31446 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CI'T'Y OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 31446
�a� A A4 o C
BUILDING DIVISION APPLICATIONIF ERMIT PLUMBING.MECOANICAL J 1 4
BUILDING PROJECT IDENTIFICA'PION
HUILDING ADDRESS: 1 SANITARY NO. APPLICATION SUBMITTAL DATE
OW E: 11 PHONE: O � CO N E: I
N/C CONTROL
ARCHITECT/ENGINEER: LIC NO: S: q.- �,N ❑ '
CONTACT: - PHONE: (((/ ///L•' BU ILDINGPERMITINFO
C/��_ ID Consultant Fees Paid by Applicant(Initial) BLD ELECT PLUMB MECH
// �S ❑ ❑ ❑
I LICENSEDCOMR\CTOR'SDECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I and licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�8)�. with Section 70)0 fDiynm 3"Ohe Businesses Icasioni Codc.a ylievescis. RESIDENTIAL:
O C full force mjIY(Rall_�J r - � �'S'- - PERMIT ISSUANCE
aUl"" Inicensc CP ns LIC,x ���VVV O'- ❑SFDWL ❑KITCIIF.N REMODEL,
6 U -;�„ �— APPLIANCES-RESIDENTIAL ❑AUDITION ❑PLUMBING RE-PIPE,
nate JYy,-�---Comlael
FMoc -ARCHITECT'SD .PANELS F1 MULTI-UNIT ❑STRUCTURAL
Z p Rn Z In nta
dersnd my plans%hall W used as public worn % DEFECATION
OZ� _ / UPT02LYIAMPS,
F W Licensed Professional - ; DEFECATION
CHIMNEY REPAIR
201.1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION -
C W�I (1VIiR IINItI AMPS ❑BATH REMODELIREPAIR El DEMOLITION
dU6 I neaso affirm on 1 wit exempt from the r Conan,Co Licensee Law for ilia
followingriiev. (Section]031.5,Husinasmpr Pmfessinnn Cole:Any city orcounty SIGNS ELECTRICAL ❑OTHGR
n131s•y which requires a pemsoa c mr,the,almc,improve,Jemolisb,nr a asig any swment
F�-�� nrionoiis issuance,elw requires @a applicant for such perniuo file asignW statement SPECIALCIRCUITMISC.
fly
that pursuant he is licensed pursuano the provisionwfthe ConNacturs License Law9
lCtapter
1e,+ no (commencing with Senion]WO)of Divinion3of the Rusinns and Nnkssiuns Crde)ar TEMP.MITER OR POLE INST., COMMERCIAL:
0.d ey that he is exempt therefrom and the basis for the alleged c,car,d m.Any violation of _ _ ❑NEW BLDG/ADDITION ❑DEMOLITION
W W^4 Section]1131.5 by any upplicam ban permit subjects the appllema to a civil penalty of POWER DEVICES
,� TENANT _OFOOD SERVICE
h
not more than five hundredllS%
doars Ed.
- - - IMP VEMIiN'P
=6F1Las to work.the pro pcuctrmYnnplendes withwagcsosoheivote(Sec.avmpensiness SWIMMING POOL ELECTRIC
W will dothewod,Code: se Com ume. Licensorowdos o,appaJPW.Bminecs ER
Hand not
I�i1- anderty a Item Code:The Conliancreo License Imo tiesnotapplytolf owner of OlT11LT5-SWITCHES'-FIXIUHEs
d 3- his own what builds or improves thereon,and who nts such work himself or through -
his own employees,provided ohm such mens to wild
within thin tet imarmfeor affucd for NEW RESIDENTIAL F.LF.CTR SQ FT.
twour-M1owevmllthav ilthe bar impmvcmcnl ieat hdnneyearofcprovetion the SQ.FT.FLOOR AREA 9SQ.lT.
cr-builder will lista the burden of proving stns he did not build(or improve for par- '
pain of sale.).
0 1,as owner of the propenX um exclusively contracting with licensed cnntraanrs to TOTAL: P w
construct the project(Sm.IDM,Business and Pmfeaiam CWe:)The Conuacmr's Li-
verve law docs non apply to an owner of pmpcny who builds or improves former,and QTY. PLUMBING PERMIT FEE
whocontracto fnsuch pmjatr with acontmctods)Iicemedptauannothe Croractors OCT-15Z
License law. PERMIT ISSUANCE x/p
lamxe
exempt under Sea ,11&PCfon r thi'maw - c Owner ALI17R-DRAIN&VENT-WAI'ER(EA) C,yfyy�.VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby oRrm under pc nd.,of pe jury one of the following declamation:
`y ❑I have and will maintain a Certificate of Conserv to self-insure for Workers Crimper. DRAINS-FLOOR:ROOF,AREA,COND. STORIES TYPECONSTRUCPION
cation,. vide)for by Section 3]1X1 of the labor Coo for the performance of the
k s Inch this permit is issued FIXTURES-PER TRAP
have and will mnlmain Worker's Cnmpensatien Insurance,as required by Section Y
37 the C:Nle.lur the c folie work for whleb this permit is iaxncJ, GAS-LA.SYSTP,M-I INCA(IUTLET5 OCC.GROUP APN
M W� e
k sssx��In. rand Palic
Co 'err t /G Polio, Nay-
m 4? GAS-IiA.SYSTEM OVER a EEA) '
CHRTIFICATE OF EXEMPTION FROM W OHKEHS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR -
_ BUILDING DIVISION FLE$
This section sad not be completed date permit is 6snmc hundred dollars(510p - GREASETRAP
or less) 1'LANCf{ECK FEE
Iconby had in anHormnationne ol heworkfor whichembufaitis perthe ul Win issucdlchall
er- SEWER-SANITARY-S'HIRM EA:200 FT.
" not employ nnY lemon in any manncrsn as to Mcame suhju�t mlhc Worken'Campen-, -- ENERGY FEE
O Z vtiou Laws of California.Date WATER HEATPR W/VENT/ELECTR
Z O Applicant GRADING FEE
N NOTICE TO APPLICANP:If.after makingthis CeniOcmeaf Exemption.youshmild WATER SYSTEMr6tEATING
F become nobject mthe Workers Compensation provisions of the I,Wr Cada you mu.a SOILS FEE
�.H forthwith comply wi,h,.ch pr..momer,lin permit shall W Jnemed rcr.akcd. WATER SERVICE_ '
a ^ _
7z CONSTRUGHUNLENDING ng agent NEW RESIDENTIAL PLMII. SQ.IeI', L\11. Date tp '
U Q - Thereby infirm thauM1ercis acninwdion lending agency for the performance of
e work for which this permit is issued(Sec.3097,Civ.C.)
0VLL 1-" rtLanders Name TOTAL:
' Lciaces Adduces TOTAL:
'7• Pi I ce'nify that 1 have read this application and state that the above information is BUILDING FE
F rn corect.I agree no comply withal[city unit county ordinances and state lows relating to QTY, MECHANICAL,PERMIT FEE
V bmildingcmGsmiction.anti hereby uulhorite reprcentatives nl ibis city Winter upon lla, SEISMIC FEB
aMwomemtioned p,way for iiepedion porpoms' PERMH ISSUANCE
(We)agree to save,indemnify send keep harmless the City of Cupertino against IiLECPR IC FEE
liabilities,"udgmen¢,cwts and eapensesw 'ch may in any way eccme againa said City ALTER OR ADD TO MECH. -
inco urn of the grunting Nis lehmio. PLUMBING FEE
AP (CANT 1 ' RST SANG WILL :ONPLY WITH ALL NONPOINT AIR HANDLING UNIT(TO Io,(KKI CFM)
S f10' MECHANICAL FTC
AIR HANDLING UNIT(OVER 10,001 CFM) CONSTRUCTION TAX
Signature of Applicants, actor D e EXHAUST HOOD(WMUCI} HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havandous material - HEATING UNIT CIG X10.000 BTU)
as defined by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety -
Coo Section 25532(x)? ar'^11 HEATING UNIT(OVER 100,IX0I BTU)
❑Yes /� •' PAID,
VENTIf,AfION FAN f51NC1.E RESID)
�sLo
t Date Receipts
Will the r smanl ur fulun:building by the B use equipment Qu or devices which
r enntaminanmos JefineJ by the Buy A.Air QuvEty.Manugemm�t BOILER-COMP(3HP OR 1g1,IXq BTU)
TOTAh:
BOILIiR-COMP(OVER I00,000 BTU)
the hazm arequirements under Chapter 6.95 of the Coli- AIR CONDITIONER ISSUAls E2551 i1 Jn"mid 1 drat l tam fIbv NEWR,SIDENTIAI.MliCll. SQ.Ff.nil I 1 nihil tyt fry th panich f prion ed tgcm ¢ - TOTAL] ISSUED BY:
fICCIfsL s