31254 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT No 312rn
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL J GV11•+
BUILDING PROJECT'IDENTIF'ICAT'ION
BUILDINGADDRS
R : ! /r SANITARY NO. APPLICATION SUBMITTAL UATI
V %J6L� - // [o
OWNER' ME: ��, PHONE CONTRACTOR'S NAME: LICNO:
NIC COO TRO
•ARCH CT/ENGINEER: LIC NO: A DNE.SS� � � ❑
CONTACT: PHONE: BUILDING PERMITINFO
C*VWC al, )M p.� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELEC PL + MEC(;
VQr"L`ICCII°NSSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JIG`/ 1•f��(
I hereby aRrn that I am licensed trader provisions of Chapter 9(commencing JOB DESCRIPTION
'p2 with Section 7000laf Division 3of me Businessand fessions Code.ondmylicenseis RESIDENTIAL,
l
FSB nfull tome and t PERMIT ISSUANCE
'� G t�Zgj ❑SFDWL ❑KITCHEN REMODEL
Q,UV License Clrk _ Contra
APPLIANCES-RESI)ENTIAL El ADDITION ❑PLUMBING RF.PIPE
tnQL Dam A CSDE .
ARCHITECT'S DECLARATION PANELS ❑MUCI'1-UNIT [:)STRUCTURAL
Ozv�Z rsmndnryplansshall uwJrspublicrcrods MODIFICATION
UPT0200AMPS El INTERIOR ❑CHLMNEY REPAIR
I- Ia�1 Licensed Rofcssional 381-EDW AMPS IMPROVEMENT
se C?Q I hereby off rat hat I am PDexeh.DEpt fnslm Nc Connra�or's License Low for the OVER I.AMPS ❑BATH REMODELBEPAIR ❑DEMOLITION
tl O y U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ' 'IR Ne
❑OTHER
3 LL F which requires a PCrmil In wm,tor ober,no,or,demolish,or repair any saacwrc
firiarmits is voince,nkootipmt,the applicam forwch perming fleusigncdstatamem SPEC CIBCU'
(commenting
Pursuant 70th)provisions of the the
License Loons Cod¢r9
ISI W�00 and he is xemiNSeafrom and ofDivision)of the Business and Professions Code)or TEMP E.1 POLE INSi COMMERCIAL:
11 d eC that io is exempt therefrom and the basis for the alleged exemption.Any violation of C1 NEW BLDG/ADDITION ❑DEMOLITION
XmI+- Section 703 LS by any applicant fora permit subjects me applicant mncivil penalty of POWER DEVICES
W^y ENANP (]FOODSERVICE
nm mare than five hundred dollars y em).
Z i PROVEMENT
E�OQ ❑ Lo the work,the the sent',structure myemntended wire wages Bred for alei(Sec compensation. SWIMMING POOL ELECTRIC
will dmhework.andtheheCrilsnm intended af.dararot apcc.]W4.Business OTHER
da:ac and Professions Cod):Thc improves
themta Liccmc taw docs not apply s if owner of 0 CUTLETS-SWI TCHGS-FI%TUR
hpropertyis own who builds or improves t such i pr who Joao such rinte himself or through
his own employees,provided that such impmvcold w arc not intended ofd or offered for NEN'RESIDENTIAL EL[CTR $
xula l4 however.the building or impmvemem is ecoid within one ycarofcompleion.the SQ.17.FLOOR AREA 5/SQ.FT.
owner-builder will have the burden of pmving use he did not build or improve for pur-
pott of sola). l
El 1,as owner of the properly,am exclusively contracting with Recessed contractors to
p,T Od -
construct the Project(Sea.7044,Businms and Professions Codc)The Contractors Li- P A
ocass,Law docs not apply to an ownurof popery who builds or improves thereon.and QTY. PLUMBING PERMIT 57 FEE
who contracts for such pmjeas with o conwchams)licensed pumand to the Contractors
[)I a.exemptlaw. PERMIT ISSUANCE MAY -7 REST
❑ am empt under Sec. .P&YCfar Naso
is ren
Owner Doc ALTER-DRAIN&VENT-WATER(EA) VA
WORKER'S COMPENSATION DECLARATION BACK FLOW'PROTECT DEVICE
penCITYurtlfKSTl30
ElI hereby affirm under penalty of penury one of the following declarai nal
I have and will maintainu Cemfomc of Coasem b"elf-insure l'or Worker's Compen- DRAINS-FLOOR,ROOF,AREA.CONE). SI'ORIGS 'I'YI'I?CONSTRUCfION
.vmion,as pmvldcd lir by Section 3900of the Lubar Conic,I'or the perlirmanee of the
ark far which this Permit is issued FIXTURES-PER TRAP V-N
1 have and will maintain Workerx Compensation Insurance,as required by Section
3700 of the"loss-{C�ode,far the performance of the work -7
Policy
this pcman is issued. GAS-EA.SYSTEM-I INCA N
OUTLETS OCC.GROUP AP
oulP.lic
IS
MY N/fns Iyyy yypa5cy'l c Policy No.40 JS .3 GAS-EA.SYSTENUOVER 4(EA)
[ C17WIIFIICr7NL'EMOF E%EMIMON FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION Riff$
ITchein�sJttytth�ioojl nnWthde,poclh)eomPvmdiUh e nitlsforonehundivddollaa($I(X)) GREASE'TRAI'
or less � O
PAHEK PEE
mof �w
the work far which this permit is ismad.lshull SEWER-SANITARY-STORM HA.2g11T.
not employ any pcwm in any manner% object t C Worker'Compcn- ENERGY PEE 11
Z 'tion laws of California.Dade WATER HEATER WNENT/ELECIR
pplkaal GRADING FEE
Z TICETOAPPLICANT:if.after making this Certificate of Exemption,you should WATER SYSTCNVTREATING SOILS hlili
abecame xobject m the Worker's Compensation pmvixiomrof the Labor Codc,you amt
Fk1
forthwith comply witb such pmvisinnx ur thin permit dual be dented revoked. WATER SERVICE.
aQ
7 Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FL PAID Rmdpl N
UQ l for
thi themereisacomaee.0n len ding agency for Ne perfomnarrcc of Date
the work for which this permit is issued(Sec.JW].Civ.C.)
fL U Lenders Name TOTAL:
W Leader' Addrexv TOTAL:
dI verify hot 1 have tCed this vpplividion million that the above information is BUILDING PEE �+
fn correct.I agree to Comply with all city andcountyordivanees and are lawsrelatingm Q'I'Y. MECHANICAL.PERM IT FEE
UZ building conorection,and hereby Immunize representatives of Nis city nn enter upon the SEISMIC THE
tbave-mentioned propedy for inspection ptrgm.acs. PERMIT ISSUANCE
(We)agree m n
save,indemnify and keep hantess NC City of Cupertino against ELECTRIC FEE
liabilities,judgments.costs and expenses Is hick may in any way accrue against said City ALT'ERORADDTOMECH. PLUMBING FEE
in consequence of the graining of this wool.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,000 CFM) )q
SOURCE RIiGULAT ONS. MECHANICAL FEE I V
AIR HANDLING UNIT(OVER IgtXs CFM) CONS'I'RUCTION'TAX
an A4 Laoti�,
ngmmureo Ppic U ntmsa Date EXHAUST 14001)(W/DUCT) .O HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE ^ .S
Will the applicant or future building Occupant store or handle hazN
aous material HEATING UNIT(To HaLood BTU) YN u
Is defined by the Cupertino Municipal Code.Chapter 9.12,and the Heals end Safety
Gyle,Section 2553200? HEATING UNIT(OVER 100,003,BTU)
❑Yes El No Ate)
VENTILATION PAN(SINGLE RESIDE / PAID Dade RceeiplN
Will the applicam or future M1 defined
t¢',N,B axe eyui it Q.or devices which
emit ha>;Wous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP OHP OR 100,000 111 TOTAL: �
Dishier?
❑Yes ❑No BOILER-COMP(OVER 100.0011,BTU)
I have mail the hams
materials requirements under Chapter 6.95 of the Cali. AIRCONDITIONER
SSUANCE DATE
fomia Health&Safety e,S ctions 25505,25533 and 25534,1 understand not if the NEW RESIDENTIAL MECH. SQ.PT.
building does outcome
ounmain he occrpam
fthe arqirmnnsw
mC n ml,.cuencc oto Ccnif isms of Occupancy.
ncrorauthm s TOTAL' / ISSUEDBY:
OFFICE