�,408 N/C CONTROL#
[RCI HI ECT/ENGINEE:R: LIC NO: ADDRESS:/N2Z S4/r-.�! d9 'tVICa ❑
S
CONTACT. PHONE: BUILDING PERMIT INFO
SeJ ^� ^Q �S 7 �— �7 D ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MMI
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARA'T'ION QTY ELECTRIC PERMIT FEE
C a Z I hereby amren that l am hcen.,d under prosuionx of Chapter 9(commencing JOB DESCRIPTION
1M1 Sectipn]O001of UivisipnJof the Business and Prolbssions Coda and mylicense is / RESIDENTIAL'
4100 in PERMIT ISSUANCE
HLL full force and etTect. ❑SFDWI. ❑KITCHEN REMODEI.
aUU License Class hiaq 67�YQ APPLIANCES-RESIUIiNTIAL ❑pDDITIQN [_1 PLUMBING RE-PIPE,
iZ 6 w Dae � C.mm¢ ,
ARCHITECT'S DECLARATION [I MULTI-UNIT 71 STRUCTURAL
PANELS
Z O w Z I umler Land my plans shall lM used as public records ]MODIFICATION
OZ�O UPT0200AMPS [I INTERIOR ❑CHIMNEY REPAIR
LW Licensed Professional 201-1000AMPS IMPf OVEMENT
y't7a Thereby affnm NVNuvlc elmmEfrom NcC Contractor's License Law for the OVER[Bob AMPS VIUHIff REMODEUREPAIR ❑DEMOLITION
x O a U following rcasoo.(Section 7031.5,Business and Professions Cwle:Any city nr county SIGNS ELECTRICAL - ❑OTHER �E�E
413 LL which requires a permit to constmm,alter,impmve,demolish,or repair any structure
F'u'O print its issuance,aka requires the applicant for such Permit file a signed statement SPECIAL Cl RCUIT/M ISC, -v
f } Nm he is licensed pursuant to the provisions of the Contractor's license LAW(Chapter 9
Zaoo (commencing with SecDion](IIIA)of Division 3 ofthe Business and Professions Code)or TEMP.M ETER OR POLE INST. COMMERCIAL:
IL L c a Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X m LL Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES
rrerc than Five hundred dollar, ❑TENANT ❑FOODSERVICE
IMPROVEMENT
=Q' ❑ Lus ownerMNe propeny.mmy empinyecs with wugesmtlmir sole comPenution, SWIMMING POOL ELECTRIC
will do the work.and use structure is not intended proffered forsele(See.]044,Business []OTHER
tail and Professions Code:'ne Commons,License Law dues bot...lY In an owner of OUTLETS-SWI"FCHES-FIXTURES
iO
a 3 pmpeny who builds or improve,thereon.and who does such work himself or through
his own employees,provided that such improvements are not intended or offered fpr NEW RESIDENTIAL ELECfR SQ ET.
sale.If.however.the building or improvement is sold within one year ofcompledon,tbe SQ.FT.FLOOR AREA S/SQ.Fp
ssomobuilder will have the burden of proving that he did had build or improve for bur- Pf Al
roTO'1'AL:
e of ame.l. All 00 T
1•J 1,as owner of the pmpen,,am exclusively contracting with licensed contractors or
onstrvcnhe preject(See.904i.Business and Professions Cour the COnrmwl rs l.i- 1996
nae law cit<srrtapply to an owacrof pmpeny who mild,or impmve#nmmoryand QTY. PLUMBING PERMIT FEE NOV 0 191,6
wbperatrams fm such projects with acntnranons)lice,.A Pursuant othe Contractors
a Licens,Low. PE(ZqT IS ANCE
❑Tem exempt under Seo. .B&PC for this reason CITY Ur Qwrrrk 1 114
Owner Date
At. IN&VENT-WATER TA) VALUATION
0 _
WORKER'S COMPIiNSATION DECLARATION HOCK FLOWFLOWO"R.DEVICE 0-10,9zo
1 hereby off rat under penalty or perjury Ane of the following declarations:
� ]]tax. a and willmorbinaction 37W of the Labor
toy Workers Cpmryn- DRAINS- OOR.R AREA,COND. STORIES TYPE CONSTRUCTION
smirk,as provided for mi Section 3203 of she labor CMe,for Nc perfomwnce of the
work for which this pmol is traucd. FIX71J4 ' P
(]I have and will maintain Worker.Compensation Insumntt,u,required by Section
37Mofthe laMuCpdgfor the performance of the work for which this permit is issued. GAS-PAS .TF.. C UTLETS OCC GROUP APN
My
Goriweor:rker'JInxu� YS` rod Poley
Policy No.: p/
GAS-H,a.SYS1 E.M.O ER -
CERTIFICATE OF E%IiMPI'ION FROM WORKERS' GR17ASFJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not becompleted ifthe Permit is for one hundred dollars(SIM) GREASETRAP
nr
jus..)(This
FEE
Icenifydtminthcpconermanceofthe workfarwhichthis permit..issued,[shall SEWER-SANITARY-STORM EA.200 FT
Dat employ any person in any manner ter zs to become subject o.the Workers'Comped- ENERGY FEE
Z union laws of California.Date WATER HEATER W/VENTIELECPR
7�2 Applicant GRADING FEE
q NOTICE'TO APPLICANT:ILofnenmakingthis Cenilicmeof Exemption,yamshould WATER SYSTEMO`REATING
a ?
become subject to she Worker's Compensation Provisions of the Labor Code,you nos SOILS FEE
tonhu'itM1 comply wilhorh provisions or this pmok,hall Is,thumbnail revoked. WATER SERVICE
aQ
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U Ihercby affirm that there is uwction lending agency for the Performance of Dane ReceipnX
(•' the work for which this permit N oWucd(See 31197,Civ.C.)
Isnders Name H/e� TOTAL:
W Lender's Address TOTAL:
I calmly than 1 have mud This application and state that the above information is BUILDING FEE
correct.l agree to comply with all city and county ordinances and state laws miming to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby a tuhorieempresenniuvexol''this city wemcruprn Ne SEISMIC FEE
shove-mentioned pmpeny fm inspection Purposes. - PERMIT ISSUANCE,
(we)agree no seve.indemnity and keep harmless the City of[upenino against ELECTRIC FEE
Iiabilinies.judgments,costs and expenses which may in any way seers,against said City ALTERORADDTOMECH.
in conseykence of Ne granting of this Fermin.in FEEy JA
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ITO 111,1103 CFM)
MECHANICAI.FEE
SOURCE REGULATIONS.
` AIR HANDLING UNIT(OVER 10,000 CFM) [ONSTRUCTIONTA%
Signature of ApplicanVConuactor Dam E%HAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant sore or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupenlno Municipal Cale.Chapter 9.12,and the Health end Safety
Code.Section 25532(#)1 HEAT]NG UNIT(OVER I00.00i BTU)
C]Yea ❑No PAID
VENTILATION FAN(SINGLE RESID) Date Receipt Of
WJI the applicant m fairs,building txeupont uu ryniperen,car devices which BOILER-COMP(3HP OR 100.000 BTU) t,
mit hazarddefined
remotions air contaminants as by the Bay Area Air Quality Manam
geent TOTAL: y�b
Ilisrin f
❑Yes ❑No BOILER-COMP(OVER 100,000 It I U)
I have read the havrdous materials mqulmments under Chapter 6,95 of die Cali- AIR CONDITIONER ISSUANCE DATE
And.Hi edth&Safety Cade,Sections 25505,25533 and 2.5534.I ukdconind that if Ne NEW RESIDENTIAL,MECIL SQ,FL
ImAdln tett corrvntly huvw tenunt,Nmlt isnry resppnsihility nc nndly the rmcupam
of Ne mems which msec be met prior no issuaneaef a Ceni&am of occupancy.
ow or Npnzed agent Date 'roTAl., lssum BY
OFFICE