31455 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECIIANICAI: 31455
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: �� 4 SANITARY NO. APPLICATION SUBMITTAL DATE
✓�tl L � oL - L to
OWNER'S a PHONE: CONTRACTOR'S NAME: LIC NO:
AIAAle, Y L/ /n8- /"j-j 13b / J / NIC CONTROOL0
MARCHIT .Nj N E : LIC NO t� AUUNI! 5: ✓ - -/// 'LA (, O O J
CON'1'ACI'; UNE: /(,L '-! BUILDING PERMIT INFO
AeAlt 4W&I 04ZGF�i
/fin' .4/`tij _ ❑ Consultant Fees Paid by Applicant(Initial) BLDG I E PLUMB MECf
ry s- �
LIC SED CONTRACTO 'S DRICLARATION QTY ELECTRIC PERMIT FEE
p Z I hereby afro That I am licensed under provision.or Chapter 9(commencing JOB DESCRIPTION
8100 with Semion]000WDivision 3 ofthe Businessand Politicians Code and my license is PERMIT ISSUANCE 9 R SIFSIF DFNTIAI:
Fes- in fall fomeand effect. ❑SFDWL [I KITCHEN REMODEL
aVU Liccnu Class Lisp APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING REmPIPE
h<i Dam TSDEContracL
Foy ARCHITECTS DECLARATION PANELS ❑MULTLUNIT ❑STRUCTURAL.
z O nz 1 understood my plans shall he used as public records MODIFICATION
Oz 0 UPTO2MAMPS ID INTERIOR ❑CHIMNEY REPAIR
rl4t:o Licensed Professional 201-H)WAMPS IMPROVEMENT
CCC6 M:J OWNF,&BUILDER D[CI,ARA'TH)N OVER IIXMIAMPS ❑BATHRF,MODEL/REPAIR [I DEMOLITION
C Q 1 be«hy affirm Thal 1 am exempt loft the Conu:mmr's License Law for the
E V Bdlnwin Section 7031 5,Husincsx and Prom%sions Core An T a ❑OTHER
g«aeon.( y city or county SIGNS BLECfRICAI. ��
30 which its issuance.
ssu a permit re cvnnmm,alma intpmve,demolish,t or repair any machine
.F.^0 Thior n he isl tensed ealsore 1.Ttthovi,imi,of,he such Cmitrim',Licese File a Laodsmtiner9 SPECIAL CIRCUIT/MISC.
fyy (commecing wait parsuanl mice pro visions Of theeBusins aLicense Loons Code)or
W a that hems
(commencing Sedion]OIX)of Division 3th theBusinessand Professions Code)or TEMP.METER OR POLE INST.
W E C met he is exempt Iherefmm and tae basis for the vllegcd cxemplinn.Any violation of ❑tN'e{�/ :�T1/psaf/�..f��]DEMOLITION
MIy Section 7131.5 by any applicant to,.permit subjects me vpplicam to a civil penalty of POWER DEVICES .� ANT a •Y.(�It�W FOOD SERVICE
F=6 not mote Than rive hundred dollars(SSW). rLinROV Faa1;NT
O Lasowncrofthc propcny,or my employees with wagesas Their sale compensation, SWIMMING POOL ELECTRIC •,Y'E#
wdl Jo Ne work,and theswnvrc is nclimmmdeJ OroRereJ for sale(SeeJM4,Bmin'ss ❑0TH
and Professions Code:The Contractor's License law does not apply to an.1 of OUTLETS-SWITCHES-FIXTURES
property,who builds or impasses thereon,and who doss such work himsef or thounith
his own anployces.provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SO FT.
sale.IL however,the building or Improvement is sold wlmin one yeurofcompetion.me SQ.FT.FLOOR AREA S/SQ.IT.
nbuild,r,will have the harden of pnry log hall,he did not build or improve for par- 1uwQ rw—
. of so
M 1 owner
l L W
1,us owner of The pmpeny,em exclusively contracting with licensed contractors ns ) v
cmimo ct the project(Sex,.7614,Business and Professions CsdcU The Commuri is Li-
cense Law does not apply to an owner of foopsoy who builds or impmvxs Thereon,and QTY, PLUMBING PERMIT FEE
whncant�xfxamchp jems wiTherommands)li<enxJ pursuanuo Ne Cmaimcmrs
Lic,n PERMIT ISSUANCE
❑ 1 u pT u S burns rcamn w
ALTER-DRAIN&VENT-WATER THAT V VALUATION
N
O e 'O 'RS COMPENSATION UECLARAION BACK FLOW PROTECT.DEVICE �"0Itit
I hereby affirm under penalty of perjury one of the following declarations: O V IJV
0 l have and will mainatin a Certificate tit Conscnsso self-houa for Workers Cumpen- DRAINS-FLUOR.R A ,COND. STORIES TYPE CONSTRUCT FON
smiun,as provided for by Section 111)of the Labor Cale,for the perfmmtonce of the
work for which this permit ix issued FIXTURES-PER TRAP Q
1 have and will maintain Worker's Compen.smion Insurance,as required by Section
3700 Of the Labor Code,for the performance of the work for which this permit is Issued OAS-HA.SYSTEM-11 .4f J'TI.1. OCC.GROUP AI'N
My Worker's Compensation Insurance cariertmd Policy number arc:
Carrico Policy Na: GAS-EA.SYSTEM-O 1�IB IS(SI I
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASF/INDUSTRL WASTE INTERC
('Itis secausimod not he complaint ifthe permit is furore hundred dollars(SIM) B IVISION FECS
or less.) GREASETHAP PLANCHF:CK
Icenify That in the performance oflhe work far which this permit is ixsu,d,i shall SEWER-SANITARY-STORM G.200 FT.
not employ any person in any manner so as To become subject To me Workers Compete ENERGY
0 z salmon laws of California.Date WATER HEATER WATNTRiLECER C Q
rzi O Applicant GRADIN r
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM?REATING
became subject to Ne Worker's Compensation provisions Of the Labor Code,you must SOILS FEE
forthwith comply with such....isi...on hie kora shall be deemed«vokW. WATER SERVICE
Q
5z CONSTRUCTION LENDING AGENCY NI7W RESIDENTIAL PLMB SPIT. PAID pate pTp
U 0 l hereby affirm that mere is a cunslrun!nn lending agency fifth,perfmircuteof
lLa f-a the work far which this permit is issued Soc.3097,Civ.C.)
V U lender's Name w�� TOTAL:
�" UJ Lends/x Address BUILDING ILS
0. 1 certify That I have read this application and stale Nat the above information is
F V) circa.I agree m comply with all city and county ordinances turd nam laws relating m QTY. MECHANICAL PERMIT FEE a�
U Zbuilding construction,and hereby amhonse preumatives ofthis city to enter upon the SEISMIC FCC W
above-mentioned property for inspection purpose s. PERMIT ISSUANCE
(We)agms m save,indemnify and keep hornless the City of Cupertino against ELECTRIC FEE
liabilities,judgmentx.costs and expenses which may in any way accost,agaiml said City ALTERORADDTOMECIL
in nxeque we of the gnommit of this .it. PLUMHING FEE
APPLICANT I''DERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,Ml CFM) /1
SOURCERr ATION MECHANICAL ITE
AIR HANDLING UNIT(OVER 11,1700 CFM) CONSTRUCIONTAX
Sign p cl )all EXHAUST HOOD(WIDUCI') HOUSING MITIGATION FEE
H .ARDOUS MATERIALS DISCLOS USE
Will thfupplivma or fair.huilding TscaToon anreor handle abandons mammal HEATING UNIT(TO 100,01M B'TU)
os defned by the Cupecon0 Municipal Code.Chapter 912,and the Health and Safety
Code,Section 25532(,)1 HEATING UNIT(OVER IW.W0 BTU)
C]Yex ❑NO VENTILATION FAN(SINGLE RISID) PAID
Date ReecipT is
Will the applicant or future building occupant use equipment in devices which
T h:yandous air construction,as defined by the Bay Area Air Quality Management BOILI!R-COMP(JHP OR llq.lgp BTU)
cord TOTAL:
District? BOILER-COMP(OVER 103,000 BTU)
❑Yes ❑Nn
I have readthe harardrosmaterials myuimmcnln under Chapter has Of me Cali.. AIR CONDITIONER ISSUANCE DATE
form.Ilcaltb&Safety Code,Sections 25505.25533 and 25531.1 undersand that it The NEW RESIDENTIAL MECH. SQ.TE
building does not currently have a animal.that it is my«sryntxibilhy to notify the occupant
of the re4ul«ments which must be met prior m Isswmc,of a Cenificam cr Occupancy.
Ownercaailhnrired agent Date '(,'„rA ) S ISSUED BY:
OFFICE