31434 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO- BUILDING-ELECTRICAL. PERMIT NO. 31 A 3 ^
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. J !•}J Lt
BUILDING PROTECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
0 3 I b acv�. l�Zab
OWNER'S kN,AME: i PHONE: COSTSFOR'S AMI::/ ELIC NO:
L NIC CONTROL#
RCHITECT/ENGINF.ER: LICNO. - ApDI�S; x�, LGhY ❑
CONTACT': PHONE: 3 (,� BUILDING PF.RMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLU MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ ❑
1 hereby affirm that Imo licensed under provisions of Chapmr 9(commencing ]OB DESCRIPTION
OOZ wish Section N0l)at'Division3ofthe Business and Professinm Carle.undmyliecuseis PERMIT ISSUANCE RESIDENTIAL
W P is full force and effxt�s 3 /
�U License Chas Lic,# ❑SFDWL O�CITCHEN REMODEL
ZZ<til Dara Commcnor APPLIANCES-RESIDENTIAL ❑ADDITION UMBING RE-PIPE
I,.=O ARCHITECTS DECLAATION ❑MULTI-UNIT STRUCTURAL
Z C N PANELS
N 1 understand my plans.halased be seJ ea public records MODIFICATION
OZ—pppppp UPT02MAMPS [:1 INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-NMAMPS IMPROVEMENT
,y bd OanI ma exILDERempt
DECLARATIONeCarlaoOVER TWO AMPS ❑BATH REMODEIREPAIR ❑DEMOLITION
1�CC Q 1 hereby eftnn that 1 R-eaempt from the r's License Lew for rhe
LLO L U following lemon.(Section 7031.5,Bamim as and Professions Cade:Any city or county SIGNS ELECTRICAL []OTHER
F which requires a gcrnit m conswct..Iter.improve,demolish,or repair any structure
pdar ta its issuance.also requUm the.ppiicast for such permit to file.signed smmment SPECIAL CIRCUITNISC,
ryt1rnz���y that he is licensed Formed to me transitions ofsbe Coatrucmra License Law(Chapter 9
COp (commencing with Section 900()of Division Sof the Business and Professions Coded., TEMP.METER OR POLE INST. COMMERCIAL:
IL,'y�' aa that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
% 4
Section 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
W yt more than five hundred dollars($500). ❑TENANT ❑FOODSERVICE
� Q I,es owner oftM ro norm Io tts with we nntheirsole coat tion, SWIMMING POOL ELECTRIC IMPROVEMENT
O ❑ d m e Yemp y g pcna
y will lathe wons and the he Contractors
tors Liceed nsor Law
dos of apply to an Business ❑OTHER
a end Profession Cale:The improv"
steno License Lew soca not apply to if owner of OUTLETS-SWITCHES-FIXTURES
.. his we who builds or improves thereon,and who docs such work himself or through — K
his own employees,provided that such impmv<menu art not intended or offered for NEW RLSIDENTIAL ELECTS SQ PC.
sale.IL however,the building or impressment is sold within one year ofcompletion,the / SQ. %R JRb $ISQ.FT.
owneol uildler will have the burden of proving shot he did not build or improve for par- ��jj
pose of saleJ.
❑1,as owaer of the property,am esclusiecly contracting with licensed contractors to TOTAL:
cense reaLa thedoes
jot(Seeapply
to n owne14, r
of prefd Profession ds ori provesThe income nd Q I V 12 1996
Li-
cense Luwdoesnmupprojets with
aofpangenywhosedporimt he
income and TY PLUMBING PERMIT
who mmwds for such projects wish.cammcmr(s)licensed pursuant m she Commmors CL� r
License U. PERMIT ISSUANCE
1 r t,uren ulry
❑Iameanniumder Sec. ,B&PCmrthisremon
Owner Date ALTER-GRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
❑Lhasa ons will maimoinoCenificam ofConumto ulhinaumfor Worker.Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPECONSTRUCFION
cation, provided for by Senior 3]110 of the Inlror Code,for the perfomunce of the
work far
which this gamut is i PI%TII0.ES-PER TRAP
❑I have and will maintain Workers Compensation Insurance, required by Sssued.
37W of the Labor Crbe.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INQ40UTLETS OCC.GROUP APN
My Worker's pcmµuu Imo sec currier and Policy number am:
Cartier. r+ �ITin t Policy No.: Ti !�q4 GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' �—
COMPENSATION INSURANCE GREASF/INDUSTRL WASTE INTERCEPTOR
(his section need not W completed ifthe permit is boom hundred doll urs($100) GREASE?RAP BUILDING DIVISION FEES
art less.) PLANCHECK FEE
Icerifythatintheperform ulaccrthe work far which this permit is issued,Ishell SEWER-SANITARY-STORM EA.20p FT.
not employ any person in any manner so as to became subject to the Workeri Compon- ENERGY FEE
',2; vaicn Lawsof California.Date
WATER HEATER WIVENVELECTR
Z O Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMIfREATING
L•' hecmtu subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FRE
forthwith comply with such provision or this permit shall he deemed revoked WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMEL SQ.PT. PAID
V 0 1 herebyoffirnthatthcre naeansuuctiom lending agencyfortheperforcumce of Date eceipt# '
the walk for which this permit is issued(Sec.3097,Civ.C.)
O Lenders Name TOTAL:
{Uil Under's Address T( AL: k
Ty.., I certify that I have read this application and stale that she above informutio t is BUILDING FEE
:r [A correct.l agree to comply with all city and county ordinances and state laws relatingm QTY. MECHANICAL PERMIT FEE
V z building construction,and hereby authorize representatives ofthis eityta enter upon the SEISMIC FEE
above-mentioned progeny for inspection purposes. PERMIT ISSUANCE
(We)agree 1.save,indemnify and keep harmless The City of Cupertino against ELECTRIC PEC
liabilities,judgments,taus and expenses which may in any way accme against said City ALTER OR ADD TO MECH. PLUMBING FE
in consequent of a granting of Nis gertnit.
APPLIC U L'RSTAN AND WILL COMPLY WITH ALL NO AIR HANDLING UNIT(O IO,OgI CFM)
SOUR +C I,ATION I MECHANICAL :E
AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUCTIO TA%
n ort of pplican Commctar Date EXHAUST HOOD OVIDUCT)HAZARDO ALS DISCLOSURE HOUSING MRIG ION ME
Ne applicant or furore ding ocIcupant stare or handle hazardous material HEATING UNIT GO 100.000 BTU) '
as definrd by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Safety -
Code,Section 25532(.)1 HEATING UNIT(OVER I W.WO BTU)
❑Yea ❑No VENTILATION FAN(SINGLE RESID) PAID
Dole Receipt#
Will the applicant or future building occupant use equipment or devices which
it tabard.air commutators as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR]BLOW BTU)
MsWn1
TO
El Yes ❑No BOILER-COMP(OVER I0),003 BTU)
1 have read she ha Mous mamriaH rt uiremenm under Cha AIR CONDITIONER'
q qtr 6.95 of the Cub- ISSUAN E ATF.
fumia Health&Safety Cade,Sections 25M5,25533 and 25534.I understand that if she NEW RESIDENTIAL.MECH. SQ.FT.
building dna
oreslily wealthy heoup.macfNi wase r
to issuance of a Cm,.IIIto of ney.
.
O orizd gem Dose TOTAL: ISSUED BY:
OFFICE