31545 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN'ONLY •r
CITY OF CUPERTINO 1 11, RUILDING-F.LECTFUCAL ,-t PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT - PLUMPING.MECHANICAL 31545
RUILDING 1'ROJECTIDPINTIFIC'ATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DA'1'I
OWNER'S NA - PHONE: CONT R'g NAM LIC NO: m
/ - �. ) %�• G NIC _ CONTROLIs
.ARCHITBCT/E GINEER: LIC NO: ADDEISS: ���`/r /4uv ♦� El
Rwe4 %"
C(ITACT. PHONE: l - BUILDING PERMIT INFO
yor _ ❑ Consultant Fees Paid by Applicant(Initial) BLDG , ELECT PLUMB MECII
LICENSEDCONTRAC'MR'SDECLARA3 0N' QTY. HLECTRIC PERMIT FEE
ec Z wt 1 hereby amrm that 1 am licensed under provisions of chapter 9(commencing • JOB DN CRIPTION
�O m5emionlWO)orUivinion3ofine Business and pr 'esaianscalu;and my license is RESIDENTIAL,
FUl in full fume dada 1'ERMI'1'ISSIJANCE, ❑SFDWf. ❑KITCHI!N REMODEL
�U�].License
Contractor
cmrAPPLIANCESRESIDEIAL
y W the ft-, ' - NT []ADDITION ❑SIRUC:PLUMBING
URAI, PE
F7 ARCHITECTS DECLARATION PANELS • `❑MULTI-0NIT ❑S'IkUC'I'I1kAL
Z p f/1 I understand my plans shall be used as public records - MODIFICATION
OZ D _ _ UPT020AMPS - ❑INTERIOR [I CHIMNEY REPAIR -
til Licensed Professianal 201-IfXX)AMPS IMPROV HENT
��dd .•ii OWNER�BUILDIiR DECLARATION.
L�S C',Q I hereby eFri.rthat I am exempt from the Condncmrs License Law for the
OVER 1100 AMPS. ❑RAEMO DE UREPAIR [I DEMOLITION
x 06 U following reason.(Section 7031.5,Business I Pm loccohns Code:Any city orcvmnty SIGNS ELECTRICAL � � HER
uu11 w WO{� which requires a Pcrinit to construct,alar,improve,demolish,or repair any stmcturc
(: h prior to its issuance,also requires the applicant for.such lcmdno file a signed stawmem SPECIAL CIRCUITIM
pa� } that he is licensed pursuant m the provisions of the Cnlnfors License Law(Chapter 9
I+I 00 B, 'amending with Seainn7001 Division 3ot'me Business and Professions Code)or TEMP.METE EY)LE INST. - COMMERCIAL:
exempt ,
Q.q o K that he is therefrom and the basin for the alleged corruption.Any violation of ❑NEW BLDG/ADDITIO ❑DEMOLITION
YXl 4• Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER I []TENANT ❑FOODSERVICH
m
^'m
zCnmore man five hundred dollars H500).
❑Las nwneof the properly.nr myemploy«s with wages as mcirsolecompcnsation. SW MING POOL ELECTRIC IMPROVEMI3NT
will da the work,and the structure is not intendedornffercd for sole(Sec,71H0.Business ❑OTHER,
L3 an and Professions Cale:The Conhactors License Law docs not apply to an owner'ol' (ID'I'LCTS-SWITCHES-PIXTURi35
property who builds or improves thereon,and who does such work himself or through
his own employees,pmvided'that sucti improvcnienw are not intended or offered fo NEW RESIDENTIAI.ELEC`fR SQ
We.If.Flotsam(be building or improvement is sold within one year ofcompletion.the FLOORAIVA VSQ.ITT.
pumer-builder will have the burden of proving that he did not build or impropun or for pu !_ �ay'
na of spleJ. - - f A 1 D
E]1,as ownei of the fiction,an eadusively emtraclidg with licensed contmewrs to TOTAL:
maws the project(Sec.0040.Business and Professions Code:l'I'he Camtraewrs I... -
ronseLew,does not apply whalite"
on nwnerof property who impooes the.).,and QTY. PLUMBING PERMIT , FEE
who contracts for such projects with a commaonat licensed pursuant to the Cmtnncuous DEC 5{� 19i
License Law. PERMIT ISSUANCEsa
lameacmptun « P
derS . ,B& Cformisreun w _
ALTER-DRAIN&VENT-WATER(EA) VAI ON I I
Own" Dam
WORKER'S COMPENSATION DECLARATION PACK FLOW PROTECT.DEVICE
I hereby upon under penalty of perjury line of the fallowing declaration
•❑I haveandwill mdiummoi Criificmenf Consenuosell-insure l'or WcalorsCanpen- DRAINS-FLOOR,ROOF,AREA,COND.
Kation,as provided for by Section 3700 of the labor Gale,for the performance of the - STORIES' TYPE CONSTRUCTION
work far which this permit Ls issncal. FIXTURES-liER TRAP -
❑I have and wiil'mainwin Worker's Compensation Insurance,'us required by S«tinn
31W of the Labor Cade,for the performance of the work far which this permit is issued. GAS-HA.SYSTEMA INC.4 OUT'LETS OCC GROUP pPN
M rWfrker' _ PIISNcy mm�her ore: - „
oro utsminnl urunca curtler and l'nl
GAS-EA.SYSTEM-OVER 4(EA)
CERTIfgC OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - GREASFANDIISTRI.WASTIi1NTI7RCEPFOR
(This«tied n«d not be completed III permit is for..hundreddollan(SHE)) BUILDING DIVISION FEES
ssJ - GRE
or lcASE TRAP
PLANCHECK FEE
codify mut inthe Performance of the work for which this parmil is issued,I shall SEWER-SANITARY-STORM EA.2011 FT.
not employ.any person in any manner so as to become subject to the Workers'Contact. ENERGY FEE
,Z station Laws of Cut funds.DateWAFER HEAIUR W/VEN'f/I!LEC'IR
Applicant • - GRADINGF13E1 "
to NOTICE TO,APPLICANT:If,after making this Ccnificuro Df Esemption,you should
WATER SYSTEM?REATINO'
SOILS ITE
hecome subject la me Wnrlot Cmm
npeatian provision of to Lahnr Code,yon must
[aLl tti' forthwith comply with such provisions or this permit shall be deemed revoked. WA ITR SERVICE
0
UO CONSTRUCTION LENDINGAGENCY 'r NEW RESIDENTIAL PCMB. SQ.Ff. PAID
I hereby affimtthm mere isaconstruction lending agency for the performance of nm R"ciptp
U,P the work for w166dons p"nti t in issued Ser.3091,Civ.C.)
Q U Lenders Name TOTAL:
Ladder's Address - TOTAL:
dI comfy that I have read this application unit state that the above information is - BUILDING FEE
h crrrecl.l egiee mcomply with oll<ity end county ordinances dad swteluws relmingm QTY. MHCHANICALPFRMfT FEE
V z building construction,and hereby authorize representatives of this city it)enter upon the SEISMIC FEE
above-mentioned properly for insperh an purpmes. PMMIT ISSUANCE
'We)agrce to save,indemnify and keep hmless arthe City of Cupertino against ELECTRIC FEE - f
Ilubillden,�udgnems,casts and cxpensos which ntny in any way ncemmlgoinn snJCity ALTERORADDTOMECH.
in cnnseyuence of the granting of this permit/ PLUMBING FEE -
APPLICANT UNDERSTANDS AN_TIOVILL COMPLY WITH ALL ONPOINT AIR HANDLING UNIT ITO 10,00CFM)
0
E GUl NS. " - MECHANICAL IEE
HANDLING UNIT(OVER I(I,(pO CFh CONSTRUCTION TAX
nmureo ApplicanVCun .or Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MAH RIMS DISCLO' G HOUSING MITIGATION FEE
Will the applicant or forum huilAing occupant scare vWlnhmanloux ntnmrinl HEATING UNIT(TO IW,ON U)
as defined by the Cupertino Municipal Code.Chapterand the Health and Safety
Coale,Senior 25532(x)7 HEATING
HEATING UNIT(OV 100,000 BTU)
❑Yes ❑Nn" PA.(//O'�j�7 •
` VF.MI'ILAq'10 N151NGLE RCSIDI Code,
ceiplp
Will the applicant or future building 9ccupunt use equipment or Acvias whichso BOB. OMP(311P OR IOO,fgll BTU)
emit hazandous air conandrams as defined by the Bay Area Air Quality Management TOTAL:
District? 5P as YV
394-ER-COMP(OVRIIIo.000 BTU) st
I have real the boundaries naterm"requirtnmms under Chapter 6,95 of the Cali. AIR CONDITIONER ISSUANCE DA'T'E
Rimia Health as Safety Code,Sections 255(15,25533 and 25534.I understand mut if the NEW RESIDENT[A].MECH. SQ.FI'.
building doxs nm mmn0y have a teman0 mal it is my responsibility m ratify me�e<upant
ofthe requirements which must he met priorto issuance ofd Certificate of Occupancy, 1.
Owner or autharize0 agent Date TOTAL: ISSUED BY:
OFFICE