31459 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL . 31459
BUILDING PROJECT IDENTIFICATION
sissIblitHEDINGADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE:
105oo SAN Fr-,L.2P-jZ� lqP _ C UpepTS N O ._
O NER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO',
�` Fs� PkJaysH(5TMff azsaa33 NIC CONTROL
ARCHIMC7VINGINEER: LIC NO: ADDRESS: ❑
CONTACT. - PHONE:
BUILDING PERMIT INFG
❑ Consultant Few Paid by Applicant(Initial) BLDG EL PLUMB MECH
❑ ❑
uCENSEDOONTRd under provisions
QTY ELECTRIC PERMIT P13E
I Hereby affirm that tum licensed under provisions of CTapmr9(etmicamag J DESCRIPTION
tg'Z„ 00 with Seclinn]INMgofDivisinn3nflhe Business and Professions Code,and my license is T
�W� full forestial URal. PERMIT ISSUANCE
�UF License Class Lic.N 'C1SFDWL ❑KITCHENREMODEL
Dam Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMNING RIiPIPIi
Z8[E-+spy ARCHITECPS DECLARATION PANELS ❑MULTI-UNIT El STRUCTURAL
54 5 74 1 understand my plans shall he used as public records MODIFICATION
oz- UPT0200AMP5 [:3 INTERIOR ❑CHIMNEY REPAIR
Fa�LD7
Licensed Professional 201.1000AMPS IMPROVEMENT
C
OWNER-BUILDERDBCLARATION -
y a Q 1 hereby affirm that I am exempt
xempt from the Contractor's License Law for the OVER I"AMPS ❑BATH REMODEL/REpA1R 0 DEMOLITION
Sg 3I U following...(Section 7031.5,Business end Professions Cade:Any city or c)umy SIGNS ELECTRICAL +-r-a�w•g-5`
t6 0 which requires v permit to conswn,alter.improve,demolish,or repair tiny swewrt `�/NN}/
E"�� prior to it.ii,ammae,also requires do.,licant for such permt1.file.signet stmemem SPECIALCIRCUIT/MISC.
9sssg tvvtyu��} that he is licensed pursuant in the provisions ofthe Comraclors License Law(Chapter 9
(commencing with Section 7”)ofDivision 3 oflhe Business and Professions CMa)or TEMP.MEfE•R OR POLE MST. '
6 6 o
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 703 L5 by uny.pplicurfar.penal subjects the applicant toe civil perch,of POWER DEVICES ❑NE BLDG/ADDITION ❑DEMOLITION
. FIZ> not more Nan five hundred dollars(3500). TENANT ❑FGDD SERVICE
_� ❑Las owner of the propeny.or my employees with wages as Neir sole etmpensotion, SWIMMING POOL ELECfRI IMPROVEMENT
will do Ire work,and the smscmre is not intended or Offered for sale(Sec.7644,Business ❑OTHER
L and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIX
property who builds or improves thereon,and who does such work himself or through
his Own employees,provided that such improvements are not intended or offeruhfor NEW RESIDENTIAL ELECfR Q PI'.
sale.If,however ilia building simprovement is sold within one year ofcompletion,the SQ,FG.FLOOR AREA S/SQ.IT
owner-builder will have Ilia harden of proving that no did not build or improve for put.
Post,of sale.). -
❑ 1,as owner of the ptop)cy,ant exclusively contracting with licensed comrmmrs to T
.martian the project(Sec.]044,Business sad Professions code:.Tot,Conhvemrx Li-
censeLawdoe,s not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who venlmela for inch projects with a coutmator(s)licensed pursuant o the Contractor's
License Law.
1 em sate ar Sec. B&P .for 's PERMIT ISSUANCE NOV 18 19 6
re ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date Cdr/ Ur 1xUrLHI INU
W RKER'S COMPfiNSA'GI on DECLARATIO BACK FLOW PROTECT.DEVICE.
Iherehye funder penury to ofCo eneofdre nt to elf-mi mforWrker Carr
❑Ihave and will maintain tCeei37W of the Labor
Code.for
for Workersce of the
DRAINS-FLOOR,ROOEAREA..OND, STORIES TYPECONSTRUCI'ION
salon,as provided for by Senior 3]00 of the Labor Code,for the performance of the
work far which this pemtai is issued.orkee ITXTURES-PER TRAP
❑1 havof and will maintain Wmerf. Compensation of the
rkfadme,h required by Ssaion
My Worker'he s
Co Cade,for thsummare cancer and Pomkfnumber sque: pclmit is issued. GAS-EA.SYSTEM.1 INC 4OUTLETS OCC.GROUP APN
My Workers Cumpenmtion Insurance artier and Policy number arc: -
Cartier. Policy No.: 'GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(This canton need Hat he completed ifine permit is boron,hundred dol tato(S 10) BUILDING DIVISION I13E5
mlo..) GREASETRAP
1'I,ANCHECK FEE
I certify that in the performance of Ilio work for which this permit is issued,)shall
nm employmty person in any manner,.as to become suNscu.the W..wo''Com SEWER-SANITARY-STORM EA.200 Fr.
Y 1- pelt- ENERGY IEE
z sation Laws)ICalif)nria.Dare
�7O Applicant WA'fl?RHP,ATERW/VF.NTIELECTR GRADING FEE
F7
NOTICE 1`0 APPLICANT.If,alter making this Cenificale of Exemption,you should WAGER SYSTEM?RF.ATING
abecome subject nt the Worker's Compensation provisions of the Labor Calc,you must SOILS FEE
L>a
forthwith comply with such provisions or permit shall be deemed revnkeQ WAITER SERVICE
Q
U,� CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.R. PAID
U 0 I for which nrind nhere is a c d(Set.30OF.Cis.agency for the perfommnce of aeipt p
fL F the work for which this pcnnil is issued(Sec.309],Civ.CJ
Q Lenders Name TOTAL:
W Lenders Address TOTAL:
0. I artily that 1 have real this application and stem that the above information is BUILDING FEE
(A correct.l agree to comply with all cilyand countyindmonas and nam laws.]aling to QTY. MECHANICAL PERMIT FEE
LJ z, building commence,add hembyvulh.du representatives ofthis city to enter upon the SEISMIC FEE
above mentioned property fm inspection purposes, PERMIT ISSUANCE
(we)agree to save.indemnify and keep harmless the City of Cupertino against ELECTRIC E
liarilities,judgmenm,calls and expenses which may m intywvyoverminutinn said City ALTER OR ADD]'O MECH.
inconsequence of the gmming Of this permit. PLUMBING FE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10,(X10 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) C(INSTRUCPIONTAX
Signature.!ApplicandCnnintear Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FF.F.
HAZARDOUS MATERIALS DISCLOSURE
Will ilio ini,icunlorlulu,.hi iking occupanlstnreor handle mvanloo,oultand HEATING UNIT(TO 100,000 BTU)
as defined by the Capsicin)Municipal Code,Chapter ad 2,and the Health.,d Safety
Coda,Section 2553260? HEATING UNIT(OVER 100,010 PTU)
Yes ❑No PAIL]
VENTILATION FAN(SINGLE REST[)) PAID
RmciptM
Will the applicant or future building occupant use equipments devices which
emit hamrdom it carcinomatous as defined by the Bay Arca Air Quality Moom,ar an BOILER-COMPQHPOR IW,WOBTU)
Dtxt icR TOTAL:
❑Yea nNo - BOILER-COMP(OVER 100,000 BTU) -
I hav<rtwl the haiaulnm materials Chapter of the Cali AIR CONDITIONER ISSUANCE DATE
rtquiremenls under Ch
forma Health&Safely Codc.Sections 255(15,25531 and 25534.I understood the if the NEW RESIDENTIAL MECH. SQ.PL
building does..currently hove a mrunr that it is my responsibility m notify Ne occupvm
of the requirements which mud be met prior Io issuuaa of a Canianore of Occupancy.
Owner or vulhnnud agent .Date TOTAL: ISSUED BY:
OFFICE