31174 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO 31'174
BUILDING DIVISION APPLICATION/PIiRMIT
PLUMBING-MECHANICAL
IBUILDING PROJECT IUF:NTIFICA'1'ION
BUILDINGADDRE.SS: .�.a� SANI'TARYNO. APPLICATIIOON^SUBMITTAL DATE
2t
OWNERS NAME: PHONE, Cd 'RACTUR:S NAME: LIC NO:
t 1 ( N/C CON I'ROLp
ARCHITECDENGINEER: LIC NO: ADDRESS: Q '� ❑
CAAA
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fccs Paid by Applicant(Initial) BLDG EL PLUMB MECH
LICENSED CON]RACTOR:S DECLARATION QTY ELECTRIC PERMIT FEE ❑ If���'.
1 hereby affirm dead 1 am licensed under provision of Chapter 9(mmmmencir8 JOB DESCRIPTION
CaZ with Section lglo)of lYv" Jnflhe tlu+ones.and Professions Gdy.one mylicnmse is RESIDENTIAL:
wow PERMIT ISSUANCE
F�.. in full force anA L CSFDWL -❑KITCHEN REMODEL
aUU LiccnJ� �l.icp APPLIANCES—RESIDENTIAL CADDITIQN [I PLUMBING RE-PIPE
tPzqg_u nam Contra , 1
F.O w ARCHITECT'S DECLARATION try pgNE1S ❑MULTIUNIT ❑STRUCTURAL
CZ I understand my plans shall be used as public recordx MODIFICATION
UPTO200AMPS C1 INTERIOR ❑CHIMNEY REPAIR
f.,N„Ir Iq Licensed fimslond 201-1000AMPS IMPROVEMENT
,Mn OWNER-BUILDER DECLARATION
a ?' 1 hereby affirm that 1 am exempt from the Contractor's License Law for the OVER I"AMPS C BATH REMODEUREPAIR C DEMOLITION
a5�• a U following reamn.(Section 7031.5,Business and Professions Coddle:Any city or county SIGNS ELECTRICAL C1OTHER
u13 0.y which requires a permit to construct,alter,improve.demolish,or repair any stmcmrc
��so prior loins iswarrct,ith.onure,daccipplicam mrsuch pctim.mfleusignedslammcnd SPECIAL CIRCUTUMISC.
that be is licensed pursvum to the provlamons of the Commators 1 icer.Law(Chapter-9
(comnencingwith Smtion7W))of Divi.sion3 trust,Bus9mcaand Pmlbssions Codgor TEMP.METER OR POLE INST. COMMERCIAL:
a a p C
that he is exempt therefrom and the husis for the alleged exemption.Any violation of CNEW BLDG/ADDITION C DEMOLITION
X^� Section 703 IS by any applicant for a permit subjects the applicant o civil penalty of POWER DEVICES
1y�y OTENTANT CFOOD SERVICE
t more wric Eve ImnthW dol furs($Sirs).
^Z i IMPROVEMENT
< C 6o the worof the propeny,or mymm�tendedwinh Bred twages as (See. 044,bompe sines. SWIMMING YWLELF.CI'RIC
and Profcwork,and Coate eContlsauninamem orowdosansale(Scc lad,war,
os ❑OTHER
a3 m and Professions Code:The Commnor4 License law does nm apply to an ownv of OITILETS—SWITCHES—FIXTURES
his own b
who builds or improves thereon,and vPoo Jaen such work himself
his or through
own employees,provided that such Improvc.Id within
are mol imm�JeJ of Offered for NEW RESIDENTIAL ELECfR SQ FT.
ownco.however The have the bur en of Timing
that he did non build or nprove fon the SQ.FT FLOOR A PAID
LSQ.FT.
er-bnildcr will have the burden of proving tem he did not build or improve for poo-
own Yf
pose ofsme.T. r
❑Las owner of the Seepin,verty,am exclusively consorting with licensed amlmnoR i- TOTAL:
anetmn the project apply
to a n,wner of and ny who loo Coney The Contmnon.Li- {{�� (7[(1M�
ccn.c Law aoesnmupply man with
icenwipenor omprovhe Contractor's
Q'!Y. PLUMBING PERMIT FEE MAY my a17
who contracts for such pmja¢woad a commnor(s)IicenseJ pursuanuo the Convacmr's
License Law. PERMIT ISSUANCE.
❑I am exempt under Sm. .B&PC for this reawn Y Ur. UurEHT1N
ALTER-DRAIN&VENT-WATER(EA) VALIDATION
•Owner Uade
WORnderPCOMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penalty of perjury one of the following Jalurmmons
❑Ihavcandwill maintain aCenilicatc nl Conscm m,¢IGinsum fur Worker's Compen- DRAINS-FLUOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
saloon,as provided for by Sectinn 3100of he labor Code,for the peHurmaee of the
work for which this permit is issued. FI%TURES-PER TRAP
❑I have and will maintain Worker's Compensation Imsumnce,as requited by Section
J1Bpol the Labor Cole,for the performance of the work far which this perm it is i.ssucd. GAS-EA.SYSTEM-I INC.S OUTLETS OCC.GROUP APN
MynWurkers Co. tan stn ja9�+and Pdicyn m r re: GAS-EA.SYSTEM-OVIiR4(EA)
s,1 t a ce e Policy No.:
CERTIFICA COT IIXEMPf10N FROM WOR ERS' GRF.ASF/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(9111aseamm need mol he coundclediOhe permit is porous,hundred dollars(SIM) GREASETRAP
or less.) PLANCHF,CK F1iE
I certify that in thelrerforunce ofthe work for which this permit is issued.)shall SEWER-SANITARY-STORM EA.200 FT.
not employ any Peron in any manner so as no become subject m On Workers Compen- IiNENGY IEE
ZZ cation laws of Califomiu.Date WATER HEATER WNENT/ELECTR
Applicant GRADING FEE
NOTICE TO APPLICANT:11,infer making this Cenificam of Exemption,you should WATER SYSTEMPTREATING
a ? became subjat to the Worker's Compensation provisions of the labor Cale,you must SOILS ME
UJ forthwith a nn ply withauch provisinncor this Permuhall be ecemce revoked. WATER SERVICE
U=) CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB, SQ.FT. PAID
'Z Ihrmby affvm thin them is a mmwceon lending agency for the performance of DomL�n RecciptM
U.Pthe work for wmi
hich phis Pert iN Issued(Sec.3097.Co,C.)
U. U Under',Name TOTAL:
Lender's Addmss TOTAL: BUILDING1 certify that I have read this application and state than the above information is
F N correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V building construction,and hembyauthorim representatives ofthiscirym enterulron the SEISMICF
ahove-mentioned propcny for inspection purposes. PERMIT ISSUANCE
(We)usury m save,indemnify and keep harmless the City of Cupertino against ELECTRI P
liabilities,judgmnns.cuss and expenses which may in any way accrue against said City ggI'ER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING F
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,01)0 CFM) MECHANIC .FEE
SOURC RIiCULATIONS. O
AIR HANDLING UNIT(OVER 10.1100 CPM) CONSTRUCJONTAX
Signature orApplic.jVConactor Dam E%HAUST HOOD(W/DUC) HOUSING MITIGATO
HZEDOUS MATERIALS DIS .O URE
Will the epplicum or frturebuildirgo:cupams net hamllehaaardousmatenal HEATING UNIT(TO 100,000 BTU)
ua defined by the Cupenlno Municipal Cole,Chapter .1 and the Hculth and Safety
Cale,Section 25532(0)? HEATING UNIT(OVER 100,000 BTU)
❑Nn PAID
VENTILATION FAN(SINGLERLSN) Dam Receipm4
Will the applicant or future building occupant use equipment or device'which
emit haeandous air contaminants as defined by the Bay Area Air Quality Management BOILER—COME(3HP OR 100.000 BTU) TOTAL.
Dissect? BOILER—COMP(OVER 100.0011 BTU)
❑Yes ❑No
1 M1avy rood the haeallous materials mquiryments under Chapter fi.95 of the Cali AIR CONDI'TIONE'R ISSUANCE DATE
hand.Health&Safety Cede,Satinets 25505,25533 and 25534.1 understand mat it me NEW RESIDENTIAL MECH. SQ.ET.
building does not curiendy have a tenant,that it is my responsibiliry In ratify the oecupam
of me requimments which must by mel prior to issuatmce of a Certificate of Occupancy.
Owner or,omhorimd agent Dam 'IO TAL: ISSUED Try.
OFFICE