31363 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. 31363� w'.1116'3 w A
BUILDING DIVISION. APPIACATION/PPRMIT PLUMBING.MECHANICAL.
BUILDING PRfIJECP IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT/
6 � v :bTA ��v� TSL,\)P �0 2S 9b
OWNPy:�p{yM' COPHONE: COME R'SN 1?:
{I/TXA NIC CONTROL.
RCHITECT/CNGINEHR: LIC NO: ADDR•S' /1 ❑
CONTACT: P170—NE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT 1'L MB MECH
❑ ❑ � ❑
LICENSEDCONTRACTOR'S nder'oDECLARATION QTY. ELECTRIC PERMIT FEC
I hereby infirm that I am licensed uMer provisions o(Chapmr 9(commencing JOB DESCRIPTION
WOO with Settled 700hu fDivision 3afthe Business.0 Premium.,Cade.nnJmy limns,is ' RESIDENTIAL
FI- in full force and Ice PERMIT ISSUANCE ❑SIUW�L [I KITCHEN REMODEL
�st License Clas' Lich
' QU Dice Contucmr APPLIANCES-RESIDENTIAL []ADDITION MBINGRE.PIPF
b„py ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT STR CTURAL
Zp 7�. l understand my pinnsshull be used.,public records MODIFICATION
OO--e0 UPT02MAMN [:1 INTERIOR [I CHIMNEY REPAIR
1q•'ul Licensed Professiannl 20LItX111AMP5 IMPROVEMENT
a OWNER-BUILDER DECLARATION
yy a� i hereby affirm that 1 em exempt fromm the Contractor's License Law for the OVER HMAMP5 El BATH REMOOELlREPAIR 01 DEMOLITION
>(a 6 V following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
4471 LLOQ which requires a Permit to consumer,alter,improve,demolish,or repair any sweture
.i prior I.it,isemme,alsa rcr,oam,theulplicatn fortmehipeoria to fileasigmedstatentem SPECIALCIRCUIT/MISC.
} thathei.lionsedru,...lmNeprovisime,.fthe Cmnwnors Licence law(ChInar9
(commencing an Seen o.7000)of Division 3.f the Businessund Professiam Ceselar TEMP.MEJTER OR POLE COMMERCIAL:
6 e,Y
that he is exempt therefrom and the basis for alleged exemption.Any violmind of ❑NEW BLDG/ADDITION ❑DEMOLITION
YW� Section 703 L5 by any applicant for a pewit subjects the applicant a civil penalty of POWER DEVICES y IMTENANTPROVEMENT ❑FOOD SERVICE
nor mora than five hundred dollar,yampi. IMPROVEMENT
� C ❑Lo the work,anid,d
proPemyemployas win wagesatheir(Sec.rn .Businessn. SWIMMING POOL F..E I
will Jo the work,and Nc situation,Comis not intended or arm it, for sale(Sec.](144,Business ❑OTNER
I {as13� and Professions Cede:The Conwcmrs License Law Jas net apply ea an owner of OUTLETS-SWITCHGS TXT P
progeny who builds er improves thereon,and who dos such work dad o l offered f h
his own employees,provided that such mentis sold
am not intended or offered for NEW RESIDENTIAL iL S
sale.i bolds,will hrive the
hn burden improvement is rolhedid one yam of complerion,the SQ.FT FLOOR AREA S/SQ.IT.
owner-builder willbavetheh�rdenofprovingthathedidnotbuildarimproveforp�r- f A Y D
pose oe sale.).
❑ Las owner of the progeny, exclusively connecting with licensednr'm
catoL:
consumer the project(Sec.]TWA,.Business and Professions Curial The Connector's Li- ffpp��spp
cense law does not apply m an owner or pmpeny who builds or impmvcs thereon,and QTY, PLUMBING PERMIT FEE BJpi:�J' �L� 19 6
whotolmam forsueh projeceswlNaamhucmr[s)Ilcenud puinumuathe Contrnetor's vv Cri/Ya t5 ,7
License Law. PERMIT ISSUANCE
O lamesemptomder Sec. ,B&PCfm Nisreason
Owner Date C' -
ALTER-DRAIN&VENT-WATER EA) VAL A
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECE DEVICE
I hereby afftpa under penalty of perjuryone M Ne following drelumterA: '
O I have and will maintain a Certificate ofConsenuo self nature for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3701 of the Labor Code,for the performance of the
work for which Nis pewit is issued. FIXTURES-PER TRAP
El I have and will maintain Worker's Compensation Insurance,as required by Section
3700 ofne labor Code,for the performance ofthe work for which this pewit is it.sti GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation lnsumnce carrier and Policy number are: GAS IA
Cartier: Pol icy No.: (1 )
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUS1 RL WASTE INTERCERTOR
(Has.,am need nm be completed Ron,pewit is forma,hundred dollars($100) BUILDING DIVISION FEES
IessJ GREASE TRAP
PLANCHECK FEF.
Ioyni(y that in the performance o h wbcxmwmbjex .rhr itisissued,'Cmppshall SEW17R-SANITARY-STORM EA.2110 FT.
nor employ a m any nu er x s became mbject m rte W'mrk<ri Compen- ENERGY FEE
.� smion Laws Lalli nnia.Date
O — WATER HEATER W/VLNT/ELECIR
Applicata GRADING FEE
NOTICE 1'0 APP L CANT:If,after..king this CaIlea of Exemption,you should WATER SYSTEh1/IREATING
m
a ; bscne subject ro the W.Oce,Campensminn pmviI f the latter Code,you most SOILS FEE
W forthwith comply with such provisions or this repair shall be demand revoked. WATER S12RVICE
a �
UO CONSONLENDINGAGENCY NEW RESIDENTIALPLMB. SQ fel'. PAID
I hereby affirm not
is isa.construction lending agency for the perfopannce BIC Date Receipt
{J. Fi the Work for which this Permit is Issued(Set 3197.Civ.C.)
O Leader's Name TOT
{Uil Lender's Address - Tl
0. 1 certify that I have read Nis application and sure that Nu above itfopa.ion is BUILDING FEE
V) toner.l eYme m totally with all city anJcmunty nrdimnces unit sure laws reltaing m QTY, MECHANICAL PERMIT FEE
G y building euuswceimn,and hereby umhoriee reprcsemmives of this city mimentpm rhe SEISMIC FEE
above-mentioned pmPeny,for inspection purposes. pit MI'T ISSUANCE
(Way agree m save,indemnify and keep harmless the City of Cupeninn against ELECTRIC FEE
liabilities,judgments,costa end expenses which may in anyway amore ageism said City ALTER OR AUU'IYI MECfi.
in.onsequencc o(ne gmntiug mf this pewit. PLUMBING F
APPLICANT UNDERSTANDS AJ4TJ WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0011 CPM)
MF.CIIAN FEG
SOURCE 'LATIONS.
AIR HANDLING UNIT(OVER III,"CFM) CONSTRUCTION X
guamraa pplicamucnnvack" - Date EXHAUST HOOD(W/DUCT)
tIOUSING M11'IGA'TI N FEL:
11A7ARDOUS MATE RIA DISCLOSURE
WilltheepColo n,l'Morocipol Cade,Chaps r912,hurdle Heal) us.,to Safrialety HEATING UNIT(IO IIXI,fI(p BTU)
as defined by the Cuponinn Municipal Cade,Chapter 9.12,and the Health and Safety -
Code.Section 255321a1? HEATING UNIT(OVER 100,00n BTU)
F1 YC' ON. VENTILATION FAN(SINGLE RES Of PAID
Date Receipt#
Will the air comr or future building excupby
Bay Area Air Qumat ality
devices Management
BOILER-COMP(3HPOR 100.00ITUI
•emir hawrdmus air cmnmmitwme as defined by the Buy Area Air Qaslity Management TOTAL:
Dis ricl?
❑Yes ON. POILER-COMP(OVER 100,000 ETU)
I have read the Instructors materials uirements under Cha to 6.95 of Ne Cali- AIRCONDITIONER
pec p ISSUANCE DATE
hard,Health&Safety Cole,Section,25505,25533..it 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building docs ma emo ndyhave a unml.that o is my responsibility to purify the accurate
of thinraryiremems which must M met Miono issuance of a Curdwatemf Occupancy.
Owner m i mhoneed.Yem Dore TOTAL:1 ISSUED BY:
OFFICE