31524 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY' S '
CITY,OF CUPERTINO- r BUILDING-ELECTRICAL .PERMIT NO
BUILDING DIVISION APPLICATION/PF,RMIT PLUMBING-MECHANICAL _ 31524
BUILDING PROJECT IDENTIF'ICA•1ACIN
BUILDING ADDRESS: SANITARY NO. APPLIC TION SUBMITTAL DATE
OWNP NA Y PHONE CONTRACTOR'S E: LIC NO:
Jpl? NIC — CONTROLM 8PIQ"J
qR IT •INEL LIC NO: AIIDR'SS; UL(J I
OB (w1
COMA •PHONE: ^ 1 ; ; BUILDING PERMIT INFO
C- Iq l 7: ❑ Consultant Fees Pail by Applicant(Initial) BL ELE PLUMB MEC -'
s
LICENSED CONTRACrOR:S DECLARATION QTY. ELECTRIC PF.RMI'I' FEE \
I hereby affirm that I um licensed under provisions of Chapter 9(commenting ` JOB SCRI N '
msectmn ioon)erni�iaimr3enn,an�ineaa dna Proreaamm actin.ane my heemeia - -
aOZO w1 ,y. PERMI'NSSUANCE 3
WF in full force and effect, OSPDWL ❑KITCHEN REMODEL
U U License Class .p
[-ZRl Dale VH�,
a il APPLIANCUS-RILSIDEWEAL ❑ADDITION [I PLUMBING RE-PIPI3
'm<L D LA ION - ❑MULTLUNIT .�RTRDGTDRAL•- PANELS
ZOyyZ 1 e Lal 1J pu cr rods " - - - MODfFICATfON.
OZ=4 - lIPTO200AMPS
.ice ; P :in • ❑INTERIOR C3 CHIMNEY REPAIR
S .201.10100AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
WWxFy- U 1 hereby union that 1 am exempt from the Couranor's License Law ler the
followireason. ProfessionsOVER]"AMPS BATH REMODEIIREPAIR �DEMOLITION
Cd U
Vng on.(Section]031.5,Business end Cede:Any city or county SIGNS ELECTRICAL El OTHER
W¢crlr' which requires u permit m conxtruct,alter.Improve.demolish,or repair any structure '
pnm to its issuance,also rtquirtatheapplicant for such penniuo fines signed statement SPECIAL CIRCUIT/MISC.
4yy{yHy shat he is licansedpurswnn ml heprovisarsofthe Contractor's License Utw(Chapter 9
5p0 (commencing with Sexam701 of Division 3 ofthe BushuCOMMERCIAL:
ss and Professions Code) TEMP.METER OR PO HINST.'
d y M ly
that he is exempt therefrom and me basis for the alleged exemption.Any violation of ❑NIiW BI,DG/ADDITION ❑DEMOLfI'[ON
YXI Ery Section 7031.5 by any applicant for o penaii subjects the applicant a civil penalty of POWER DEV/IES E.S ANTS ❑FOOD SERVICE
tmmetirmfivehundlnddollars($5W). IMPROVEME , D
.FZa b l as owner oEd, propony,ter my employees with wages as their sole compensation, SWIMM P LLLLCtgwc g- g.A
rya will dothework,and thestructure,is not intended or offered forsele(See.7044,Business 11 OTHER
i a 3 and Isidevbns Code The Cianow as I.Iceme Law due,o01 apply m an owe,or OUTLE"S-SW P TURBS
.. property who builds or improves thereon,and who docs such work himself or through -•f
his own cmi,luyas,provided that such improvements are nm intended or on'eed or Burl AL LE SQ ET. fia 13 ED
sale.If,however.the building or Improvement is sold within one yearofcompletion.the SQ.FT.FLOOR AREA $/SQ.FT.
owner builder will have the burden of proving that he did not build terr improve for par- 'CIIY yr l,UmH FINQ
pose of sale). -
• [-1I,as owner of the property,am exclusively a,ntr.eing with licensed contmemrs Ir TOTAL:
construct the project(Sec.7041 Business and Professions Creic:)The Cununcmfs Li- I '/J_O ��•
se Gnedecanot apply man owner of property who hadd.eo reproves lhercon,and QTY. PLUMBING PERMIT I E ��✓✓ ,
who cuntmns for such projects wilhncem d a,)I2r edp arttrothe Contmcmfs
• License Lm". "1 u PERMIT ISSUANCE'
amexempt underS ,B&PCT Ithis rears.
Owner Date ALTER-DRAIN&VENT-WATER(EA) ., .�^w VALUATION -
- O SATION DECLARATION r RACK FLOW PROTECT.DEVICE : I✓O
Ihercbyui under powlty of perjurymne of the following dedwaiions: �/t e/•
•❑ I have and will maintain a Certificate ofComentao self-insure for Workefs Camper- DRAINS-FLOOR,ROOF,AREA,CONE). ,
' cation,ns provided for by Section 3700 of the Labor Cede,Iia ibe perawasoce o1 the "' STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Cmmpenmtion Insurance,as required by Section
3700ofthe labor Code.forthe performance uf,h.wod fmishichthis permit isisaued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AEN
My Worker's Compensation Insurance carrier and Policy norther we: I Ina�g�.-s�f1
Carrier. .CH
No, - GAS-LA.SYSTBM OVER 4(EA)
' - ✓ / /.����12_
' •C13RTIFR:xrE OF Imlt(TION FROM WORKERS. /
COMPF:NSAEION INSURANCE GRHASEANDUSTRL WASTE INTERCEI'TOR '
(Thi section need.,it he c.nnpleaed tithe pen it is forma,b.rme1 wIhwa P$I W d I . BUILDING DIVISION FEES
GREASE'IRAP trt
m less) - PLANCHIiCK 12E
Ioy my Perinthe my fricbmmanner
thework for subjectch to permit is iss'Comer. SEW17R-SANITARY-STORM EA.2001T. '
not employ any Parma in any manner m as to become subject Ib the Workers Compen- ENERGY FEE
'Oz samn Laws of California.Dam - WpTI?R HEATER WNIiNTIELECTk
Z 0 Applicant GRADING FEE ..
rrri .N. NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/IREATMO
.�' become subject m the Worker's Cmopensatien provisions of the l..bmr Code,you must SOILS FF.i?'
Forthwith comply with such previsions or this permit shall be donned revoked WATER SERVICE -
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.f4. ? PAID
V 0 I nerebyaffirtn met there isammSinn leading agency lin the performance of it Data - 'Receiptp
m
{L H
the work nn which this permit is issued(.5m.�3119p,Civ.CJ
0 lender's Name TOTAL: 5
GUS) Lendets Address -� ' - TOTAL:
P. I mr ify that I have rend this applicution and state that the above infornwtien is - BUILDING EEP Z go(
fA coma l agree to comply with all city and county ordinances and nam laws relating m QTY. MECHANICAL PERMIT EE
U'b building consmection,and hcmhyamnmir.creprcecrwives ofthis city m enter upon the 5615MI P
above-mentioned pmpeny for inspection purposes.
(We)agree to save,indemnil and keep hornless C' of Cupenlnr ids lost PERMIT ISSUANCE ELI
FEE
liabilities.' d mes,cosaand as sec wIt rot in accrue ngnin11 said City PETER OR ADD TO MECH.
e dthei nota'. spa PLUMBING FEE,
AFPI eT NO 'TA A '0 P. WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM) - MECHANICAL IEE
SO Rf 'UL ONS
• � 1f rL�/a AIR HANDLING UNIT(OVER intonI CPM) CONSTRUCTION TAX
S' amr picam o he or •'Date - IiXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
AZARDOUS MATERIALS DISCLOSUREt
Will lhmpplicant or future building occupant some or handle haa.dinnna en.1 HEATING UNIT(TO IN3,000 BTU) n
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 2532(u)'1 / HEAT ING UNIT(OVER 100,1011 BTU) -
❑Yes viii - VENTILATION CAN(SINGLE RESID) •- PAID
` Dale Receipt p
Will the applicantter frmrt building occupant use equipment mdevices which
Jmil hazadmhs airworn ilw as as defined by the Bay Are.Air Quality Management BOILER-COMP(1HP,0R 100,0110 BTU)
District? / - -, TOTAL:
❑Yes. �,qr� - BOILER-COMP(OVER Ifsk 3BTU)
AIR CONDITIONER,
Itheh zaN� nmmn sreyui c sunder Chapter 6.95 of the Call- ,ISSUANCE DATE
is IT Imes afety i mien 0 , unit 25534.1 understand that if the NEW RESIDENTIAL MECIL SQ,PP. - -
builAin dt%x tcu c m I til s y e,twedoliy In notify he occupant _
m
in
, its ort ace ofd pj'( y. --
ror ug m ,/ Bute TOTAL: ISSUED I3V:
OFFICE