31376 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. 31^3 7 6
BUILDING•SIVISION APPLICATIONIPERMIT PLUMBING-MRCHANICAL 1/
BUILDING PROJECT IDENTIFICATION
BUILDING ADURI55: SANITARY NO. APPLICATION SUBMITTAL DATE
0�.OWN NAME: PHONH: CO ACfOR'SN r. - LIC NO: �./
c(.,� 2h ��if"- to
CONTROL#
RCHDT:Cf/ENGINEER: LIC NO: ADDRfi. `!,f e' ll ///�• r ❑
CONTACT: PHONE: vJ `// ,//gf/ BUILDING PERMIT INFO
S� jy�y/1�/a� ❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MUCH
/ 13 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing )OB DESCRIPTION
�•-IQty 00 with Section 7")of Division Sof the Businessand Professbns Code.and my licensen; RESIDENTIAL,
DEN'I'IAL'
FCC ' fail force and offPCRMITISSUANCE
e�P. 9e 35,% ❑SFDWL C)KITCHEN REMODEL
License as Lic.N s7 isnAPPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING RE-PIPE
'��YdJ Date
Contractor 4
(-,z ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z O Zy 1 understand Typhus Kali M wed a public records PANELS ODIFICATION
CZ- UPTO 201)AMPS s
CZ-0 ❑INTERIOR HIMNEY REPAIR
1-•4Y LL Licensed Professional - a 201-IfNMAMPS IMPROVEMENT
9 •,ql OWNER-BUILDER UCCLANATION OVER IUM]AMPS ❑BATH REMODEI/REPAIR [I DEMOLITION
Iyy,5��K 6 1 hereby affirm Nat I am exempt from the Cantracmr'x License Law for the ❑OTHER
47x,5 following...(Section40]1.5,Businessand Profession Cade'.Any city or county SIGNS FLECUtICAL
47�WC('� which requires a Permit to conswct,alter,improve,demolish,or repair any strucwm
y .aJ prior m its issuance,also requires the applicant for such#ermines file a.signed statement SPECIAL CTRCUOUMISC.
w7yU Nat he is licensed pursuant the provisions ofthe Commcmrs license Low(Chapler9
CO (commencing with Section](NN])of Division3of the Business and Pmfesaiom CNe)rm TEMP,METER OR POLE INST.' COMMERCIAL:
d..c ev Nut he is exempt therefrom and the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DHMOLITION
�pWp54, 4• Section'/031.5 by any applicant for a Permit subjects the applicant o a civil penalty of POWER DF.VICF3
41�rn ❑TENANT ❑FOOD SERVICE
E-Z p., oat mom has five hundred t dollars y employees
IMPROVEMENT
O �Lo the work,
,the pourvis .isrod ployeeswi.wages ns.ei(See compensation. SWIMMING POOL.ELCCfRIC
Ila will dothedark,Crude:
o Cereisnotintendedo Law itdfor sale(Sec. ,an Business OTHER
and Professions Cade:The eves thorai License Law does not apply m an owner of OIIThEfS-SWITCHES-FlX'NRBS
r his o,regency who builds or timed t x t such i and who does such work himself m through
his own employees,e provddW that such mens iseoldw are not intended or offered for NEW RESIDENTIAL ELBCfR SQ FT, -
wle.If.however.Nhavethburdng or en of Waving
tithat he withinoneb yearor Imosefarpm, Pf SQ.Ff.FLODRAREA LSQ.FT.
' the
owner-huilder will have the burden of proving that he did not build or improve for Pur- Y
a,
1,as
ownrtee 2+y 199
I, s or of the property,um exclusively and summering with licensed contractors i- TOTAL:
comwctthe pmjet applyoan Basineasandrtywho tum CWc:) thereon,and
who contracts
Forsch plyman with
er aafpmpens whosebuilds arimpro the Comucand QTY. PLUMBING PERMIT FEE IINv
License Law.for such projects wdtttacomruaor(a)Iicencd pursuvmmthe Coatmdnls
0lannexa } PERMITISSUANCE - 1r�-'
❑lam exempt under Sea ,B&PCfor Nis reason
Owner Date ALTHR-DRAIN&VENT-WATHR HLA) VALUATION
�
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE.
I herebyaffirm undo penalty oepejuryoneof me following orker's Co
Qihnve and will
ed!for by Section
of Con sem toCodensure for Workersce of the
DRAINS-FLOOR,ROOF AREA,GOND. STORIES TYPE CONSTRUCTION
workr pravlded for mi Section 3100 of the labor Cede,for the performance of the /
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers ante afthe w rkfor hi h required by Section -
J]IM)of Ne laMrCWe,for the performance of the work for which this permit is issued, GAS-HA.SYSTEM-I INC.40UTLLTS (ICC.GROUP APN
ely W.11,7,Compeou ti In urticj'''nit Policy nnW;her:ye:
Cartier.S�J�Y �xe m rlicy Nn.: /.� GAS-CA,SYSTEM-OVER 4(EA) _
CERTIFICATE OF CXFF ON FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION HIS
(Thus section need not he completed ifthe permit is fortune hundred dollam Hi 100) - GREASETRAP
nr lest.)(Thus
FET.
I certify that mine performanecafthework forwhich this permit is issued.lshall SEWER-SANITARY-STORM FA.200 Ff.
not employ any person in any manner so as to become subject ers
subjeco the Work 'Compcn- BNHRGY FEE
zz scion Laws of C.1ifomih.Data WATER HEATER WIVBNT/EL=It
0 Applicant GRADING FEB
y NOTICE TO APPLICANT.If,after making this Cenuticate of Exemption,you should - WATER SYSTEM,TREATING
abecome subject to the worker's Compensation provisions of the Labor Code,you must SOILS PCE
forthwith comply wird such provisions or permit shell be deemed revoked. WAFER SERVICE
a Q
CONSTRUCTION LBNDlNGAGENCY NEW RESIDENTIALPLMB. SQ.ff. PAID Dam Receipt
L) 0 I hereby that pe.ere isnemswe compaction lending Civ.
agency(onhe performance of p
Newark for which this permit is ismcd(Sea.309],Civ.C)
D IT" f" Lenders Name " TOTAL:
U Lenders Add., - TOTAL:
BUILDING FEE
[r 1 cmi(y o comply 1 have mad rhos application yo dram ces the above ws relating is
taA building ogreemnd hereby dryandmiz countyordinmsesand stem lows relating to QTY. MECHANICAL PERMIT FEE
building conamnion,and hereby auNorize rcprcunmtives of this city wonder upon the SEISMIC FEE
above-mentioned property for inspection purpouts. I
PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless Ne City of Cupertino against ELECTRIC FTE
•
liabilities judgments,casuand expenms which may un any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the grunting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCC H•CUL TI '
Z� AIR HANDLING UNIT(OVER IB0dgICFM) CONSTRUCIIONTAX
SignommafApli ontri D e EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
A7ARDOUS MATERIALS DISCLOSURE
Wilhhe pplicant or future building occupant store unbundle hazardous material HHATING UNII'(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(.)4 HEATING UNIT(OVER 100,000 BTU)• .
❑Yes ❑No VENTILATION FAN(SINGLE RFSID) PAID
Dam Receipt#
Widousll the appnintaricandsant or building by the Bay Aequipment orualitdevices nagemnt BOILER-COMP QHP OR 100.000 BTU)
Dmir hazardous air cnmvminams ns defined by the Bay Area Air Quality Management* TOTAL:
Dtxm<r^
❑Yes FIN. BOILER-COMP(OVER 100.1100 BTU)
'
I have read the hazardous controls requirements under Chapter 6.95 of me Cali- AIR CONDITIONER - ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25514.I understand Nm if the NEW RESIDENTIAL MBCA. SQ.FT.
building does eat currently have a tenant,Nat it is my responsibility to notify me occupant
of the rryuiremems which must be met prior br issuance of a Certificate of Occupancy.
Owner or au.oneed agent Date TOTAL: ISSUED BY: V,Y�rj Imo(
OFFICE