31186 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL (�
BUILDING PROJECT IDENTIFICATION
BUILDI OD s SANITARY NO. APPLICATION SUBMITTAL DATE
OWNERS
S NAME: - ` ^ PHO ;:-� ' CO 1 ACTOR'SNANf� G.�C N I
NIC CONTROL k
RCHITECT/ENGINEER: LACING: p : `rlkh �J J,- S_4.x�- ❑,
FCONTACTI • 'PHONE: BllILDING PERMIT INFO
❑ Consultant Fees Paid by Applimrit(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
hICENSEO CONTRACTORSp DECLARATION QTY ELECTRIC PERMIT FEE CPCZhy ellirm that 1 nm licensed under previsions of Chupar 9(commencing JOB DE$CRI ION
UIDIENTIAL-
")of Division 3 of the Inco esspnd Prof, ions Cade,aodmylimamis1400ndA'figri / GL L PERMIT ISSUANCE AWL ❑KITCHEN REMODEL
V ll,- VV�LO ❑ApDITION ❑PLUMBING RE-PIPE
-/� Convector AP IANCES-RESIDENTIAL
o l,, 11 ARCHITECTS DECLARATION - ❑MULTI-UNIT i ❑STRUCTURAL.
PANE S
z p-Z - I understand my plans shall he used as public recoils MODIFICATION
OZ-0 UPT02 AMPS ❑INTERIOR ❑CHIMNEY REPAIR '
F+.y.F' Licensed l'mfessional - 201-I111K1A 1P5 IMPROVEMENT'
�ya OWNER-BUILDER DECLARATION OVER IB00 PS
9 W 1 hereby affirm that 1 am exempt from the Contractor's License Law for the t[l
ODELIREPAIR ❑DEMOLITION
3 a v
following reason.(Section]OJLS,Business and Professions Code:Any city or county SIGNS F.hIiC CAL
which requires a permit to eonmm�.ober,improve,demolish,or rtpair any amcture T/ F
priarm its issuance,also requires the applicant for such permino rile o signed statement SPECIAL CIRCUI PSC.
a� that he isliectnedPmm rdwthepmend.asciftheCnamactorsLwars,Low(Chapers
CC (commencing with Secuon 7")of Division 3 ofthe Busincemad Professions Csaid)or TEMP.METERORP I.11 INST. AL:
G q m y that he is exempt therefrom and the basis for the alleged exemplar,Any violation of /ADDITION ❑DEMOLITION
4• Satin.7031.5 by any applicant fora parotin subjects the applicant to.civil penalty of POWER DEVICES
ot marethnn five hundred dollars(5500).' ❑FOODSERVICE.0l,mnwner of theproperty,or my employees with wages as their sole compensation, SWIMMING POOL ELE. CENT
will do the work,and thesvu tme is not intendedoruffimed far auto(See 7044,Bnomes and Professions Code:The Contracmrn License Law does not apply to an owner of OUTLETS-SWITCHES-FI URES
property who builds ar improves thereon,and who does such work himrolf orthrough his own employees,Provided that such improvemems me not intended or offered for NEWRESIDENTIALELECfR SQ Fr.
aide.If.however,the building or improvement is sold within one year of completion,the FLOOR AREA $/SQ.Fr.
owner-builder will have the burden of proving that he did not build or improve for pur- -
pose of salej. '
❑h vs owner of the property,am exclusively commsdng with licenad mmramrs to TOTAL:
construct the project(Sm.7W,Business and Professions Code:)The Contractors Li.
cerise Law does not apply to an owner of property who builds or improves therson,iind QTY. PLUMBING PERMIT FEE
who contracts for such prneca with a eanaacror(0 licensed pursuant w the Contractor's
License Law. PERMIT ISSUANCE
❑ lameamptundcr Sce. ,B&PCfor Niaeamn
ALT -DRAIN&VENT-WATER(EAj
Owner Dae ER - VALUATION ,
WORKER'S COMPENSATION DECLAkATION BACK PLOW PROTECT DEVICE - -
I hereby.affirm ander penalty of perjury ane of the following declarations:
❑I havermd will mnint.a.Ceniftcamof Common o selRimart for Workers Co.,.- DRAINS-cFLOOR,RODE AREA,COND. -
sommu as convicted for by Sion 3710 of the Labor Cade,for use performaace of the STORIES TYPE CONSTRUC1tON
rk for which Nie permit is iasud. FIXTURES-PER TRAP t
1 hove and will mninmin Worker's Compematinn Insurance,us reyulyd by Section '
37M of thqUbe Code,for moment!of the wofkArwhi Edit imindislnaad, GAS-EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP APN
My WorLfm, .action or. ecannoand Poltc t)p ,il�'Ny^'
Cartier.VA PION OSI— GAS-EA.SYSTF.M.OVER4(LA)
CERTIFICATE EXEMPTION FROM WORKF?RS' GREASFANDUSTRL WASTE INTERCEPTOR
COMP. pleled NINSURANCE. BUILDING DIVISION FEES
(this action ted not becompleted URIC permit is for one hundred dollars181 W7 GREASE TRAP
or lens.) PLANCHECK FTE
Loy my Nuttinthe perforanymnnnce ero as
this Permit is iss'Compmll SEINTR-SANITARY-STORM EA.200 FT.
not employ my person in any manner so ao to become subject to the Workers'CamPcn- ENERGY FEE Ll
,Z nation Laws of California,Doe -
WATER HEATER WNF,NT/ET
O Applicant EC7R 0, GRADING FEE
&nNOTICE TO APPLICANT:If,after ranking this Cenificate of Bacraptica,you should WATER SYSTBMITREATING
j> become subject to the Workm
Workers CoPematic n provisions of the Labor Code,you..at SOILS FEE
forthwith comply with such powinmom this perroudoll d damed revalued. WATERSERVICE
az CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr, PAID
- I hereby affirm that hem is a commurdan lending agency for the performance of
V 0
a Receiptp
IL E•' the work for which this permit is is ad(Sec.3(19],Civ.C.) z
C 1 Lendcr'a Name
Gia Lender's Address - TOTAL.
I certify that 1 have read this application and aatn Nat the shove information is I BUILDING It
(n correct,I agree to comply withal]city.ndc....yoNittancesmndsmw
mlaarelatingto QTY. MECHANICALPERMIT FEE
V z building mnsvuctioaand hereby authorize repecscromives of this city m enter upon the SEISMI Isgx/ Ila
abovcmendane l property for inspection purposes.
zest PERMIT ISSUANCE
•(We)agree mauve,indemnify and keep hnnnlcss the City of Cupertino ngti ELECTRIC FP.Fvy i
Iinhilitiea,judgmems,costs and expenses which may In any way accrue against said City A ROR ADD TO MECH.
in consequence of the granting ofthis permit PLUM GFEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR ANDLING UNIT(TO IR"CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR H DLING UNIT(OVER 10,0M)CFM) CONsMUCTIONTAX
Signature of Applicant/Convuctor Data L•XHAUS' HOOD(W/DUC1T HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building acupont store or handle hazardous material HEATING U T(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Sado.25532(u)7 HEATING UNI VER 100,I00 BTU)
❑Yes Nn VENTILATION FA (SINGLE RESID) PAID
Date Racip,#
Will the all contaminant or art building by die tint use Bay AmAir QNUldMadi9WhITh . BOILER-COME(3H R100.000 BTU)
emit hmzallous air contaminants es Acfited by the Puy Area Air Quality Mamngencm TOTAL:
DisVicr!
r]Yet BOILER-COMP(OVER 0,0100 ETU)
1 have read the hozaNdus nwtorials requirements under Chapter fi.95 of the Cali AIR CONDITIONER ISS')1A CE D/p/F
Tarot He h&Safety Code tions 25505,25537 and 25514.1 undersand thm if the NEW RESIDENTIAL MECII. $Q.Ff. Y l
buil ng are not cu�ntly a unix my espansibiliD to no1ifythe pmt
of a mentarre ust he me stay aeofmC f y
0 erormthinnz m, t TOTAL: Vf 6A
ISSUED BY:
OFFICE