31477 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. q
IRUILDING DIVISION APPI.ICATIONTFRMIT PLUMB •L�TNG.MECHANICAL 31 /t 7,7
_ I BUILDING PROJECT IDI?NPIFICA1'TON
BUILDING ADDRESS: - SANIT'ARY NU. APPLICATION SUBMITTAL DATE
:
OWNE AM: NE: C RA AMP CNO:
_ SIC CONTNOLX
ARCHITECf/ENGINEEW , - LIC O. - AO R ❑
CON'EACT. yeoeE: BUILDING PERMIT INFO
t ❑ Consultant Fees aid by Applicant(Initial) - BLDG F,IXC'IPLUMB MECH
• LICENSED CONTRACTOR'S DECLARA'T'ION QTY IELECTRIC PERMIT FEE
1 hereby affirm Thal I am licensed under previsions of Chapor 9(commencing JOB DESCRIPTION
a2 with SectionTII10)of Division 3'ofthe i{usirsomod Professions Code,up my lwroticir - - - - RESIDENTIAL,00 . P17RMIT ISSUANCE
Tense Ilf cc and efrm ❑SFDWL T ❑KITCI{EN RILMODEL
�V lu License Clus LIC.N APPLIANCES-RESIDENTIAL' " ❑ADDITION El PLUMBING RE-PIPE
F 7�-a Dem - Conuamnr
Vs ARCIIFTECT*S DECLARATION PANELS„ EIMULTI-UNIT ❑STRUCNRAI.
b,psn
7.O soft 6T underswnd my plans shall be'uscd3s public recmds - MODIFICATION• '
UPT0200AMIS,;. 7
OZ—Q ❑INTERIOR ❑CHIMNEY RIEPAIR
'�4k� Licensed Professional .2111.10W AMPS _ IMPROVEMENT
�e+� Oat I am exempt m DECLARATION OVER 1000AMPS' C BATH REMODEL/REPAIR Cl DEMOLITION o
"'K Q I hereby affirm that 1 1. exempt frons the Contractor's a License Law for the
ippi55,�O y V following rancor ISe it 1 703LS.Buainess and ice.elisions Code Any elry 'aract ly C SIGNS I!LLCTI{ICAI. COTI?ER
as401'-
which report rc ill t { h r, p e J I tt r p ranyswaure
prom I also q prapplicantf hp 's rile g eJChapt col SPF.CIAI.CIRCUIT/MISC.
1Cg2.5,4�9N•
(that commencing
n licensedpursuant_tit theprovisions oftheContractor's sn L (Chapter or
ss+�'00 (0at he
a nh5eni ad ad the
barst, or the
Business Pmf. nvi Coded or TEMP.MF'fEH OR Pf11.F.INST. COMMERCIAL: '
a y o C that h'e is exempt merefrnm end the boils for the allcgW evemptinn.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
i�CylNy Section 7031.5 by any applicant for a armiasubjectithe applicant to a civil penally of POWER DEVICES CTENANT ❑FOOD SERVICE
Gnot marc than rive hundred dollars($5110). IMPROVEMENT,
❑ Las owner f the property,or my en+ployces with wages as their sole compensation, SWIMMING POOL ELECTRIC -
will do the work,and are structure is not amended orofferen for sale(Sec.7144,Business ❑OTHER
,YaT and Pml'essiuns Code:The Cmnmms-
nr's LivenLaw dues nal apply to an ownm of OUTLETS-SWI'fCHCS-PIXTUR
property who builds or improves thereon,and who docs such work himself or through
his own employees,provide{that such improvements are but intended or ntfemd for NEW RESIDENTIAL ELECI'R SQ FT..
' sule.If.however,the buildiiii impovadcnt is sold within doe year of completirmthe SQ.FT FLOOR ARIA $/SQ.PT.
owneemilder will have the burden of proving that he did not build or improve for pur-
pmerfeale.)., „ _ -
C I.as owner of the turnery,am exclusively contracting with licensed cnmracion to - IOTAL: .
construct he project(See:7044.Business and Professions Chic:)The Commemfs Li-
cerise Low does not'apply to an owner of prep,ny who builds or Improves m,rermrnd QTY. PLUMBING PERMIT i FEE
.no co anuric fersuch projects wit.commcwr(s)licensed par uznuo the Contractor's r License Last. PI?EMIT ISSUANCE.
❑
Iran exempt under Sec. ,B&1'C fur Ibis rcusun
ALTER-DRAIN&VENT-WATER(EA) - VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION PACK FLOW PROTECT.DEVICE '
I hereby affirm under Penalty(it perjury one of the following declamtions:
I have and will maintain a Certificate of Consent loself-inion,for Workers Compton- DRAINS-FLOOR.ROOF,AREA,COND.,
san,as provided for by Section 37M of the Ivhor Craft,fin n the performance of the S'IORIHS TYPI?CONS'I'RUC'I ION
ed
w rkfir which this peril is issued. FIXTURES-PER TRAP
have end will maintain Worker's Compensation Insurance,as required by Section '
700oftbe Labor Code,(bar cperfo rather ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INCAOUTLES - OCC.GROUP APN
My Wit k�r'-C� c varier and Policy Ruyuryy _
Cartier.(—y�+�C( �•a Policy No:,x !/L �� GAS-HA.SYSTEM OVEN4(EA)
' CERTIFICATE OF F.XHMPfION FROM WORKERS'. '
COMPENSATION INSURANCE GREAS171NDUSTRI,WAS 1'17 Hill URCEITOR
BUILDING
.(This section risen not lc completed ifthe peril is forms,hundred dollars($100) - DIVISION I9';t!S
OREAS
or less.) CTRAP PLANCIIECK FEF. -
Ieemythatinlaraddonamnceofthewurk fmwhich this permit isissued.ishan SEWER-SANITARY-STORM EA.200 tT. - - -
our employ any Person in any manner in as to hamne suhjectto the Worker,'Croquet- ENERGY Efir.
z cation laws of California.Date WATER HEAT'IiR W/VI!NT/IiLELTR
" o 77 O Applicant WATER
FEE
ti NOTICE TO APPLICANT:II;after making this Cerlricme of Exemption,you should WATER SYS'I'EM(1RHATING
I•-' ' become subject to she Workers Compensation provisions of the Labor Code,you must SOILS PEE
forthwith comply with suchp ovisiorro,this permit shall b:dcemed revoked. WATER SERVICE _
CONSTRUCTION LENDING AGENCY '' NEW RESIDENTIAL PLMB. SQ.PII PAID V Dare RmeiplN O Ilwods, (firm ded there iso crmlrrcarn Itoningrgcn,y farilie'nermnnance of
Ibe work far which this Permit kismet Scr.3091,Civ.C.)
Lenders Name TOTAL:
r W Leaner',AddressTOTAL.: _
1 certify that 1 have rend this ap,bralio.moisture that the above infitation is BUILDING FEE
fatl a+rut.I agree It,annply with all city and courtly onlinanms and none laws relating o QTy, MECHANICAL PERMIT FEE
U z building construction,and hereby sulhmizercpresniumives ofthis city oentnrdpon the SEISMIC FEE
ah.vio aentio ad propcny for inspersion pu posei. PERMIT ISSUANCE
(We)once to snvo,indemnify and keep lie... Om Ciryof Cupcnino a got., 'P,LECI'RIC FIT!', '
Iiabilities,judgmetns,costs and expenses which may in any way occur,against said City ALTER OR ADD TO MECH.
in r n.equcnce'gf he granting of this permit. f PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CFO 10.000 CFM)
SOLI REGULATIONS. MECHANICAL FEE
- AIR HANDLING UNIT(OVER 00,00001M) CONS'IRUCTIONTAX -
r o ppIFvm nnracmr ate EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
MATERIALS DISCL0SU r
Willmenpplicant or future building rboost store nr handle hazardous mmcdalt HEATING UNIT(TO 100,00i
as defined Oy Ilse Cuper ire Municipal Code,Chapter 9.12,and(lie Ileulth and Safety
Cada Section 2553200? HEATING UNIT(OVER I W,fgq B'TU) ,
0 Ye, ,.ON. - PAID
- V13N1'l1.ATI0N PAN(SINGLE'RESID) Doe Receipt N
W11 the applicant or future building occupant use equipment or devices which BOILER-' (7f{p OR 100,(1(10 BTU)
mit hozallous air contaminants an defined by the Buy Area Air Quality Management ,e TOTAL:
)"anct^
\\ ❑Yes ON. ., _ BOILER-COMP(OVER Ioo,006irru) -
O 1 have read the handader atcnals - p AIR CONDITIONER
req ata d Chat 6.95 rid+ Cali- ISSUANCE DATE
forma Health&Safety Cars.Sections 25505 25533 and 25534 I malcoland thI d the � l/ /J
buildingdresnetcumenlly ha t m.Najd smynesprnsibiltytonotifyourecupant NEW RhSiUIiMfINMECII. SQ.E -T. LL)
more regmremems which most be mel Puerto issuance of a Cenificme of Occupancy.
• Owner or authorized agent Uate TOTAL: ISSUED BY:
OFFICE