31340 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 313 /1 0
BUILDING DIVISION APPLICATIONA'ERMIT PLUMBING-MECHANICAL. 3 �K14
BUILDING PROJECT IDENTIFICATION
BUILUINARtSS:
GUUll SANITARY NO. APPLICATION SUBMITTAL DATE
Q � S-t e S
OWNER'S NAME: PHONE: CON TRACTOR'S NAME: LIC NO lit _
ry
SOn "1 NIC CONTROL#
•ARCHITEC7UFNGINEER: LIC NO: DRESS: `� ❑
Ab
CONTACT,. PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ILECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRd under
DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby afr that 1 ant fthe Bu under ndfi.bon of mchapter v(commencing JOB DESCRIPTION
BOZO with Senior FIINI)nf Uivisiun3uRhe Business and Professions Cods.,mal my license is RESIDENTIAL
F full fu ,"anJc c PERMIT ISSUANCE
GVU Lima, las, '�°'�33 9 1fc♦ Z ❑SPDWL ❑KITCHEN REMODEL
t zwost= Dam COmmc L¢an Me<,:y%, � APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
FhZ dcrsmn III ECI'SU LARAI'ION ❑MULTI-UNIT ❑STRUCTURAL
',ZO,�,,, YPI c alIb ub' recent, PANELS
O'Z-+GIUP TO 200 AMPS MODIFICATION
F al Limow r ,.morel El INTERIOR +RRT7 EY REPAIR
201-1000AMPS �`��\\\
OWNE&BUILDER m the CoATI09 IMPROVEMENT
< I hereby off rat that I am exempt from the COmmctur'n Liceme haw for the OVER 000AMPS ❑BATH REMODEI/REPAIR C3 DEMOLITION
k3 a U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
F LL O ma which requires a Permit to construct,alter,improve,demolish,or repair any structure
w.] Fri.rmitets>uancealso reyuirav the applicant fmwch penult,,file a signed statement SPECIAL CIRCUFOMISC. $N
ay2that he is licensed pursuant mdse pnliolles of the Contractor.License],a. Clo Pter9 rw
I+I�CO (commencing with Section7")of Division 3 of the Business and Professions Caft)or TEMP.METER OR POLE INST. COMM R IA 7�/�
a q o c that he is exempt therefrom and the basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031,5 by anyappreant fora permit s.bjemstha p,them,I...en penalty of POWER DEVICES
F Z�•
of mote than five hundred dollars($500). ❑TENANT ❑FOOD SERVICE
❑ Las owner of the progeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVF,MFNT
p. will do the work,and the slaccumc is not intended arol'fered for sale(Sec.7044,Business - ❑OTHER
W 3 end Pmfc,"am,Code:The Contractor',Lirenm Law Anes not apply to an owner of OUTLETS-SWI'I CHIS-FIXTURES
progeny who builds,or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or Offered for NEW RESIDENTIAL ELI,'CTR SQ IT
sale.If,however,the building Or l rom-cmenl is sald within one year of completion.the .FLOOR AREA $/SQ.FT.
ser-builder will have the burden of proving that he did not build or improve for pur-
posea[s
1,as owner of the progeny,am exclusively slid Protracting with licensed moremors ro TOTAL:
eanse La the project ISec.]fans,alines,mid fty who brei Code:i Theves thereon, Li- /
c eawdoes not or such apply toan with
acc muctuny whobuil Pre improve,Contan,and QTY. PLUMBING PERMIT FEE
who seL.ty.for such projects with acommcmrts)licenced pursuant India ConwaOr,
License Low. PERMIT ISSUANCE
lam exempt reinter Sm. B&PCfor this reason
ALTER-DRAIN k VENT-WATER(EA)
Owner Dam VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one ofthe following declaration, J4 /,J\
❑ I have and will maintain a Cerificate of Consetn to elf-insure for Wmkers Compere BRAINS-FLOOR,ROOF.AREA.COND.
smion,as provided far by Section 3900 of the Labor Cale,far the pcdita ttar of the STOR16.' TYPE CONSTRUCTION
work for which Nis permit is is ied. FIXTURES-PER'fRAP
I have and will maintain Worker's Compensation Inmuncer,as reyuired by Section
3900 of the Labor Code,for the Performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4OTTLETS OC .GROUP APN
My Worke33' Coryryge mien I rand Volicy'j4q' ark
Comer. S�rAi r3 $ ,ptyt,0e4arric Policy No.: \3 /�Gq GAS-BA.SY$'TEM-OVER 4(EA)
CF,RTIFICATEE OF EXEMPTION FROM WORKERS'
COMP17NSATION INSURANCE GRFASEiINDUSTRL WASTE INTERCEPTOR
(Thls,ection need na M completed tithe permit is fnrone hundred Dollars($IIXp
If
"V,
I VISION FBHS
or less.) GREASETRAP
1 cenify hot in the performance of the work for which this permit is issued.I shall
;BUILDING
HECK FEE
stem In SEWER-SANITARY-STORM EA.200 FT.
employ any person in any manner so as to Mronm subject the Workers Compere ENERGY FEE
z ration Lawn of California.Data
o WATER HEATER W/VENT/ELECTR G FEE
Z o Applicant
N NOTICES subject
APPLICANT We,k H.after making this Ccnilix of'b Emmption,you should WATER SYSTEMMOIATING
`Uj became mbjeat y the Workers Guopcor this provisions of Talent Code,you must
1 O forthwith comply with such provisions or this permit shall he deemed revoked IiF.
WATER SERVICE
.7 z CONSTRUCTION LENDING AGENCY - NEW RESIDENTIAL PLANT SQ.FT.
UO flumbyaffitmtbmtherickaconsuunion lendin6 agency hn the perfommncc of Date Receipt Is
4. (~ the work for which this permit is issued(Sec.3097,Civ.CJ
o ULenders Name
Linder,Addmx. TOTAL:
I cenify that 1 have mad this appliention and,tate that the shove information is TOTAL
Fr N correct 129M m comply with all city and county ordinances and stale laws relatin m NG FIiE,Zbuilding construction,and hereb s QTY. MECIJANICAL PERMITFEEb yuuthmia rpruumauvesnithis city toen¢rupon the FEEshove-me eia gre progeny fm inspection purposesPERMIT ISSUANCE(Wq agree to save,indemnify and krep hannleh.the City of Cupenino agniO r IC FEEliabilities,judgments,costs and expema which may in any way secure against said CityALTER OR ADDTO MECH.me ocquramof the g,.ningof hisR it NG FEEAPPLICANTUNDERSTAN AND ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT UX)111X%1 CFM)CEREGULATI NSNICALMAIR HANDLING UNIT(OVER 10.(100 CFM) UCTION TAX
Sig to of Applicant ore- Date U EXHAUSTHOOD(W/DUCI]
HAZARDOUS MATERIALS DISCLOSURE. HOUSING MITIGATION FEE
Will the OPPEecan-1 metre building Occupant store or handle hazmdous material HEATING UNIT TO 100.(NAI BTU)
us defineA by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)I - HEATING UNIT(OVER 101000 BTU)
❑Yes F1 No
VENTILATION FANISINGLH RESID) PAID
Will the air conn or future building by the B use equipment Qu or devices which Dute Receipt p
emit hazardous air contaminants u%defined by the Pay Area Air Quality Management BOILER-COMP(3HP OR 100.00(t BTU)
Uivlrid^. TOTAL:
C]ye., ONO BOILER-COMP(OVER 100,0)0 BTU)
1 have read the hazardous materials reyultnnem,under Chapter fi 95 Of the Cali- AIR CONDITIONER
fornix Health do Safety Cran,Swore 25505,25533 and 25534.1 understand that if the ISSUANCE DATE
building does not enncrely have a tenant.that it is my responsibility to notify tM occupant NEW RESIDENTIAL MECH. SQ.FT.
of the requirements which must he met prior to issta nae Of a Ccnificam of Occupancy.
Owner or numunzed agent Date TOTAL: ISSUED BY: 10"Or I
OFFICE