31346 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO 1, BUILDING-ELECTRICAL PERMITNO. a] 346
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL. J
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRE.SS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNERjRyNAM(y �K PHON13: CONTRACIOR'SNAME: ` LIC NO: g'
NIC CONTROL
ARCHIL j(,71ENGGIINNEER:r ICNO_^ AU I) `\ El
CONTACT. PHONE
: l� CRS . BUILDING PERMIT INFO
4(A- VA.6 b 0 Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CON TRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE /cfJJ(` (/�tl��� ❑ ❑
I hemhy.frothat at Ionni licensed under pisi
mvore me
of Chapter 9(commencing JOB DESCRIPTION
w.�0Jaz with Satieande ect, sionJofNe Rosiness and Pmfeasinns Crde,nndm licemeis
y \ PL'RMITISSUANCC RESIDENTIAL:
in(all(arca and eRed.
�F.UU License Ciro Lica 3 Zo7 ❑SFDWL EI KITCHEN REMODEL
NG4 Dated—! /-t[—Cnnlmnn APPI-IANCP_S-RESIDENTIAL []ADDITION C3 PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS
F-,']tn ❑MULTLUNIT ❑STRUCfURAL
z O j2Z 1 understand my plans shall be used as public records MODIFICATION
Oz^pppp UPT02(p AMPS ❑INTERIOR El CHIMNEY REPAIR
rr?I"'W Licensed Professional 101-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
R Q 1 herehy vffvm that 1 nm exempt from Ne Contractor's License law for the OVER IIXp AMPS 11 BATH REMOD IJRF,PAIR Q DEMOLITION
�ggq5�4U (allowing reason.(Section 7031.5,Business and Professions Rade:Any city or county SIGNS ELECTRICAL. ❑OTHER -A:tk 9t)CA Can.
FO which requite a permit to construct,.[tea improve,demolish,ar¢pair any mmcame -
priortoitsissuance.also requires the applicant for such permit to rile a signed smmment SPECI AL Cl RCUIT/MISC.
,!(y that he is licensed Pursuant o the provisions of the Cnntmdor's license Law(Chapter 9
QO (commencing with Section 701181 of Division 3 of the Business and Professions Code)or TEMP.M ETER OR POLE INST. COMMERCIAL:
4 K
that the is exempr therefrom and the basis for the alleged exemption.Any violation of P ❑NEW BLDG/ADDITION ❑DEMOLITION
rn Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of MWI2R DEVICES
not more Than five hundred dollars Won). ❑TENANT ❑FOODSERVICE
�SG ❑ Las owner of the Pmpeny.or my employms with wages as their sole cnmpensminn, SWIMMING POOL ELECTRIC IMPROVEMENT
F will da The work.and Neswcwrtis not intended ornlfertJfor sale(Sec.7044,Business ER
4 3 an and Professions Code:The Connector's License law does not apply to an owner of g OUTLETS-SWITCHES-FIXTURES
^ property who builds m improves thereon,and who does such work himself m Through
his own employees,provided That such impmvemcnt arc not intended or offered for NEW RESIDENTIAL HLECIII SQ FT,
.R.If,however,the building or improvement is sold within ane year of completion,the SQ.IT.FLOOR AREA $/SQ.P..
owner-builder will have The burden of proving that he did not build or improve for pur-
pose of vale.).
❑ 1,as owner of the property,am exclusively contracting wit,licensed con nanous m fSs
consancT The pmjan(Sec.7044.Buslnus vad Professions Coda)The Conwclofs Li- G'r
cense Law dnes not apply to an owner of pmpeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
whncommca lar such projens with acommmojs)liccnttd pumuan to the Contractors AIL
License Law. PERMIT ISSUANCE if 0
❑Tani exempt ander Ser. ,B&PCforlhisreawn 77--
•Owner Date ALTER-DRAIN&VENT-WATER(EAU �/y It. / VALUATION
WORKER'S COMPENSATION DECLARATION BACK MOW PROTECT.DEVICE
I hereby affirm under penalty of)x jury one of Ne following declarations:
El I have and will maintain a Certificate of Cansem to self-insum for WeArea Courpcm DRAINS-FLOOR,ROOF,ARBA,COND. STORIES TYPE CONSTI<UC'I'ION
action,as provided for by Section 370)of the labor Cale,for the performance of the
work for which this parol,is issued. FIXTURES-PER TRAP
❑ I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Lahr Cale,for be performance of in,w,ok for which this permit is issued, GAS-VA.SYSTEM-I INC,4OUT1.ET5 OCC.GROUP APN
My rrker'xpnsnpcgVpylrance lca/aierbe
Carrier olcyN':i1u ] 17/'%l OAS-IiA.SYSI EMOVER 4(TAT
R
CEATIFICATEE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRRASHANDUSTRL WASTE INTERCEPTOR BUILDI r Dl ON FFiES
This lection real on he cumplemd ifthe perm))is me one handled dollam(S I0)) GRPASETRAP
m lcssJ PLANCHECKPEB
I certify NaT in Ne say ro m e, ...1 woek anc o.b ei Nis permit is issued i shall
nm antiany person in un manner so ns to become sub en to the Workers'Com SEWER-SANITARY-STORM EA.200 PI'.
y j pen- ENERGY FEC
Z 7� ppan icant of California.Data O Applicant WATER HEATER WNEN/F:LECIR GRADING
17 V) NOTICE TO APPLICANT:If,afar making this Carificam of Exemption,you should WATER SYSTEMFLREATING
a ; become suhject m the Worker's Compensation provisions of the Labor Cale,you most SOILS FEC
W fanhwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI.MB. SQ.FT. PAID
V Q I herehy affirm that there is u construction lending agency for the smear mance of —Dal / Receiptp
4. ti The work for which this permit is issued(Sea 309E Civ,C.)
O U Lenders Name TOTAL:
Lender's Address TOTAL:
W
1 certify that 1 have read this application and slate that The above information is BUILDING FEC• /0
IAcunrvt.l agree To comply with all city and county nNinancestudsm¢Iawamlydngto QTY. MECHANICAI.PERMIT FEE
L)z4 building construction,and herebyeuthorim repersentatives ofthis city to enterupon the SEISMIC FEE
above-mentioned property far inspection purposes. TERM IT ISSUANCE(We)agree To save,indemnify and keep harmless the City of Cupertino against ELECTRIC FIF
luddlities,judgmems,cons and expenses which may in any way seethe against said City ALTER OR ADD TO MECH.
in crosequerecof the granting of this permit. PLUMBING E
APPLICANT TNI EIISTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO IB0p CFM)
SO JRC ATiONS. /fn M[CHANICAL
mar1_O / AIH HANDLING UNIT(OVER IO,t1MICPM) CONSTRUCTION Tp
Signature of Applic,im-o7ma—racefir J'fiLuu✓VV/// OData O EXHAUSTHOOD(W/DUCT) HOUSING MRIGATION 'E
HAZARDOUS MATERIALS DISCLOSURE
Will The applicant or future building oecupam store or handle hawdnus material HEATING ENT r(To RM000 BTU)
as defined by the Catarina Municipal Calc,Chapter 9,12,and the Health and Safely
Code,Section 25532(x)7 MATING UNIT(OVER IDQ00)BTU)
❑Yes DN. PAID
VENTILATION FAN(SINGLE RE.SID)
Will he applicant or fare hnilding occupant use equipment an devices which _ Date Raeipt 1
mit hmallous air contaminants as defined by the Bay Are.Air Quality Management BOILER-COMP(3111'OR 100,0110 BTU)
Uislrim7 U
❑Yes E]No BOILER-COMP(OVER I100,0030 BTU) Tfl
I have read The hauNous materials requirement under Chapter 6.95 of the Cali- AIR CONDITIONER
ISSUANCE DAT
mous Health&Safely Code.Sections 25505,25533vnd5534,I understand Natit N
e
building does rat yhove amount,that is Iresponsibility
nitomainlythesaNEW R ESIDENTIAL MECB_ SQ. T.
of threquirements which nun he ten prior o issuance of Certificate of Occupancy
Owner or authorized agent Date TOTAL: ISSUED BY: Mf
OFFICE