31225 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CUPERTINO BUILDING-ELF.CI'RICAL 1'IiRMIT NO.
BUII,UINC.RIV[SION API'LICA"1'ION/PERMIT PLUMBING-MECHANICAL. 31225
a BUILDING 1'ROSE6"1'IDENTIFICATION BUILDING ADDRESS: SAND'ARYNO. APPLICATIONSURMITI'ALDAT
2a�1 S CJpFtj0
ER'5 NAME: PI ION1i: CONTRACTOR'S NAME: LIC NO:-T Maustietst) 2,1
Q 4 N/C .y CONTROL It
CHITECT/ENGINCER: ^IC Is(:.y ADDRESS: ��� / L ❑ -�t
CONTACT: PHONE, BUILDING PERMIT INFO
Q ❑ Consultant Fccs Paid by Applicant(Initial) BLDG EL? PLUMB MIiCIi
LICENSED CONTRACTOR'S IDECLARNI'ION QTY ELECTRIC PERMIT F
1 hereby arum mw I aw licrnxd under prod:inn:of chapter 9(cmnmencing JOB DESCRIPTION
O�CZ) with Section70(XB of Division 3 ofthe Bminess and Professions Code and mylicenseiv Ip
F W in full force unit c0ec�. PERMIT ISSUANCE FOWL ❑KITCHEN REMODEL
�UU License Class Lic.N APPLIANCES-HESIDENI'IAI. AODITIO [I PLUMBING BE PIPE
,ostia. Date Contractor
FOw ARCl/ITECI"S DECLARATION PANELS ULTI-0YIT ❑STRUCNNAI.
Z O n2 K I understand my plans shall be used as public records MODIFICATION
OZ—p UPT0200AMPS F1 INTERIOR El CHIMNEY REPAIR
[-�n L Lq LicemM Professional 201-ff)w AMPS IMPROVEMENT ILL..'''
�W2, OWNER-BUILDER DECLARATION OVER 1000 AMPS
C1 BATH REMODEL/REPAIR Dp1v1OLITION
saC C Q I hereby affirm that I am exempt Gnat the Contractor's License Law for the I
YGcYyy, L U Billowing mesa (Semon 7131.5,NuJmesx and Professions Cude:Any cit,cowt, SIGNS ELCC'IRICAL []OTHER
oe which requires a permit to an iamet,alter,improve.demnrsh.or repair any.snuclum
^u'O� prior m its issuance,also requires the applicant for such perminn file a signed statement SPECIAL CIRCUIT/MISC.
� } that he is licensed pursuant to the provisions ofthe Contractors License Law(Chapter 9
Ied+1,C 00 (commencing with Section 7")of Division 3 ofine Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
6 L ey that he is exempt therefrom and the basis for she alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
na Section 0031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES [D TENANT A �fiQPD SERVICE
t more man fi ve hundred dallurs($5g0. H 11
IMPROVEMENT
❑ 6� ❑ Lata,w of andind
pe or,mor is oannaatswithwnedalo,,a,formai(Set.uumpcnsminn, SWIMMING POOL ELECTRIC
W
will Jothework,andtM1e he Co cisnotmmaeirw Lawdoa not
owner
vv BOTHER
W 3 and Professions Craft:The wens thereon,
License law docs ons apply to if owner of OUTLETS-SWITCHES-FIXTURES NOV !0 v
his ofampandy who baled,or improves thereon,and who does such wink deed or or through NEW REST :NTIAL ELECTS S
his awn employee..pow idea mos such improvements am not intended or uRered for
sale.If.however,the building or improvement is sold within one yew ofcompleticotme SQAf� I V14 00µAREA ASO.IT.
owner-builder will have the burden of proving that he did not build or improve for put- Lf ULWCHII VU�rY
pose o[sa[el'
❑ 1.as owner of the propery,am exclusively cowraceng with Ikensed contractors to
construct the projcel(Sec.9H44,Business and Profession.Code)9Lc Comrmou's I, -
nttlawJoesnotupplytomUwnernlpmpenywhohuilJsorinlprovesmereon.end Ql'Y. PLU -R FEE 777
who contracts for such projmts with a cuntraaogs)licensed personal to the Contractor's
License Law. PERMIT ISSUANCE
❑I.exam tundcr Sc c. ,B&PCfor this maven
).. ALTE;R-DRAIN&VER WATii iAl � � VALUATION
or, WORKL i'S COMI'L SAl (IN DL'CLAHAI']ON RACK IROW I'HOTEC'I'.D13V / O D
I hereby affirm under penally of penury one of the following Jcclwalinns:
0Ihaw andwill mainmin eCenifimm of Cnnscnuosdf-inmmfnr Wnrkcrs Compcm DRAINS-FLOOR.ROOF,AREA.COND. STORIES TYPE CONSTRULTIOt
salion,as provided for by Section 37M of she Labor Cade,for the perform nce of the
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
3700ofine Labor Code.for the performanceofmc work for which this permit is isxucd. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP MIN
My Worker's Camlaw,raion Insurance carrier and Policy number art:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(HA)
C17WIIFICATE OF EXEMPTION FROM WORKERS' GRFASFJINDUSTRI.WASTL'INTERCEPTOR COMPENSATION INSURANCE BUff )IV ON IEES
Ohiaart need nut be completed if the permit is I...reloodeeddollws(SI00) GREASETRAP
or less.) PLANCHECK FEE K Z
i [certify that in me perfmmama mOhe work for which this permit is issuad,[shall SEWER-SANITARY-STORM EA.2110 FL NWI
not employ any venue in any manner so as to became whjea e+the Workeri Compen- ENERGY IEE
Z onion Laws of Calillnnia.Dote WATER HEATER WNENT/ELECTS
zApplicant GRADING FEE
NOTICE TO APPLICANT If,after making this Cenificatc of Fi cmption.you should WATER SYSTENU BEATING
SOILS IEE
become subject H+the Worker's Compensation provisions of the Labor Cade,you muss
fonhwi0+comply with such Provisions or this permit shall he deemed revoked. WATER SERVICE s
0
p' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PIMB. SQ.fT. PAID Doe ccipsp
U Q I hereby affirm that here in a construction lending agency for the performance of
LL P Ihcworkonwhichdio parm,a kwcd(Sce.3197,Civ.C.)
'TOTAL:
C) U Leeders Name
UJ Landers Address T
1 sanity thin 1 have read oris applundion unit state that the above information is BUILDING
L h corccs.I agree h+comply with all city and county ordinances and state laws relating ,, QTY MECHANICAL PERMIT FEE
U Z building consomction,and hereby uumorm mimsentatives of this city to enter upon she SEISMIC FEE
above-mentioned property far inspection Inufa es. PERMIT ISSUANCEELIiCfRIC FEE O
(We)agree to save,indemnify unit keep harmless the City of Capetian against
1 ahilitiex,jud,lowal.cosh and expcnna which may in any way accrue agaimisaid City ALT ER OR ADD TO MECH. PLUMBING FE23
in mmequcncc of the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00d CPM) MECHANIC FEE
SOURCE REGULATIONS. `
AIR HANDLING UNI'p(OVER 10.000 CFMI CONSTHUCTIONTA%
Sildawrc of Applicant/Contmenr Dam EXHAUST HOLD OVIDUCT) HOUSINGMITIGAT NFEE
HAZARDOUS MATERIALS DISCLOSURE
Will thenpplieram m future building na'upuntslnre or handle Imanobse,mwerial HEATING UNIT CI'O I(X).(1X)13 1'u)
as defined by the Cupertino Mumcffad Code,Chapter 9.12,and the Hcahh moil Sawa
Code,Section 2553201? HEATING UNIT(OVER IIX OM HI U)
1
C]Yes F1 No VENTILATION I'AN(SINGLE RESID) PAID
Dole Receipt M
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HPOR 100,0TU)
emit huamous air contaminants as detinet by the Bay Arca Air Quality Management TOTA110 BL.
District? BOILER-COMP(OVER 1(Xim)11 DO)
❑Yes ❑No
I have mad the hwaidnus materials requirements under Chapter 6,95 of the Cali- AI R CONDI'I'IONER J n iarwtwi
fnmia Health&Safety Code.Sections 25505.25533 and 25534 I umlcrsund that if me NEW RESIDENTIAL.MECH, SQ,FT. J
building does not currently have a tenant.that it is my responsibility In ready an recupam
of the ems which mass the 110 o issuance of a Cedar, '.r�Oc+�aq 7 - ! -
Own t �7 n�^gT _J ISSUED BY:
nFFiCE
1 L / 2-9
2 S ADDITIONAL PERMIT FEES I '
(' BUILDING PROJECT IDENTIFICATION VALUATION
RUILOinc
ATCRESy. / O C-' /(/ A 7 )
l /, /� i l�
OWNe
rvgME Rs
q pkfD / Q,$b Q�(( FEE SUMMARY
NIP..Nl
41
C.NlEACTOR s BUILDING
qA
LIC.NO. PLAN CHECK
f oNTRAooREssCTon s FEE
rF
RNONE SEISMIC FEE ,
t QTY. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP ELECTRIC
LIGHTING FIXTURES PLUMBING '
PPLIANCES-RESIDENTIAL
MECHANICAL
PANELS
SIGNS - TOTA
SIGNS TRANS.
0 I SPECIALCIRCUIT
PERMIT VALIDATION 1
EMP.METER OR POLE INS.
t MOTORS SEE FEE SCH.
O SERVICE CHANGE 1
Fo TOTAL f
y ISSUANCE DATE
LU j CITY, PLUMBING PERMIT FEE eLOD. ELECT. vLD. ME
d0
.
❑ ❑ ❑ ❑ I )
D Z ALTER-DRAIN&VENTWATER (EA.)
L) O BACKFLOW PROTECT.DE VICE
LL
O w DRAINS-FLOOR,ROOF,AREA.COND.
d FIXTURES-PER TRAP
N
GAS-EA.SYSTEMI INC.40UTLETS
j V GAS-EA.SYSTEM.OVER 4(EA.)
INDUSTRIAL WASTE INTER.
t Y-7+1 LAWN SPRINKLERS-11NC5V.B.
s !-j LAWN SPRINKLERS-OV ER
SEWER-SANITA RV-STORM EA.2001t/
%• WATER HEATER W/VENT
• WATER SYSTEM
- WATER TREATING EQUIP. ,
s I
\`
ply, MECHANICAL PERMIT FEE
T \tr'• 1 E ALTER OR ADD TO MECH.
'+ \' APPLIANCE
4.+ . .• , ,
AIR HANDLING UNIT(TO tOp00GF.M.)
AIR HANDLING UNIT(OVER I0.OWGF.M.1
`` + •� EXHAUST HOOD(WITH DUCT)
! HEATING UNIT(TO 100,000 B.T.U.)
,( HEATING UNIT(OVER 100,0008 T.U.) \ 1
-1 VENTILATION FAN(SINGLE) \
BOILER-COMP17 M.P.or 100,000 B.T.U.) I
BOILER-COMP(Ow-,100.000 OT uI_SEE EEE SCR.
--- --_— TOTAL I Ir-
S