31169 "'—APPLICANTTO FILL IN INFORMATION WITHIN RED LINES,USE BALL POINT.PEN ONLY - -
CITYOFCUPERTINO - - BUILDING-ELECTRICAL ; PERMITNO 'a� ^
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. - y1 164
BUILDING PROJECTIDEN'1'IFICATION V y VVV
BUILDING ADDRESS: ^- .SANITARY NO. APPLICATION SUBMITTAL DA'Z'E
OWNERS NAMIi: PHONE//: CONTRACT'OR'S NAME: . bG.c.Cts✓ LIC NO. I
Q 1 i•. �•�O- S tOEMl6 O IS i�aiYll'✓ O NIC . CO/` NtR01.#
RCIIITECT/ENG1NEEk: LIC NO: ADDRESS: • • /I�]g -�L/`/J_}'
^ U -)�o E
F�-O,:Crz)
ON'fgq': PHONE: - - BUILDING PERMIT INFO
'a'F LeN PEifP,x ,((�� �9I ���EC���
{ / �I^ti � ❑ Consullanl Fees Paid by''Appllpent(Initial) LDG, LI \ PLUMB No
i LICFNSI3DCONTRACI'OR'SIIECLARATION QTY. ELECTRIC PGRMIT FEE
I hereby arr mai I am Ramwd under provisions ar enapti:r 9(commencing •'° , JOB DESCRIPTION
tSection 91X107 rdfav sinnJoUe Businessand PnifcssinnsCndo,and my licerocls rliHMrrasundcE RESIDF,NTIAI:mu force ane effm. 31 ❑SFDWL ❑KITCHEN REMODEL
�UODo[. CLlCs ',4`•�'. Lintr APPLIANCES-RESIDENTIAL
Dam.-- r—Cnmlac�. Tf - ❑ADDITION ❑PLUM BING RF,.PIPE,
ARCHITECT'SUECLARKHON []MULTI-UNIT El STRUCTURAL
PANELS
Z004 erslnndntyplimshall hlicrecmtls s - MODIIHCATION
OZ4I i�-s /tis UP TO 200 AMPS Y El INTERIOR ❑CHIMNEY REPAIR
Fa3F^t�s Licensed Pmfessional 201-10110AMPS IMPROVEMENT
Y
OWNER-BUILDER DECLARATION - OVER 1(KK)AMPS ❑HATH REMODBIIREPAIR L1 DEMOLITION
C < I hereby.R�n nal I am exnnpt tram rte Conlanoo License Lew for the _
aqS O y U which lug«asnn.(Section ministrant,
t,alum,improve,
ve,de o demolish,
Code Any dty stcounty SIGNS ELEGTRICAI. ❑OI'Hf;R
which requires a pcmiil m ronslmm,ober,improve.Jemnlish,or repair any structure _
prior 1 1' 1. y Ill pplleu I f h p rt I b d a l nrnt
y SI'CCIAL CIRCUIT'/MISC.
hat he licensed pa n the provisions ofn C t cm License L (Chapter 9 _
X00 fcomire icing with Setion 7(X101 fD sa 3 flh Busin[xso dl I•xslore COdc)or 9 LMP METER Off POLE INST. COMMERCIAL: {
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iq5 an Seminar 7031.5 by any rip,lic..t torn permit subjects Itis applicunl I...od poodlyol POWER DEVICES
u+^H - TENANT ❑POOD SERVICE
> of are than five hundred dollars(5500).
�GQ ❑I,azowner0fne prnpeny.nr my empinyeeswin wngesusiheirsolecompensmian, SWIMMING POOL ELECTRIC - IMPROVEMENT
will do the wark.and thestmclure is rill iriNadedoxoffered for sale(Sri.7044,BaslnesaTHBR'
and Pmfi,,xioms Code The Contractors License Low does not apply In an ow.m',d013TLETS-SWITCHES-FIXTURES '
L .. property who builds or improves thereon,and whit does such work himself or through
his own employees,provided that such Iniprovemems me an,inlcnded m offered for NEW RESIDENT IAL ELECT SQ FT
saleIf,however,the building or improvement is sold within one year ofcomplminn,the SQ.FT.FLOOR AREA -$/SQ.IT.
woerbulder will have the hunhen ofp ving that he did not bold or improve for put, ° r
Immo( 1 7 -
❑1,as come,of the property e e d ivdycontracting win licensed contiacmrs In T t' �00
initry 1 theproject(Sec 0W 7D a d Pr f:xt ns Calc)The Contractor's Li- -
censelawe«sort npPty man owner of progeny who builds or nnprnw,mWvr.and Qqy, PLUMBING PERMIT FEE '
who contracts for such prijcc s w'ah it commmons)licensed pursuant o the Contractor's
License Low. PERMIT ISSUANCE
., ❑ l am exeniplunder Sec. ,I3'&P C for of reason
Owner Dme' ALTER-DRAIN&VIiNT-WATI3R IRA) VALUATION
WORK ER'S COMPENSATION DECLARATION 13ACK FLOW PROTECT DEVICE gni
I hereby amrm under penally of peri my one of the following declarations:
I haveand will maintain.Ccmficamof Conxemm sellhinmre for Workers Cmr,wn- DRAINS-FLOOR,ROOF.AREA.COND. STURIE5 'rYPIi CONSTkUCTION
sation,as provided for by Scroi 3700 of the Lubar Code,for the perimota nee of the _
work for which this permit is issued, FIXTURES=PER TRAP ,
1 have.nd will Inaimain Worker's Cou,so,itlon Inxuatice,as required by Section
37M oflhc Labor Code home pertnrrnanceofthe work for wbichlhis permit is issued. GAS-h.SYSTEM-I INC.40upLE'1'3 OCC GROUP APN
My Wor ,,Zc mansalam Insurance carrier and Policy mm�ba rr - -
Carrie(...�'Y—�/'1M Fg Policy Nn.1 '(� ��� 3fS GAS-F,A.SYSTIiM OVER4(EA).
CERTIFICATE OF EXEMPTION FROM W OIiKERS'
!� COMPENSATION INSURANCE - GREASFIINDUSTRL WASTE INTERCEPTOR
fDils section need nal h completW if the permit is foroine hundred Dollars(8100) BUILDING DIVISION PEES
or how) - GREASETRAP PLANCHECK FEE rM O
Iccnily that in the perfiinnancc of the wtrkfar which ibis permit is i>suN,l4huh `
.at emre
ploy any peno in any marine,ria.i object to become sobjeco the Worken'Com _ SEWER-SANITARY-STORM E.A.200, ENERGY FEE
,Z lotion Laws of California.Dam pen
WATIiR HEADER W/VENT/ELHCTR
•Z GRADING FEENOTI
h
NOTICE
TOo APPLICANT.W..k IL C ir mamaking,pc Certificate of iLabor io de,y u null WATER SYSTP.M/fRl!ATING _
bcaimemomply the Workers Coons or thisPermithot nfnemed rCndeyou muse SOUS IEE
[[1
forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE
Q
'7z _;CONSTRUCTION LENIANGAGENCY NEW RESIDENTIAL PLMW. SQ.Fr. ' PAID
V O I herehy oflimnhat then-is pamstruction lending agency for the performance of - m Receipt#
:w f✓
he work for which this permil is issued(See 3097.Civ.C.) -
U [miter's Name - TOTAL:
Lendeh Address ' TOTAL:
d •• 1 rvoil,Ilan I have rend mi,appli,oi.n and norm IM1at the ita,c information is _ B ING FEE �^
N codecs.I agree to complywnh all city and county ordinances and slam lawn relating to QTY. MECHANICAL PERMIT FEE.
U7. buildingGinmruelinn,mW M1eraby aunaris.c repruenmtives nfthiscitymenterupon the SETS CFEE G
above mentioned property for inspection Purynui. PERMIT ISSUANCE
(We)agree ,,save,indemd k
indemnify oil harmless rte City of no Cupertiagainst ' ELE CFEE .
liahililies,judgment,costs and expenses which may in ally way olsrve against seiJ City ALTER OR ADD TO h1ECH.. -
' in conscyuence of the granting ofihix permit.
PLUMBI FIRE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON,POINT qIR HANDLING UNIT G 01O.01D CFM)
SOURCE REGULATIONS. - MECHAN AL FEF.
- AIR HANDLING UNIT(OVER 10,10M CFAU CONSTRUCTION X
Signature ofnpplicanJContmtor r Dale EXHAUST HOOD OVIDUCT) � HO USING MITIGATION FEE
HAZARDOUS MATERIAI S DISCLOSURE ' , _
Will lhe.pPlica.t or future bonding occupant smrc or hhndle hazardous maledul .HEATING UNIT DO 1010M B'IGI
as defined by the Criterion Municipal Code,Chapter 9,12,and rte Health and Safely WAY 15 a
Code,Section 25532m)'t HEATING UNIT(OVER 100,00t],BTU)
J DY C]N .. w
VENTILATION FAN(SINGLE RESID) PAID
thebuilding
Will applicart fm b ilding arrogant use equtpmeal or de ices whichv{!(Ffggplln
•milh J orom v . defined by the Ray.Area A Qalty Mamigemem BOILER-COMP(3HP OR 100.000 BTU) O
TOTA1,:
Disttin.
❑Yes �Nn BOILER-COMP(OVER 100,004)BTU)
•
s' .' -
Ihave read(he hazardous mamrlal,nNuircn¢nls under Chafer 6.95of the CAL. ^r AIR CONDITIONER � � ISSUANCE DATE
foods Heithda&Safety Coxhc.Sections 255(15 25531..it 25534.1 undersand Nal if the NEW RESIDENTIAL MECH. SQ.ler.
buldiagd ImrrentlyM1 trmp It.,ill, Y pnsibllltym notify the occupao -
oflhe I awtirh noto,he ,poor to i,s.a,c of.Ccniermeot0crr,ons,
Owner or authorized agent Date A ' ISSUEDBY:
'OFFICE