31373 (2) APPLI ANTTO FILL IN INFORMATION WITHIN RED LINES=USE BALL POINT PEN ONLY
CIT OFFCUPERTINO , BUILDING-ELECTRICAL PERMIT NO. 31373.• ^ �p p�
BUILDING 3.I� J{ 3 DIVISION APPLICATION/PERMIT PLUMB NG-MECHANICAL
BUILDING PROJECT IDENITIFICATION
BUILDINGADDRL•SS: SANITARY NO. APPIIACArION SUBMITTAL DATE
n OWNE AME: CONTRACTOR'S NAME: /{�L�I^C NO:
I /�. 6 ��(/� aSa W) �L. NIC CONTR p
RdUTF.CT GINEER: LIC NO: ADD ❑
/ r ,bel/ -e-
CONTACT: PHONE: BUILDING PERMIT INFO
S� _��� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARXHON QTY. ELECTRIC PERMIT FEE
O C Z I heathy affirm that 1 am Encased..on,powisions.(Chapter 9(commencing JOB DESCRIPTION
with Section 7[1(1(1)nfDivision]of the Business and Professions Code,and my license is
�00 PERMIT ISSUANCE RESIDENTIAL:
In full face and effect.
aUZV License Cie. Lic.p ❑SFDWI. ❑KITCHEN REMODEL
ti 6 i Dam Com ontor APPLIANCES-RESIDENTIAL. ❑ADDH'ION ❑PLUMBING R&PIPE.
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
0- '/ia I emotional my plans snail he used as mblic records PANELS DEIFICATION
�Z UP TO 200AMPS
• O _ ❑INTERIOR XID11
IMNEY REPAIR
ul LirenseA lholcesional 201-1(100 AMPS IMPROVEMENT
1; •..]4I OatIn. UILDEEv DECLARATION OVER IWOAMPS ❑BATH REMODEUREPAMOLITION
I0.' 6 I =so affirm on 1 am exempt from the Conioactor s License Lew for the
C 3 e,V which following ma urea a Permit
to construct.
Business and Professions Cole:Any city orrcounty
Lure SIGNS ELEM RACAL [I OTHER
].0..0.0 which reyuires a permit to amswa,alter,improve,demolish,or repair any structure
Prior to its issu:mce,idso requires theapiderit for such permit in fileasignedsmmmemSPECIAL CIRCUIT/MISC.
1 pN. that he is licensed pursuant to the provisions of the Conrtaaors Liceme Law(Chapter 9
1 00 (commencing with Section 7")of Division Sof Ne Business mut Professions Codepr TEMP.MUTER OR POLE INS( COMMERCIAL:
that he is exempt therefrom and the hnsis for the alleged exemption Any violation of ❑NEW BI.DG/ADDITION ❑DEMOLITION
^yy Section 71131.5 hyunyapplieralfraprook subjects the applicant to u civil penalty of POWER DEVICES (]TENANT ❑FOOD SERVICE
1#...ZY not more than five hundred dollars(SSW). IMPROVEMENTC"Q ❑ 1,as owner of the property,or my employers with wages as their sole compenwtinn, SWIMMING POOL ELECTRIC
22 will the wa,k,..d His,stmcmre is nm imendedornfercd for salc(See.]044,Business ❑OTHER
1 and Professions Code:The Conuashas License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
.. property who huilds or improves thereon,and who does such work himself or through
his own employees,provided that such inipromormas am not intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If,however,to building or improvement is sold within one year ofcomp]etion,to SQ.ft.F. O AREA WSQ.RT.
owney-builder will have the burden of proving that he did not build or improve for par- rso C/
pose of sale.). ,CAVI y
I] 1,as owner of the progeny,um exclusively contracting wit licensed commemss to TOTAL: (y
constrict the project(Sec,]044,Business and Profewinns Cale)The Contmcmrs U.- ���V �Is
tens Law does not apply to an owner of properly who builds or improves thrown,and QTY. PLUMBING PERMIT FEE X79
who contracts far such projects with acmrawturi)licensed pumuantto the Cmuricmrs r L`
License Law. PERMIT ISSUANCE rCn ryJ�
❑ 1 oro exempt under Sec. B&P C Ini this reason L✓
ALTER-DRAIN&VENT-WATER(EA) VA DATION
Owner Date ���
Wm under
WORKERS COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE
1 hereby v affirm under penalty of perjury one of the following definer's Co:
❑]have and will smuinmineCertificam ofConsent to self-insure for Workers Compcm IlRA1NS-I1QOR.BOOP,AREA.GOND. STORIES TYPECONSTRUCTION
sails,os Provided Ina by Section 3]00 of the Labor Cude,far the perfomlance of Ne
work for which this pennon issued. e FIXTURES-PER TRAP /
❑ 1 have and will osis.for
Worker's Compensationofthe
hw Insurance,h required,i Section
]Olgafine Labor Cale,for I performance ofthewlic for which this permit is issued, GAS-EA.SYSTF.M IINC.40lTILRTS C.GROUP APN
Ca War ke��..'9s Conppensainn ln,�s�� ecarieraad Policy numbcruti�,,,
Canner. 7" policy Nn: Z4r 7`� GAS-EA,SYSTEM-OVF.R4(EA)
in CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GREASEIINDUSTRL WASTE INTERCEPTOR
(This section need not tc completed ifthe proem is fmooe hundred dollars(5100) BUILDING DIVISION FEES
to less) I GREASE TRAP PIANCHECK FEE
I certify that mine perfonnaaceufte work for which this permit is issued,Isha11 SEWER-SANITARY-STORM CA.200 FT.
nut employ any Person in any manner was m become subject to the Workers'Conupen- ENERGY FEE
O Z Saban Laws of Cnlifomia.Dat WATER HEATER W/VENI'B1.ECTR
2. 0 Applicata GRADING FEE
ran NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should WATER SYSTF,M/IREATING( SOILS FEE, became sobjeal to the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provision or this permit shall le deemed mvokd. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENT'IAI.]'LMB. SQ,FT. PAID
V 0 I hereby affirm that there is o construction lending agency lir the Performance of Dae Receipt#
f; [[[..ytttthe work(ora which tis permit is issucJ l5ec.3W),Civ.CJ ,
0 Lender's None TOTAL:
WLenders Address TOTAL:
y I certify that I have read this application and state that to above information is RUE G FEE •00
V) correct,I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE t
LJ Z building eonstruction,and hereby sutorizerepresentatives ofthis city 10 enter upmthe SE. IC FEE Oa
r abovomemianed property fnr inspection pmposev. PERMIT ISSUANCE
Ove)agree so save,indemnify and keep boom...the City of Cupertino against ELE C HE
liahilities,judgmenm.costs and espcnscx which may in any way accme against said City ALTER OR ADD TO MITCH.
in asequence of the granting of this permit PLUMB] FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
MECHANI LFEE.
SOURCP RF�aUTA ON
A �l AIR HANDLING UNIT(OVER JO."CFM) CONSTRUE ION TAX
Signature. Applic 'met,,, / Dat EXHAUST HOOD(W/DUCT) HOUSING MI ATION FF.E
AZAREGUS MATERIALS DISCLOSURE
Will the applicant or Home building occupant store or handle mandous material HEATING UNIT(TO 1 LYLWI BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
Cale,Section 25512(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yes .
VENTILATION PAN(SINGLE RESIDE PAID
Will Neu applicant or future building Dat Receipt p
pp d by the
A ea Air Quality
devices nt BOILER-COMP(3HP OR 100,IX)B BT
emit hwardous tetra contaminants as tatted by the Bay Arca Air Qualiy Management U)
Uusoict? 'TOTAL:
❑Yes []No BOILER-COMP(OVER I10.01)0 BTU)
1 have read the Entomion materialsAIR CONDITIONER mquitmenu under Chapter 6.95 of Ne Cali- ISSUANCE
(omit Health&Safely Calc.Sections 25505,25533 and 25534.1 milerswnd that if the NEW RESIDENTIAL MECH. SQ.FT,
building does noteurtmly have a mown.that it is my respensibilly to notify to occupant
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner,or authorized agent - Date TOTAL: ISSUED RY
OFFICE