31131 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 31131
BUILDINGADDRESS. SANITARY NO. APPLICATION SUBMI77AL DATE
2.2 5_7 1 E�2f,. )UPN FoAO N '-)j 2(o q-7
OWNER'SNAME; PHONIi: C(IN'I'RACTOR:S NA ME: LIC NO.
°.7NoZp �S KAoeu �-1 R'P p. L� - -VII-r S12)SB NIC CONTROL
IM P.CHITECf/ENGINEER: LIC NO ADDRESS, LiLi Mlit,^ LJ. V_t0►" G4gZa fty, 12740 PaIl9-ele>
CONTACT. .11C)/ PHg1�:t ZryO BUILDING PERMIT INFO
���eK4Z + I ��ISO ISO 0I 6� g r ❑ Consultant Fees Paid by Applicant(Initial) BLDG %U.ECL- PL Me MECH
Earn
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapmr 9(commencing JOB ESCRH TI N
C T4Z with Section 0(HApnf Division 3ofthc Business and Professions Com,and any licensees RESIDENTIAL:
0,O " PERMIT ISSUANCIi
1.111 orce and cffay. C
, [I KITCHEN
DEL
<W Dmense Class Commctor S APPLIANCES-RESIDENTIAL. ❑JgS'rF',DITION ❑PLUMB NG RF PIPE
F Wan � CI'9DECLARATI LIMUITLUNIT ❑STRUCTURAL
Z - 1 understand ur Ir r h II he peed uv puM1lic recta s PANELS MODIFICATION
ZOr4„ YP,rss u
O{�Z—� UP TO NIOAMFS ❑INTERIOR ❑CHIMNEY REPAIR
t�N�41 Licensed Pasfesvional - 201-I0011AMPS IMPROVEMENT
.o m OWNER-BUILDER DECLARATION OVER IIHHIAM PS El BATH RCAIOUF:I/REPAIR El DEMOLITION
1 handl.ffir m that 1 am exempt frothe Contractorns
's License Law for the _
U following reason.Seeman 7031.5,Bminass imd Professions Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
Mn which prepares o permit to consumer.alter, m
,improve,deolish,or repair any structure
F.�0-1 prior m its iuuame.tilso myvimsthe applicam forsuch pe.it o fileasigncdemmmem
SPECIAL CIRCUIT/ V
"y thatheis licensed pursuant o the provisions of the Contractor's License Law(Chapter9
W CO (commenting with Section 7000)of Division 3ofthe Business and Prnfessians CaAt)or TEMP,METER OR I' -
that he is exempt therefrom and the basis for the alleged exemption,Any vwhil on of LDG/AUDITION ❑DEMOLITION
�co Section 70)1.5 by my applicant for a permit subjects the applicant to a civil peraltyof POWER DEVICES NT ❑FOOD SF. CE
r mora than fee hundred deuars($.5110).
0I,as ownensllhe pnspcnY,nr my employees with wngcs astheirs0e compensation, SWIAIMINGPOOLfiLECfR1 ROVEMENT
will do the wofk.and the morcapr is no(intended monorail t....le(Sea.7044,Bpvinw,c TIER
kid3 m and Professions Code:The Contractor's License Use does not apply to an owner of OUTLETS-SWITCHES-PIX1'U
pufa ny who builds or impasses thereon,and who does such work himself or through
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR FT.
aide If,however the buildiagor impmsusnemissold withinone yenraf completion,the .SQ.FT.FLOOR AREA f.
ow c of s elder will have the harden of paving that he did not build or improve for Pur-
pts of sale.).
❑has owner ole,, Property,am exclusively contacting with,F..C.-.wears i.
nsrminhe p Jeet(Sec.7(N4,Business and Pndessiuns Coda:)TM1c Comsumnrs Li.
censeLawdcesnotapplywunawnnofPrepareMoo builds
...mprnvosmercon,trod QE'Y. PLUMBING PER IT F88
who,Law ds s not apply to o with a comacmrls)licensd purspan0o lee Cnnwmand
License Law, PERMIT ISSUANCE
❑I am exempt under Sec. ,H&1'C for this mason '
ALTER-DRAIN&VIINT-WA'1'HR(CA)Owner Dat VALDAI'ION :
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE A
Ihercbyaffir .halm Pencltyafpcd.,.aa.f the following deelarntinns: 1 3'
`� ❑ I have and will maintain.CeniiameofCamem,,selTiroomfor Workers Cconen- DRAINS-FLOOR,ROOF,AREA.CONED. STORIES' TYPF:CONSTRUC'1lON
sada.,as pmvidad for by Section 371x1 of the Lose,Code,for the performance al the -
work for which this permit is issued. FIXTURES-PER TRAP
FiI 1 have and will maintain Worker's Compensation Insursnce,as requimi by Section
J"I�fU of the Labor Cole,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTL (KC.GROUP APN
My Worker a Compensation Invurance carrierand Policy number am: QF
Career: t al.D1EIA sAil-U'" Policy NawY: GAS-EA.SYSTEM-OVER ' )
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF.ASPIINDUSTRL WASTE 1 EPTOR I
BUILDING p MON FEES
nless�This section need not he complaint!if the pemrit is forone hundred dollars S100) GREASE TRAI'
L, PLANCHECKFEE �a
Toy any that in the perfampoany
un wofkforwhich this perfuladh ed,Co pan.oull SEWER-SANITARY-STORMP.A.200FI'. •�
not employ any person in any manner as as m become wby3'e,m ro hL�Vorkers Cnmpen- CNERGY FEE
union Laws al Cu �mia.Dole 21 I
OApplicant�l�tJ+-r4i� WATER HEATER WNF.NT/ELECfR 0 GRADING 17EE
F7 fA NOTICE TO AP LICANT:IL af¢r his Certificate of Exemption,you should WATER SYSTEMORCATING
became subject to the Workcds Com pmvisiuns of the Inlsor Cade.you mon SOILS P13C
CaLI Ids forthwith comply with such previsions nr this parr itshall be deemed revoked. WATER SERVICE -
Q
� z CONSTRUCTION LENDING AGENCY NEW RESIDENT']AL PLMB. SQ.FT. PAID Lt
L)0 Ihcnby offirmdmt theprisaconsmoeion lendingagency for thepnformarecaf D' eceiEd#
fL H
he work for which this permit is issued(Sec.3097,Civ.C.)
Lenders Name TOTAL:
LUkI Lenders Addrtm - - T(TAL:
�' fy I vrr ifY That I have real this application and store that fl e.have information is BUILDI _.
V) correct.l agree to comply with all city and county ordinances and state laws adoring to QTY. MECHANICAL PIIRMIT FEE
U s huildingeonsmetion,and hereby authorize representatives ofrhis cityrocnmrupon the SEES
MC r^
uhnvcmentinnI o a6party Na inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERM I'IISSUANCE ELEC'R ;
liabilities,judgments,cans and expenses which may in any way accrue against said City ALTER OR ADD TO MECH,
in canseeuenec of the gra i gofthispermit. PLUMBING FE
APPLICAN UNDERS' S AND WILL COMPLY WITH ALL NON-POINT AIR I IANULING UNIT(TO 10,000 CFM) MECIIANICA FEC
SOURCE :HJ TI
AIR HANDLING UNIT(OVER 10,(00CFM) CONSTRUCT]]
lgm or r pliamascrntracmr Date EST MOST GOOD W/DUC17 HOUSING MITIGATION E
HAZARDOUS MA'I'I;R1ALS DISCI.OSURIi
'lir applicantarfulurcbuildingrccupantnomorhandlehazanlousmaterial HEATING UNIT('10111(1,000 BIG)
m defined the Cupertino Municipal Code,Chapter 9.12,add the Health and Safety
Code,Section 2553200 HEATING UNIT(OVER 100.180 PTU)
❑ a, ❑Nt PAID
VENTILATION PAN(SINGLE It1i5ID) Dare Rmeipt N
Will the applicam or future building occupant use equipmem tor devices which
emit Inuumam air contaminants as defined by the Hay Area Air Quality Management BOILER-GOMP(3HP OR 100,000 BTU)
Dlet' TOTAL:
ctP
❑Yes B ll.r.-2-COM P IOVI:R 100,0011 BTU)
(]Nu
I have read the hazn dous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Form.Health&Safety Code,Sections 25505.25533 and 25534.1 understand deadline NEW RESIDENT IAL MECH. SQ.FT.
of the nguirenontortech host r, etpthato isua reofaCriiyco nmifrhoracupant �.
ofrhemquiremnrn normal,
nave bemenprior to issuanceofa Certificate of Occupancy.
Owner or authorized agent Dare - ' TAL. ISSUED BY:
OFFICE