31128 (2) APPUCANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE:RMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 31128
BUILDING PROJECT IDENTIFICATION
UILDING ADDRESS: / SANI'1'ARYNO. APPLICATION SUBMITTAL DATE
cGc r a T Z�
N 'S AME: CO R R:S NAME: LIC NO'.
N/C CON'IROLN
ARC :C"/EIJpINEER: / .I Abl i a / e �� \fa—/vr/ ��J /�•1
0NTAC`L PHONE:: BUILDING PERMIT INFO
9 /J� ❑ Consultant Fees Paid by Applicant(Initial) a1 IlG ELECT' PLUMB MECH
Q(/%
LICENSED Bad I I COMRd under S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby eRrm that I am licenced under provisions or Choc 9(commencing JOB DESCRIPTION
DaZ anSection,ndefecpivixionJofthe Busincaaand Profeasionv Cale.and mylicense is
00 PERMIT ISSUANCE RH-ID_S ENTVV TITS
in full force and effect.
�UU License Chas LiCN ❑SPDWI. C1 KITCHEN RF.MOUF,1.
NZa Date Common, APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPR
,pal ARCHITF.CI-S DECLARATION PANELS I ❑MULTI-UNIT ❑STRUCTURAL.
Z p!9 Z 1 understand my football he used as public memis MODIFICATION
O Z::!! ` UI'T02W AMPS r
0 ❑INTERIOR Q� p S 6CHIMNEY REPAIR
�"+,r/,1" Licensed Professional 201-1000AMPS IMPROVEME:�f A u
OWNER-BUILDER DECLARATION OVF.RJ WI)AMI'S
yq C Q 1 hereby affirm that I am exempt from the Contractors License Law for the ❑BATH !I REPAIR (]DEMOLITION
x 3 6 U fallowing Mason.(Section 7031.5,Business and Professions Calc:Any city nr county SIGNS ELECTRICAL D OTHvitr n^�`,"Gp'sY•,--RB
u1 0 watch requires a permit to construct,alcor,improve,demolish,or repair any structure
LSO prior to its issuance,also requites the applicant for such Penniuo file asigned stvmment IAL CIRC yy�x
thin he ds liems<d p.auam m the provision..of the COmmanr's Liunse Law(Chnple 9
(wmmencing whh Scetiml]IXXpof Division 3 afthe Businessand Pro(oadmin Code)or ;T EMP.ME'1'li OR I .I �AL""UP 1,1'ryl.
that he is exempt therefrom and the basis Iia flm Wlcged exOnai m.Any......lion of - D N'W BLDG/ADDITION D DEMOLITION
^n Secdon]W LS by any applicant fora pemlit subjects the applicant toacivil penehy of POWER DEVIC
on 'NANT ❑FOOD SERVICE
F Z t more than five hundred dollars(55061.
OD1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL Ell FCFR IC Is -
will do the work,and the structure is not intended or offered for sale(Sec.70cm,Ha.vinevv 0 D OTHER
and Prnfcsxions Code:The Contractor's License Law docs not apply to an owner of )UTLETS—SW I'PCHES—FIXTURES
property who builds or improves thereon,and who does such work himself Or Ihmugh
his we employees.provided that such improvements me not intended or offered for NEW RESIDENT JAL ELECfR SQ PT.
side.IL howevevthc building or improvement is sold within one year of completion,the SO.IT FLOORARE - 5/SQ.FF.
owner-builder will have the burden of proving that he did not build or improve for pur- O I
pose of me).
0 Las owner er of the property,am exclusively contracting with licensed conhmmra to
construct the project(Sec.7M4,Business.nd Professions CMc:)ne Commcntb Li_
nwLawdoes not apply toanowner ofpropcny who builds or improves themon,and QTY. PLU6IBING PERMIT FEE:
who commuts lmsuch projects with a commucmr(s)licensed pursuant m the Contractor's Q�
License Law. PERMIT ISSUANCE
0 l am exempt under Sec. ,B&P C for this reason
ALTER—DRAIN&VENT—WATER IEA)
Owner Date VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under Penalty of perjury one of the following declarations: `
❑I have and will maintain a Cenificam of Consent to self-insert for Workers Cout DRAINS—FLOOR,RODE AREA,CONI, STORIES TYPE CONSTRUCTION
seti..n,as p nvided for h Section 3]flfl of the lanhar Code,for the performance of the
work for ieh this pCe,er tis issued. FIXTURES—I'lilt TRAP
❑I by nJ will e, orke11 Co ensatinn Insurance,es require.by Section
0Wof od xlm to o..hoo Insurance,
which thispermitis issued. GAS—FA.SYS'ILM-1 INC.40UT1ET5
MyW a and Isdicyn.mbome: OCC.GROUT' APN
/ Came: er ePolicy Nn: GAS—EA.SYSI'EM-OVER 4(RA)
ERTIFICATE OF EXEMP'HON FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUS'I'RL WASTE IMI'IiRCP.FFOR
(This section reel not he completed if Ne pemtit is for one hundred dollars(5166) BUILDING DIVISION FH1jS;
or less.) GREASE TRAP PLANCHECK FEE
Icenify that in the Performance of the bac for which this Permitis:soled,lshall ��
not employ any person in an mannered u m become subject m the Wnrkerr'Cnm SEW ER —STORM❑A.200 FI'.
Z
Y Ire^- ENLHGV FIiE
panic Wws of California.Dxm ATER HEAT'IiN VENT/GLEC'FR
pliant - GRADING FEE '
ti TICS TO APPLICANT.If,after making this Cernficale If lixemption,you should 5'IEM/fRBATE
NET
a , Mcome subject m the Wmkcr's Compensation provisions of the Labor Code,you most SONS FEE?
{✓a foMwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE
Q
CONSem is ac ONLIira lNGAGENCY NF.W RF.SIpI:NT'IALI'LMB. SQ PC PAID
UQ I f..by offivawhich
thsenhurcissued(Sec.3 lending agency for the perl'nrtnance of Date Receipt tl'
� F the work for which this pcmtit is issued(Sec.309],Civ.C.) '
O U Lender's Name TOTAL.:
W Lenders Address f
a I certify that 1 have real this applicminn and scare thatthe above information it BUILDING PGC
EZ) covect.Iagree...comply withWl city and c..muy ardinuncev:cod scone lnw.v rcl:ningm QTY. MIiCHANICAL PERMIT PEI:
U buiddi.,.araruction,nnd hemhyamborie o,mvcrmtivesofthiscdym cant,upon the SEISMICITE -
above-rocramneA property for inspection purposes. PERMIT ISSUANCE
( agree to s mdemnily and keep homeless Nc City of Cupertino against ELECTRIC FF.F. 40,
liabiliti p Igments, nl expenses which may in way eccmc against said City pLT[R OR App TO MECfI.
in Mrs ft, mins of this permit. PLUMBING FEE
APPLI .A e UNDI ;TA ���eDvyr�y h COMPLY WITH ALL NON-POINT AIR HANDLING UNITOG 111,1X10 CFM)
SOUR^ ! I ,AT M � ^ aa� �a MECHANICAL PEE
U� AIR HANDLING UNIT(OVER IO,(Xp CFM) CONSTRUC"HONTAX
Signature ofAMlicanVContractor l /Date\ EXHAUST HOOD DAIMUCT) HOUSINGMITIGATION ME
MATERIALS DISCLOSURE.
Will the applicant or fumrc building aeaupam smm..r hn the hazmdons roan... I]HATING UNIT LTO 100.000 BI ED
as defined by the Cimarron Municipal Code,Chapter 9.12,and the Health and Safety -
Code.Section 25532(a)Y HEATING UNIT(OVER IOQ000 BTU)
O Yea ON. VENTILATION FAN(SINGLE RESID) PAID
Date Rccei,i#
WIIIIheair imam orfmnm dcEang by the rt use Bay Arco
Air ent or Cold,Mceswhich BOILER—COMP(JHP OR 100,00013TU)
emit ictvuNous air ammminnms as def neJ by the Bay Arev Air Qmlity Management
District? TOTAL:
es FIN. BOILER—COMP(OVER I00,00s)RTTp-
eve mad the h. Jou materials rt AIR CONDITIONER
gairemems under .1 and 6.95 of the Cali- ISSUANCE DATE
/�J��/\)
forma uhh a&ry aS 55115,I tJ ands: ilk a)rmfly th tom:paha NFiW RESIDEN'1'IA),MECH. SQ.IT, - Q/
bull.: J:cx vrren hn resperosibllity n:notify the nnvpam
of th ui h' no .once of.Certificate of Occupancy. ���/l�
Conservator arimd agent Dote T T ISSUED BY: V✓V11
OFFICE