31239APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION P ICATION/PERMIT PLUMBING -MECHANICAL.
BUILDING. PROJECT I DENTIFICATION
PERMO'NO, 31239
BUILD] NO ADDRESS:
bgg( N , "k q50 l4
SANITARY NO.
APPLICATION suBtinrIAL DAD'.
OWNER'S NAME: ]'HONE:
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CON ACfOR'SIS ': LIC NORVO:
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❑
CONTROL#
ARCHITECT/ENGIN EER: LIC Not
ALJ HESS: ` ` 51
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IM
GONI'A(T. PHONE:
BUILDING PERMIT INFO
TvtQk�l WOO d�C�` .� � e
L
❑ Consultant Fees Paid by Applicant (Initial)
HI M i- ELECT' _ PLUMB MECH
Z/ D/
CONTRAC'I ORS DECCLLARNI ON
LICENSED mde
I hereby affirm al I am licensed trar pmvisb.s or chapter 9 Rnmmencing
with Section700hi'Division 3 of the Business and Professions Calc. and my license is
infullforceand )r1. 9
Licc is eC Lic.p
Date CanlructOr
ARCHITECTS ❑IiC1.ARATION
I undersand my Nan. hill beuseG as Public records
QTY. ELECTRIC PERMIT FEE
tIZZ
100
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JOB DESCRIPTION
RESIDENTIAL'
❑SFDWL ❑ KITCHEN REMODEL.
[-]ADDITION ❑PLUMBING RE -PIPE
El MULTI -UNIT [I STRUCTURAL
MODIFICATION
ERIOR C1 CHIMNEY REPAIR
MPROVEMENT
11BATH REMODEL/REPAIR❑DEMOLITION
❑ OTHER
PERMITISSUANCL
APPLIANCES -RESIDENTIAL
PANELS
UPTO 200AMPS+
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby from that I an, exempt from the Cretracmr's Liansa Law I'ur the
following reason. (Section 7031.5, Husiws.nd Pmrfic,o ns GMe: Any city m county
which requites a permit to commact. alter, improve. demolish, or repair any structure
prior m its issuance. also requires the applicant for such permit to file a signed samment
mat he is liecasedpormanttomeprovrsionsofthe Contractors License Law (ChnprerY
Code)
(cat he sem it therefrom widthbaiDivision3 oftheeged emnndon Any violation
that he is exempt therefrom and the basis for the cts dud exemption. Any violation of
Section ]113 LS by any applicant lure permit xubjedx+be appliaunuoaeivil penally of
nounotelh.m Eve hundred dollars (5500).
01, as owner of me progeny. or my employees wirh wages os mcir sole compens.It.
will do me work. and me mucture is not inandedoroRercd forxale(See7044, Business
and Professions Cale: The Cnnvanors Licence Law does not apply to an owner of
pmpeny, who builds or improves mcame. and whit does meh work himself nr thns.,
him own employees, pnrvidcJ Ilial such improvements are mot intended or offered tnr
ales IL however. the building or improvement is sold within one year of completion. the
201d01IDAMPS
OVER IIKKIAMPS
SIGNS ELECTRICAL
LN
SPECIAL CIRCUGUMISC
s
TEMP. M1tETER OR POLE INS.
•—;�
❑ NEW BLDG/ADDITION ❑ FOODDEMOLI RVI
mos
�p.T❑FOOD SERVICE
f IMPROVEMENT
OTHER
Pl1W1iR DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-SWTTCHM-FIXTURES)# O
NEW RESIDLN I'IAI, ELECTR SQ Fr.
SQ. FT. FLOOR AREA
sitiq TO.
nor -builder will have are burden of proving that he did not build or improve far pur-
pose of soled.
licensed comctoTO
e progeny. am exclusively contracting wim mrsto
❑Lasowner of mg
,J
(T� 111
b {�•'
L:O �O
onstmct the project (Sec. 7194. B .... c,s and Profession, Codc') The Convector's Li-
cense Law does not apply to an owner of propcny who builds (it improves thereat.and
who contracts for such projects with a comaciond licensed pursuant to the contractor.
License Law.PERMIT
❑Iamcae idtim rScc. ,B&PCfmmi1smmr
QTY. PLUM13ING PERMIT FEE
�e
ISSUANCE r1
AUfER -DRAIN&VENT-WATER (EA) e
BACK FLOW PROTECT. DEVICE
-
Owner Dal IO
WORKER SA'1'ION DECLARA'T'ION
VALUATION
^ cc)
J�j/
on
1 hereby afenn under pamahy of perjury one of die following de rker's m:
mall,
STORIES
TYPE CONSTRUCTION
(have and will marry eCion37M of be Lid , a e,far the Worker's Co.,.-
mean, as pmvidhi for mi Section 3]00 of the labor Calc, for me performancc of the
weak for which this pennil is issued.
DRAINS - BOOR. ROOF AREA, COPD.
FIXTURES -PER'TRAP
❑ 1 have and will maintain Worker's Compensation Inm ane , as required by Section
3700.fmcl bor odgtarmepedormunee oft he work for which chis permit is Issued.
OCC. CROUP
APN
GAS- EA. SYSI EM. INC. 4 OUTLETS
My Wor '. C analnlnamaa mricrond Policy. n� w%
Carrier: Policy No.: a,
GAS -EA SYS 'IEM.OVER 4 IEA)
GREASERISDUSTRL WASTE. INTERCEPTOR
CERTI ATC OFEXEMPIONFROMK RKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(Thkaerion neednot be complelctl11 the pumitls(Domehundred dnllors(51I%q
or loss.)
GREASETRAPr%
1'LANCHECK PEE L f
SEWER -SANITARY -STORM EA. 200 FT.
ENERGY FEE O
I cenify that inure perfom+ance of the work for which this limon is issued, l shall
mol employ any person in any no so as m become subject to the WorkaY Compcn-
WATER HEATER WNENT/ELECTR
WATER SYSTEM/TREATING
GRADING FE
., ,Z
tiO
fin
ration Taws of California. Doc
APPlicant
NOTICE TO APPLICANT: IL idler, making this Cmificam of Ewmptmn, you should
the Worker's Comptiom Pro' War, of the Labor Cade, you ntua
beanne subject m m.sn
SOILS FEE
WATER SERVICE.
PAID
ore Remain #
4
jJ
Q
Z)ze
J O
m H
•�
U
i" G
h
LJ �
forthwith comply with wch provisions a this pemnil shall Fz decreed mvakcd.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that hem is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3049, Civ. CJ
Lender's Name
NEW RESIDENTIAL PLMB. SQ.IT.
TOTAL:
TOT 1.:
Lenders Address
I cenify the 1 have mad this application and slam mal the above infommtinn is
corrcet.Tagree to comply with all city and county ordinances and sate laws rehding to
building construction, and hereby authmbc representatives of this city to enter upon the
BUIL 1 PEE Q O
QTY. MECHANICAL PERMIT FEE
SEISMIC .0
451
PERMIT ISSUANCE
ELECTRICEE f
abtweenendamed property for inspection purposes.
fWcl ngrce m save, indcmnily and keep harmless the Chy of Cupeninn against
ALTER OR ADD TO MECH.
PLUMBING "Eli r 30
liabilities,judgments costsund expenses which may in anyway acerae against said City
nsr:qu the tingaf thi mitt.
APPLI U I ANDS WILL COMPLY WITH ALL NON -POINT
ATT S.
AIR HANDLING UNIT GO 10,000 CFM)
MECHANICA FliE
AIR HANDLING UNIT (OVER IH,(XIfICFM)
CONSTRUCf10NTnX
a� IL••• �
♦Calc
Signawry pplamadlConvacter I
HXHAUSTHOOD(W/DUCT)
HOUSING MITIGATION PER
HAl RDOUS MAI ERIALS DISCLOSURE
HEATING UNIT (TO I0o.000 BTU)
Will mcapplicamor home building mcupantsmrenr handle hvatdme, martial
as defined by he Cupeniro Municipal Cale. Chapter 9.12, and the Health and Safety
Code, Section 25532nd?
f%No
HEATING UNIT (OVER 100,000 BTU)
PAID Date Receipt#
VEN HLATION FAN (SINGLE RUSID)
BOILER -COMP (3HP OR 101,11011 BTU)
timms❑Yet
Will the applicant or future building tncupmn use equipment or devices which
t hada dmoi air contaminants as defined] by the Bay Area Air Quality Mmagemem
tri,l?
❑Yas TINA
%
TOTAL:
BOILER - COMP (OVER 100,tl1p B'N)
AIR CONDI I IONER
sea oils mmerto. quirtments under Chapmr 6.95 of the Cilli-
SS C A
NEW RESIDENTIAL MECH. SQ. PL
fot c. Section- 5 51 25533 and 2.5534.1 understand that if the
tlhevice¢ nt, til is my responxihilily to nt®fy the «cupant
of m I svaxe of a Cmificate of (kcupan<y.
aorived
ISSUED!iY: U ILL N
TOTAL:
Ownerent Dam
OFFICE