31351 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEMFINO BUILDING-ELRCTRICAL PERMIT NO. 31351
BUILDING DIVISION APPLICATION/PERMIT PLUMIBING-MECIIANICAL
BUILDING.PROJECTIDENTIFIC'ATION
HUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
6 No.z �vD wA _ t 1 1 a 6
OW :S NAME: �� 1jONE: ; CONQn AME: �L)C O��Ll NIC CONTROL#
kRCHITCCT/ENGINEER. LIC NO: AUDRE�:�U ��� lr9 C(�tA El
CONTACT, PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MCCH
LICENSED CONTRACT ORS DECLARATION QTY ELECTRIC PERMIT FEF, El 0 li El
1 hervhy affirm that 1 am licensed under powmans of Chapter 9(commencing JOB DESCRIPTION
woZ with Semi.n]INq).f Dlvininn3rfthe Business and Praesi. CnJc,n JmyliommIs RESIDENTIAL:
F�� full force and effete, ^ PERMIT ISSUANCE
Wim '" ") 9 a.S ❑RFDWh ❑KITCHEN REMODEL
<UU Licenu Class c# APPLIANCPS-RG RESIDENTIAL ❑ADDITION ❑PLUMB ING RE-PIPE
�<1 Date COnlDECL
RCHI'1IiCr'S Of:CLARATION ❑MULThUNIT ❑STRUCTURAL.
Zpv=iZ I understand my plans shall he used as public records PANELS # MODIFICATION
OZ=Z UPT0200AMPS ❑INTERIOR El CHIMNEY REPAIR
F.N.,f"„W Licensed Professimul 201-1000AMPS IMPROVEM&N'T
C C C Q I hereby affirm Net I um,exempt fatty Ne C rt aura License Law far the OVER Paul O BATH REMODEIIREPAIR ❑I1EMOhITION
following reason.(Section 7031.5,Bravos,and Professions Code:Any city of county SIGNS ELECTRICAL ❑OTHER
413 LL rF which requires a permit to construct.alter,improve,demolish,or repair any structure
prlarto its issuance.alta requires theapplicant foreuchperrluo file a signedstatemeut SPECIAL CIRCUIT/MISC.
that he is Received pursuant o the provisions of the Contractors License Use(Chapter 9
ad (commencing with Section 7")of Division l of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
in 0Y e C Nat he is camp therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^m Section 1111 LS by any applicant lornpermit subject the applicantm a civil lwouhyol' POWER DEVICES ❑TENANT FOOD SERVICE
not more than live hundred dollars($500).
F-2 Y IMPROVEMENT
6I]Lo the work,and
Pre Sumeonnyemplended wiNemdfrsaleirm.compensation, SWIMMING POOL ELECTRIC
W will Jo lesions Codec he Contractors
License La do Goma applyo1 an Business ❑OTHER
W and Professions Code:imp ove%t mo License do Nes ora apply m an owner of OUTLETS-SWITCHES-FIX'I'UkES
a 3� property who builds or imprmas Merton,and who etas such work himself or through
his own employees,provided tha such improvement&am not intended or offered for NEW RESIDEM'IAL ELECTR SQ Fi.
sale.if,however,the building or ngsmvcment'wmW wilhirow,year of completion,the SQ.FT.FLOOR AREA S/SQ.TL
Own
er-builder will have the burden of proving that he did not build or improve for pun _
p se of sole.).
❑ Las owner a the pmwrt�704 urn exclusively Protracting with licensed cnmroaors i. TOTAL A
move Law
notfpplyto1an owner
smad rprty wh&Ion&Ca IrJThcscvthe or, Li�
c Lrwdoe¬applyman with
aofpmPrrtywcesedprsunproves Nemrn,and QTy. PLUMBING PERMIT ItiC
Li,eme Law.for such Projects with a comroctoKs)licensed pursuant w the Contrucmr's C
Licen.m exon PERMIT ISSUANCE T D y
❑lam exmr:p ander see. ,B&Pe mrlois reasam \ /ar�i- V
gibiu
ALTER-DRAIN&VENT-WATER HDO N'VALUA
Owner Date
WORKER'S COMPENSATION DHCLARATION BACK FLOW PROTECT,DEVICE
1 hereby affirm under penalty of perjury are of the fallowing decimations:
I have and will maintain a Certificate ofCousm m.self-insure for Worker's Compete- DRAINS-FLOOR,ROOF.ARBA.COND,
sari..,as Provided 0m by Section 17011 of the Labor Code,for the performance of he STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation]as u..re,as rtgairtd by Section
3700.(the Labor Code,for the perfonnanaof the wad forwMch Nis pcmtit is issued. GAS-EA,SYSTEM-I INC.4 OUTLETS (RCC.GROUP APN
My WorkereiWAllpi. r,S,arti r and Policy nuy�b r.µ..n��/��/
Cartier: (/tf(CF INS 1po1my No.: /V L. h fl GAS-EASYSTEM-OVER4IEA)
CERI'11-ICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be completed if the permit is forone hundred dollars($100) GREASETRAP
or less.) PLANCHECK FEE
I certify that in the performance of the work for which this permit is Issued.,shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as m subject become subjeco the Workers'Counter. ENERGY M—E
O z satin laws of Cation ire.Dom WATER HHATER W/VENT/ELEGTR GRADING PEE
Applicant
Z N NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSMMT`REATING
FNN^ become subject to the Worker's Compensation provisions of the Lahr Calc,you must SOILS FEE Irrhwith comply w.h such povisirnsnn[,is permit shall bedwnred revoked WATER SI?ftVICE / 1 pp.(Z_ y
YYJJ Q
UO CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL,PLMB. SQ.FT. PAID Date Receipt#
I hereby off rte that there is a cyp vection lending agency for the pcR.rmance of
U.F the work for wlarlimis per mit,,i lSv, 1119],Civ.CJ
Lenders Name TOTAL:
ULenders Address
} 0. BUILDING FEE
F' 1 certify that 1 have recd this applicminn and state that me oMrvo inlnrmation i&
h correct,l agree to comply with all dry and county ordinances and stare laws relating to QTY. MECHANICAL PERMIT FEC
L.) z building construction,and hereby ruthorim reor.onomives of this city to enter upon the SEISMIC FEE
above-menlimed protocny for inspection purposes. PERMIT ISSUANCE
(We)agree ,,nave,inder nifssy and keep harmlethe City of Cupertino against ELECTRIC FEE
Iiubilities., formal. xpenses which may in anyway accrue against said City ALTER OR AUDIO MECH.
conscyucn N<gmntin (obis p. 1 PLUMBING IEE
APPLI T UNDER ST HS A ILL COMPLY WITH ALL NON-POINT AIR HANDLINGUNIT(TO FLOMCF,M)
MECHANICAL FEE
S CE RIiGULAI' i S.
AIR HANDLING UNIT(OVER Ia0MCFM) CONSTRUCTION TAX
Sign
cof Puny mmcnv Date 17XHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
AZARD(J .MAI ?RIALS DISCLOSURE
Wil rheapplicani or future building occupant score or handle hawrdrus material HEATING UNIT TO I FIRM)III'U)
dcfin.d by the Cupertino Municipal Code.Chapter 9,12,and the Health and Safety
Code,Seelina 25532110] HEATING UNIT(OVER 100,000 BTU)
E]yes Fl No PAID
VENTILATION FAN(SINGLE RESID) Date Receipt#
Will the applicant to future building ss .,a,use equipment or devices which BOILER-COMP 0HP OR 100.000 BTU)
,nit le,a drus air mnts rt
aremo e defined by the Bay Area Air Quality Management TOTAL:
District! BOILER-COMP(OVER 100.000 BTU)
, )
LI
s ON.
rend rhe hazardous matenals naimunciev under Chapter Was of Nc Calm AIR CONDITIONER ISSUANCE DATE
&Safcry Code.Sarirns 25505,25571 and 25514.1 undersmnJ ear ifthe NEW R[SIDEYI'IAL MECH. SQ.Ff.
nm currently have a tenam.that it is my reponsihlllty m notify the«cupamments which must M:mer prior to issuance of a Cmificam of Occupncy.
me .,car Uare TOTAL ISSUED BY.
OFFICE