31147 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. /M1 �� )t4�
BUILDING DIVISION '�APPIACATIONA'ERMIT PLUMBING-MECHANICAL. 3{J
BUILDING PROJECT IDENTIFICATN'IO
BUILDING ADDRESS: SANT"fARY NO. APPLICATION SUBMI'I'TN,DATI
1 of son 4Qe, I
OWNS ' NAME PHONE:PHONf;:_ �� COMA 1 NAM1fE: LIC NOr—r
1VA `J 'lL N/C CONTROLa
ARCHI ECT/ENGINEER: LIC NO: ADDRES ' // ❑
g �U
CONTACT: PHONE. BUILDING PERMIT INFO
,f(fs �
El Consultant Few Paid by Applicant(Initial) BLDG ELECT P UMIi MECfi
z�
I11u` El NI ❑
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed ander provniotr of chaffer 9 xammeneing JOB DESCRIPTION
05% wim Section 7(W)ofDivkian 3,adw Business and Proli.esiome Cade,andnt license is PERMIT ISSUANCE
{^+II— . y NESIDENTIAL .
C,F Cannot CIT, effect_
aUV limns,CP,. Lic.p ❑SFDWL ❑ ITCHEN REMODEL
inQ1 Dde�Contmnur APPLIANCES—RESIDENTIAL ❑ADDITION LNBhNG RE-PIPE,
ARCHITECT'S DECLARATION PANELS
F,D m ❑MULE]-UNIT ❑STRUCfURAI.
Z p-Z I undemtand my flan,shall be used us public records MODIFICATION
OZ—� - UPTO 2IXIAMPS ❑INTERIOR El CHIMNEY REPAIR
t—G/E-W Licensed Professional 201-100(IAMPS IMPROVEMENTWk�.J OWNER-BUILDER DECLARADON
x1 C w Q I hereby affirm that I am cxemfl from the Contractor's License Law far the OVER Fm0AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
{y 3 dCI CI fallowing mason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL
❑OTHER
Ir.m which requires a permit to construct,aper, w
improve,demolish,or repair any sewre
aoQ ptiorm its lsetenca,ahtiteyul,c,lhuapplicanl for such scram, it tilt aslgned%orwoant SPECIAL CIRCUIT/MISC.
f�T', 'hat he is licensed pursuant to the provisions ofthe Contrai License law(Chapter 9
W CCp0 (commencing with Section 7")of Division mills,Nosiness and Professions CaTOor TEMP.METER OR POLE INST. COMMERCIAL'
E mx e C But be is eacmpl therefrom and he bases far the alleged eaemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Way
Section 70315 by any applicant Inc a permit subjects the applicant to a civil penalty of POWER DEVICES -
F-Zy not more than five hundred dollars($500). []TENANT ❑FOOD SERVICE
f=C ❑ I.as owner of the property.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
N wit l do the work,and the structure is not amended or stfcted for sale PS".9(A4,Business ❑OTHER
i3 m and I'rnfession,Calc:'Thc Ci ntzacmr's Lure-Law dress not apply to an nwncf of OUTLETS—SWITCHES—IT TURES
Rini who builds or improves thereon,and who d«s such work himself nr through
his own employees.Provided that such improvements are not intended or offered far NEW RESIDENTIAL ELECIR SQ FT.
sale,if however,the building or undroventen is.sold within tine yet rnfwmplclionthe SQ.EL FI.)OR $/SQ.Ff.
er-builder will have the burden of proving that he did not build o,improve for Pur-
pose of sale.).
❑ 1,as owner of the property,um exclusively contracting with licensed contractors to TOTAL: IdAR 9 1•$ ❑r[4r�p
nGnmt Ibe protan(Sec.9014.Bas nand 1'nsfca a Codea'fhc Convueor's Li- II
c uLawdoesnotapplyloanownerofpmpanywhobuildsorimprovesthemon,and QTY. PLUMBING PERMIT FEE 011Y
who contracts for such portieres wim a commnons)licensed pursuant to We ContinuitiesUr UUY
Liamse Law. ' PERMIT ISSUANCE tHl(�VU
❑ l am cacmpt ander See. .13&P C tot his icasnn
Diane, Data ALTER—DRAIN&VENT—WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby afford under penalty ofperjury aneof IM1e following declazue ns:
❑I have and will maintain a Certificate ofConsene to elf-insure for Worker's Compen- DRAINS—FLOOR,ROOF.AREA,GOND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which ft,pe...it is exam. FIXTURES—PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
370011 laMr CM,for the performance mare work fur which this permit is issued. GAS—EA.SYSTEM-I INC.J OUTLETS DEC.GROUP APN
My Workeey ane n insuT.tnTe carrierund Policy numberwe
99�� F.1 )/
Currier: �-$(ti' �,—u Pl( Policy No.:Ii'72Q =7 GAS—EA.SYSTEM-OVER 4(EA)
CER I'IFICATE OF EXEMPTION FROM WORKER- —��IS'1V
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(Thismxlinnnced not lsea.mplaned Tile,panni,is Ruane hundred dollars($Ego _ RU ILDING DIVISM IS
nr Ices.) GREASETRAP
PLANCHECK FEE
I.,airy main the any ormenceofineweak forwhlchthis permit is i hill
mol cm to anWER—SANITARY=STORM EA.200 FT.
p y y pawn in any manner so s¢t hcaome suhjen m the N'orkcn Co.,..Compen- ENERGY FI31i
,z, sution Laws of California.Da
Z� Applicant m WATER f1I3Al'ER W/VENT/ELECI'R GRADING FEE
h NOTICE TO APPLICANT:If,after making this Ceni icate of Exemption,you should WAGER SYSTEMEI BEATING
a ; become subject m[be Worker's Compensation provisions of me Lahr Cale,you most SOILS FEE
fonhwim mmfly with such pootimarria,mi.,Per nit shall be demaed revoked. WATER SERVICE
aQ
CONSTRUCTION LItNDING AGENCY NEW RESIDENTIAL PLOD. $Q.FL PAID
L,0 kbar hick his
that crauoisucsd Nee.30 lending agency for porfnntuncenf Dale RmcipeN
� � the work bar which this pernw ie imueJ f5ec.301),Ca,C.) '
Q Lender',Name TOTAL:
Lander',Address TOTAL:
F}•' M 1 certify that 1 have read his ufplicatinn and same the In,above loftmmtica is BUILDING 103E
(0 correct.1 agree to comply with all city and county maneuver,and true,laws relaing as QTY. MECHANICAL PERMIT FEE
U Z buildingenmlruction.and heeebyaumorize rcpesemativevafmis city memer upon the SEISMIC FEE
ahwe-mentioned property for inspection pu0mses. PERMIT ISSUANCE(We)agree it save,indemnify and keep hamlcss the City til Cupeninn against ELECTRIC ITH
Iiahiliticsjudgmentv,enl and its pcmrcswhichmtyin any way relool gain,l said City ALTERORADDTOMEC L
in conxyuencc of gr Cling ofthis it PLUMBING FEE
PI'LICA�
A ' E'STANDS WILL COMPLY WITH ALL NON-POINT AIR HANDLING ONE TO 11,000 CFM)
SEE MIiCHANICALFEE
(/ AIR HANDLING UNIT(OVER I0.0110CFM) CONSTRUCTIONTAX
Si m n pplic.m` Door Data EXHAUST HOOD ONMUCTI HOUSING MI'T'IGATION PEE
-HA%ARDOU$ ,RIALS DISCLOSURI3
Will the applicant or future huilds g acupane store or handle hazardous ma¢rial I IIAI'[NO UNIT TO I W,000 BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.11,and the Ileath and Safety
Calc,Section 255321ay! HEATING ON IT(OVER 100,003 RTI1)
E]Yet •RA No
T VENTIfAT10N FAN(SINGLE:BESIDE PAID
Will the applicantunt or future building occupant sex equipment or devices
Date Receipt#
mit hmrJnus air ronmminan,a,de)nof bythe Buy Arca Air Quality Manage cal
BOILER—cUMP(3I IP OR 100.0m)BTU)
District! TOTAL:
❑yep �,yry-':��� tlO1LER—COMP(OVER 100.000 BTU)
1 have a n I the nored"J.v l'1eter,.Is requirement,audit,Chatter 695 of the Call- AIR CONDI'TIONF,R ISSUANCE DATE
fume.Heald&Saf Cale.Seainna 255(M 25533 and 25534.I understand mot if the NEW RESIDENTIAL MECH. SQ.FT.
buildingd c nely have nam,maeili: yrespmsibilitym notify meacufanl
aft In. o r H uunmof,cenific Occu un
r amboneed agent D I TOTAL: ISSUED BY:
OFFICE