31221 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
31221
BUILDING ADDRESS: SANI'I'ARYNO, APPLICATION SUBMITTAL GAFF
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W' 'g NAh]E: ^D PHONE:v� CONTRACTOR'S NA : Q LICA
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5ButmostmahwookiR: LIC NO: ADDR S:• ❑`
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CON ACT PHONE: 'BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) •BLDG ELECT PLUMB MF,CH
❑ ❑ K ❑
LICENSED CONTRACTORS provisions DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby a)linn thin I um licenced under ndPoof Chapter 9(commencing JOB DESCRIPTION
�a'Z withSectionfand e)ec Division i of the Rosiness and Prafnsinns Crsdc,and my license is EF51DENTIAL
�O O PERMIT ISSUANCE
F In full fume and effect.
tY_F ❑SFOWI. ❑KITCHEN REMOUEh
QUU License Class Contract.,
Z APPLIANCES hQL Dem Comracmn ADDITION �VLUMBING RE-PIPE
Loon ARCHITECTS DECLARATION El MULTI-UNIT ❑STRUCTURAL.
Z O,A Z I understand my plans shall be used as public records PANELS
y_ MODIFICATION
O Z UP DO 20(1 AMPS
_ Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
_r
201-I(ggIAMPS IMPROVEMENT
Ccw
OWNIiR-BUILDER DECLnItA'I'ION OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
Q I hereby nffinn that 1 em exempt from the Comracmr's Licence Law for the
(3 L U following reason.(Section 9031.5,Huslncss and Professions C:dc:Any city or county SIGNS ELECTRICAL ❑OTHER
LLLL1l u.� which requites a penrdt m construct,ale,improve,demolish,or repair any swewre
F"N0 j poormits issuance.also requires the applicant lr isuch penniuofilen signed statement SPECIAL CIRCUIT/MISC.
ad} that he is licensed pursuant o the previsions ofthe Communes License Law(Chapter 9
,='Cz (commencing with Section7000)ofDivision 3 ofthe Business and Professions Cosm)or TEMP.METER OR POLE INST, OMM R IA
a 3 c that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION
�1� Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑DEMOLITION
F Z'> not more than five hundred dollars WOOL ❑TENANT ❑FOOD SERVICE
�SQp ❑ Las owner of the progeny,or my employees with wages as theirsale compensation. SWIMMING 1,ELECTRIC IMPROVEMENT
F will do The work.and the structure is not intended oruff d for sale(See ❑OTHER
3 m and Professions Cale:The Contactors License Law does not apply to an owner of OUTLETS-S W ITCHES-ETXTUR
propeny who builds or improves thereon,and who does such weak hilowif or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECI'R 5
sale.IL howescr.the buildingor improvcmmm is sold within oneycaof completion,the SQ.FT.FLOOR AREA SISQ.FT.
ei-builder will have The burden of graving that he did not build or improve for put- '
Ruse of sale.), pp��
❑h as owner of the property,am exclusively contracting with licenced contractors to TOTAL: D
comanect the project(See 7144,Buxines and Professions Code:)The Contracture Li- ��� e 9
Li-
cerise law does not apply to an owner ofpropeny who builds or improves thereQon.and TY PLUMBING PERMIT FEE (] ��
who contracts fir such projects with a esmtractons)licensed pursuant to the Contractor's
License Law' PERMIT ISSUANCE /t7�
❑1 am exempt under Sec. ,B k P C for ibis neoson / Cb! U'•
I Owner Dam
ALTER-DRAIN$VENT-WATER(EA) VAL A
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby aff under penalty of perjury one of the following declinations:
i]Ihave and will moimainn Cenifica¢ofConecnT fo self-insure fin Wn.ker'e CoT 1,0- BRAINS-FLOOR,ROOK AREA.COND. STORIES TYPE CONSTRI1CfION
vas tion, provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issuedFIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
3700of the Lab of Cock,fo !�rfo ounce ofob work for whichthis permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCO GROUP APN
My Wor C(o_�99B����(PPP?ensatioIMl4 arrieranJPolicy pb�—
Carticr: E' , lu u rCee Policy No j1 7�O�e3,�c� GAS-EA.SYSTEM OVBR4(EA)
CE tTIFICAE FEXEMPTION FROM WORKERS'
COMPFNSA'I ION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(This section need not Ise completed if the permit is fiction hundred dollars(S I W) BUILDING DIVISION FEP.B
or Icss.) GREASE TRAP ixwPLANCHECK FEE
Iccnify Net inthe perfnm,unce isp
ofthe work for which thcmrit is cA.l shall SEWER0FAER
SANITARY-STORM EA.200 FT.
not employ any person in any manner m as to become subject to the Workers'Compen- ENERGY FEE
rz smien Laws of Caffarniu.Dae
O O A licant NFM/ELECIR
Applicant, GRADING FEE
Z
h NOTICE TO APPLICANT:If,after making this C,mp am of Exemption you should EATINGbecome subject tothe Workers Compensation provisios of Ne lbor Calc, ou must SOILS ME
forthwith comply with such provisions or this permit shall be deemed revoked.zCONST RUC'HON LENDING AGENCY PLMB. SQ.ET JELECTRICFEE
UO l hereby affirm Nat mem is a emometion lending agency forte perfrmance of ate eceiptN
the work for which'his I conko Issued(See.3097.Co,C.)Lender's NameO U TOTALW4 LundeinAdtresaI renify that I have tend This application and.nate That the aKrve information is EELe) connect.l agree to comply with all city and county ordinances and.stem laws relating to QTY. NICAL PERMIT FEE
U Z building construction,and hereby authorize representatives of This lily to enter upon the
above-mentioned property for inspection puryoses.
(We)as.to all,indemnify and keep harmless the City of Cnpcnlno against PERMIT ISSUANCE EIiabilhow,judgmems,cons and expenses which may in any way accrue against said City ALTERORADDTOMECILconsequence ofthe grnting of this nit.APPLICANT UNDER. ANDS ILL COMPLY WITH ALL NON-POINT AIH HANDhING UNIT(TO 10,OOo CFSOURCELA' NS. n FEE7, AIR HANDLING UNIT(OVRR 10,M)CPM) ION TAX
Sign of App VCon ' Dam EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATIO ,E
Will the applicant or future building occupant som or handle hmardoas material HEATING ON IT TO 100,MI DTD)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade.Section 25532(a)7 HEATING UNIT(OVER 100.000 BTU)
❑Yes ONO
VENTILATION PAN(SINCLE RBSN) PAID
Will The applicant m future building occupant use equipment or devices sshloh Date Rec ipt p
emit hardm
avotaa,r ummminams ns defined by the❑Try Area Av Quality Mvnugement BOILER-COMP(JHY OR 100,000 BTU)
DisWa7 'IOTN.:
❑Yes 0 N BUILP.R-COMP(OVER Ig1,0IXl B'TU) F
AI R CONDI]TONER 'r k
1 have mud the haanrdn a niutions 25505.25533
5 5.2553 cna under .1 undimatu of the Cali- ISSUANCE DATE
Tania Healthm Safety Calc.Sectionst,mini 25533and255]4,Iuncrady td thatifthe NIiW RESIDENTIAL MECH. SQ.FT.
buildingdoes notcurrently have atenant.Nat it ismyce 10 llonfitoue ofyemoccupant
of the nequiremcn6 which and be tan prinnoismance oro Certificate offkcupancy.
Owner on authndad agent Date TOTAL: ISSUED BY:
OFFICE