31297 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
` CITY OF CUPERTINO s. •'BUILDING-ELECTRICAL PERMITNO. r5 /�
BUIDINGDIVISION APPLICATION/PERMIT .PLUMBING-MECHANICAL J( LJM
BUILDING PROJECT IDENT'I FICA']ON
BUILDING ADDRESS. - S"II/ SAN]'1'ANY NO. APPLICATIONSUBMITTALDAT
OWNER'S NAME: PitNE: CONTRACTORS NAME: LIC NO.
a�r NIC CONTROLp
• ARCHITECf/ENGINEER: i� LICNO:. ADDRESS: pw ❑
UO o
CONTACT. ( µggg -S-' PHON�EE:m..,, BUILDING PERMIT INFO
7�'� y( fj-�/FLS ?`� /' �t� ❑ Consultant Fees Paid by Applicant(Initial) nIDG ELECT , PLUMB MUCH
7th �IIKS,G} ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE
1 herehy alirzn that I am licensed under provision.or chapter 9 fcolmnencing OB DESCRIPTION
O�Z with Section]000)or Division3nfthe lusinessend Professions Cede,andmy lieenseis RESIDFN �-TIAL:
FOO flllform,and cicc. PERMIT ISSUANCE -'
U f, 'n _ � Q CSFDWL ❑KITCHEN REMODEL.
�UU License Clam - LIG,k—` _ �. 'cam r
Inca Dum Cnmmcmr APPLIANCES-RES II3ENTIAI. ❑ADDITION CPLUMNING RI PIPE
F.Do0 `ARCHITECTS DECLARATION PANELS - ❑MULTI-UNIT ❑STRUCTURAL. '
ZOyZ Iundersand myprem shall beoseJ aspnhlicrermil, MODIFICATION
OZ-C UP'TO 200 AMPS CINTERIOR PCHIMNEYREPAIR
W Licensed Professional 201-I000AMPS IMPROVEMENT
C C Q 1 hcrchy off nn
OWNER-BUILDER DECLARATION.,Cnnur'v Licvnsn Lew for the OVER Intl AMPS C BATH REMODEIIREPA1R (]DEMOLI rION
t1OaU rullowin Section]031.3.Business and Professions Cale:An 1 t ❑OTHER �1�uO�ily r��X�•+•.Jae.
�d g reason.(, y city m county SIGNS ELFiUTRICAL —y�L -�'—X
n1 40 5 whim mquim a permit m crnrtm<t,vlmr,impmve.demolish,or repot any swcrure - ry pa.jr A•6n 7n/� lip
F.
� prior to its issuance,aLm requires the applicant fonuch pcnnino Elcosigned smtcment SI'ECIAh CINCUITIMISC.'
2, y thmheisl'mensedpursuanuntheprovisionto(theCnntraznnr'sLicenselaw(Cnupmr9
u1�00 (commencing with Section 70aXBofDivision 3 of the Business and Professions Cows)or 'I'F.MP.METER OR IVLEI COMMERCIAL:
o.a C that he is exempt therefmm and the basis for the alleged exemption.Any violminn of - C NPW BLDG/ADDITION ❑DEMOLITION
Section 911.31 5 b lienar for v 't sub amts then Meant to a civil - II f POWER DlzlviCES
' may rive
00)n j applicant @'^a Yo CTINANT CFOODSERVICH
or more than five hundred dollars(b5W).
AZT ` IMPROVEMENT
�pQ
1,as the work,the Ompcny,mmyemntended withwagesfor Iale(Se.compensation. SWIMMING .ELECTRIC
L�+.+
will do the work,and the stmdurc is not intended or offered for Isle(Sec.9(W4,Business COTHER
aim
and Podcsions Code:The Contractors License Law does nor apply or an owner ld OUTLETS- ITCIIIS-PIURFS
Property who builds or impmve%decrees,and who dos such work hornet of through
hie own employeesprovided that such imp..vemcros arc nm intended or offered for NEW IDENTIAL 171-11 R SQ ir,c
late If,however. buddingora,...venumtiseold viMnineyc"tilcompletion.the SQ'MI OORAREA $/SUFI'.
o urns,builderwill have the burden of proving that he did not build or improve for put
pose of sole.).
1,c owner of the property,tun exclusively cdnrmami with licensed crmmmors to TOTAL: n/` Zen
Construct the project(Sec.9144,Business and Professions CrdI The Comruclor's Li- •s�-'�aIv,h 4 -
cenmLaw does act applytoonowner ofproporywho buildsorimposts theater,and QTY. PLUMBING PERMIT EE \`Vr
who crmmes for such projects with a ennnacmr(s)licensed pursuanuo the Contrecusrs Ch(�nf
License law. PERMIT ISSUANCE `�
C I am exempt under Sec. .B&P C far this mann
ADIER-DRAINAVf:M-W'ATE (:A VALUATION
OwnerDam-
-
WOR KER'S COMPE NSATION DECLARATION BACK FLOW PRO'I'ECT.DEV ICE ���• GD
I hereby offum under penalty of ps jury one of Inc following dcdamtons; O
C l have and will maintain a Cenificale of Consenuo self-insure for Workers Compen- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPECONS'IRUC'HOls
,mien,as provided for by Section 3900 of the lahor Cade,far the per17om4nic'of the' t
ak for which this permit is Boad. FIXTURES-PER TRAP '
I have and will mations Workers Compensation Insurance,as rcquimd by Section
3900 of the Lahor C'de.for the pedormmnce of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4O TS OCC GROUP APN
My Werke' Compensates hnsuf �carz�icrvrm Policynu�nj�'� -
Colon".�u - --= T-R Policy Nn.: ^r r`�6�/23��a GAS-EA.SYSTEM-OVER4 :A)
CERTIFICA'TT�T,:r'O---ENEMPMPr1ONFROMWORKERSpp I/l/S GRIiASE/INDUSTRLW EINTERCIiI'MR'
COMPENS;61ON INSURANCH BUILDING DIVISION FEES
(This%eerion need nm be cnmpletW ifthe permit iz fowme huntreddollms(5100) GREASETRAP - '
I,less) PLANCHECK FEF.
I certify lbar in the perlotanoce of the work lin which IIn%farm,is i.csred,l shall SEWER-SANT RY-STORMEA.20oIL. '
ern employ tiny person in any munnecm ax m became subjmuo rhe Wnrken'Compen- ENERGY FEE
Z serine Laws of California.Date WATER HF ER WNENT/ELECTR '
t z Q Applicant GRADING FEE '
NOTICE1'0 APPLICANT I:after,making this Cenifcam of Exemption,you.hould' WATE YS'I EMITREATING
UG
[+ ; become subject to the Workers Compensation provisions of the Labor Cede,you must SOILS FEE
forthwith comply with such provisions or this gamut shall he deemed revoked. WAIR'SERVICE
Q
7 Z CONSTRUCTION LENDING AGENCY [w RFSIUFNTIAL PLMB. SQ.FT. PAID R t If
U O l hereby arum that there is a construction lending agency for the performonce of -
P the work Tor which this permit is issued(See NN],Civ.C.)
p V Lender's Name - TOTAL:
} W lenders Address .TOTAL:
fy, 1 bo
certify that 1 have read this application and state that the ave information is BUILOIN 'E
.F, UG clover.1 at to comply with III city rad county orainomce5 and slate low.relating to QTY. MECHANICAL PERMIT FEE
V Z building construction.and hereby amortize repowrtzrlves of this city to enter upon the SEISMIC
%act-in o
nnumai ppeny far ovation.purinses. PERMIT ISSUANCE
(We)agmc e,save,indemnify and keep I onlw the City Lf Cnpcono atimmr ELECTRIC Plili
liabllites.judgment%,costs and expenses which may in any way accme against said City ALTER OR ADD TO raMECH.
mnsryucnce of the gnting of this perosit. ' PLUMRING FF.E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT,. AIR HANDLING ON]'1'(TO 10.000 Clrb
MECHANICAL FEE
SOURCE REGULA'ITONS. ,
' AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUCTION TAX '
• Signature of Al+plicna/Contractor ,Dum EXI MUST HOOD(W/DUCT), - HOUSING MITIGATION FI
ILCEARDOUS MAd ERIAI S DISCLOSURE
Will thar.,icem or forte building eMcupam zmre or handle Imeallous material HEATING UNIT GM 100,0011 BTU)
as refined by the Copsnino Munlclpal Code,Chapter 9.12,and the Health and Safety
Calc,Section 25532(a)'! HICATING UNIT(OVER IW.(XX)B )
❑YesVENTILATION FAN(SINGLP FSID) PAID -
Will thea Meant or fumrc balldin•uccu r n use c t nr dvvicc,which
Date Itweipr n
PP b P•'tn yuiptQ BOILER-COMP LHIPG IIX1.000 BTU)
unit huandous air conmmi...,,as defined by the Bay Arta Air Quality Management TOTAL:
L".
601LBR-COMPO :R l IX1,InM1 BTU)tQ Nn mast the hamrdous m¢rials mquimmcnrs under Closer695of the Cali- AIR CONDITI 'RISSUANCE DATE
&Safety Code,Section,25.105,25533 and 23534.1 understood that ifrhe NEW RES iN'I[A],MECH. SQ.FT.
Icernpargyz watch rpusr bet wroiauamlYoraCenilicaeofOttupamytn.,rd gem\I - um TOTAL: ISSUED BY:
OFFICE ,