31137 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY.
CITY OF CUPERTINO BUILDING.ELECT'RICAL. PERMIT NO. 3113 7
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL.
BUILDING PROJECT IDR STIFICATION
BUILDING ADDRESS: nn\\ SANITARY NO. APPLICATION SURMITTAL DATI
Lq ER'S NA E: /1_. PHONE: CONTRACTOR NAME: LIC NO:
v e I_ N/C CONTR\OLLer
AskARCHITECTIENGINEER: LI NIO- ADDRESS: ❑ V
C[IN'FAC'F PHONE: BUILDING PERMIT INFO
Kk f MLQ-4�C`N ���5��5 5� ❑ Consultant Ftt4 Paid by Applicant(Initial) BLDG ELI"T PLUMB /My�E�CH
�y X
LICENSEDm CONTRACTOR'S DECLARATION QTY ELECIRIC PERMIT FEE �1Kf`
I hereby al5rthat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
HOZ withscction 7")ofoivision3 oflhe Businesxand Professions Cole,and my license is RESIDENTIAL:
�W� in full force and effect. PERMIT ISSUANCE _ ❑SFDWL ❑KITCHEN REMODEL
r„)
rF Class
Data Commcmr APPLIANCES-RESIDENTIAL
❑ADDITION [I PLUMBING RF.-PIPE
ad
ARCHITECT'S DECLARATION ❑MULTI-UNIT El STRUCTURAL
F C'n PANF.I.S
OZv� 1 understand my plans shall he rireJ as public records , MODIFICATION
=10 UPTO200AMPS El INTERIOR El CHIMNEY REPAIR
F4Wi� LicensedProfesstrod 201-100DAMPS IMPROVEMENT
ne 3 OWNER-BUILDERexempUFCe CannoON OVER)"AMPS ❑BATE
RE ODI?IIRIiPAIR .MOLITION
ao..C Q 1 hereby affirm that I em exempt tram the Commcmr's License L.aw for the
X 3 L U following mason(Section]031.5.Business end Rnfessions Code:AnY city m county SIGNS ELECTRICAL DOTTER
YY17 0Q which requires n permit to Construct,alter,improve,demolish,m repair any swcmrc
OJ
prior it)its issuance.also requires the applicant for such pennitto file a signet sammem SPECIALCIRGGIT/MISC.
} that he is licensed puremormthe Immismasofmc Commercis License Lave(Chapter
� GAO (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POI COMMERCIAL:
a M TZ that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4,
Section 7031,5 by any applicant for a permit subjects the applicant to o civil penalty of POWER DEVICES
❑TENANT ❑FOOD SERVICE
nrn mom then fee hundred dollen($5110),
Q ❑ Lo the .,k,.nd propery army ci I ended withwagesmaleSed?094.Bmiinn, SWIMMING POOL CL[CT IC IMPROVEMENT
will do lmbowonsCda:The ounure stinsLi,ar,a 1-aw rde.at,( p,ly ,, n, wne,(if El OTHER
d 3� and,.,won
Code:The Cmrtmeness Liad vv Lnw doe.oat apply m un owner of OU'111i3'S-SWITCHES-FIXTURES
progeny who builds or improves thereon,and who does such work er or tbmugh
his own employes,pmvidW n
that such improvements ere ot intended
d o hr offered for NEW RESIDENTIAL.LiLF.CTR SQ FI'.
sale.If,however the building or improvement is sold withinone yrm.!r mpletnn,the SQ.Ff.FLOOR AREA SISQ.F..
owner builder will have the burden of proving that he did eco builder improve for pury
poscnf.e.). P' A M
1,as owner of the property,am exclusively contracting with licensed contractors m
construct the project(Sec.7044.Business and Professions Coda,I"e ConwmOrs
came Law does not apply to an owner of property who builds or improves thereon.and contractsQTY, PLUMBING PERMIT FEE AP - 7
who contracts for such p jects with a contentions)licensed p rondo to the Contractor's R n
ECT
License Law. PERMIT ISSUANCE
I um exempt uncle Sec. ',B&'PC rormisrmuon CHIN
�Gwner Date ACALTF.12-DkAIN&VEM'-WATBR(EA) VAIAATION
W KF.R:S C MI'ENSA3lON DECLARATION BK FLOW PROTECT.DEVICE
I hereby tffinn under penalty of perjury one d the fallowing declarations:
❑I have and will maintain a Cerifcate of Ccnsentto self-insure for Worker's Copper- DRAINS-FLOOR,ROOF,AREA.COND.
nation,as Provided for by Section 37W of the Lahr Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued, FIXTURES-PER TRAP
❑1 haveand will mainmin Workers Compemmi,n Imumnce,as required by Section
37W of the labor Cade,for performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS (ICC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Carries Pull icy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF"i EMPION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUS'FRI.WASTE INTERCEPTOR
(fhixHectic.neWnal becumPlennl If the pemth Is fornne hundred Jnllurs(YIaff BILI ANC1 ISIONFEES
in lens.) GREASCTRAP PLANCHECK FEE
I ecrofy that in the performance of the work for which this permit is ixsucd,l shall
not employan Person in any manner so u.to heenme subject the Workers'Cont SEWER-SANITARY-STORM EA. Ff.
y 3 pen- � ENERGY FEE
O Z section Laws of California.Data WATER HEATER WNENTICLECTR
Z O Applicant GRADING/1111
i NOTICE TO APPLICANT:IL after making this Cerifctm of Exemption,you should WATER a SYSTE-MiTRL'ATING, bem
coe subject m the Workers Compensation provisions of the Labor Cale,you most SOILS
forthwith comply with such Provisions or this Forditshallbe deemed revoked. WATER SERVICE
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL I'LMtl. SQ.IT. PAID
UQ l far
rwhich rat thauhereissued(Secninn lending agency for the performance of -Dam HeceiptM
W F he work far which this peomh is Issued(Sec.3097,Civ.CJ _
Q U fender's Namc 'TOTAL:
W
IatndcLI d caddy t TOTAL:
I s.that I have read this application and.late that the show information,palis BUILDING FE �a
sF.r IA nmcm.I agrccmromply hereby city and amrestra ietsof and slam lawny upon gm QTY. MECHANICAL PERMIT FEIi
U z abovengcnnnuuctinmand hereby amtion purposesematives of this city mentor upon the SEISMIC PEE
above-meeionenc propene for inspection keep
PERMIT ISSUANCE
(We)agreemsave,indemnify and keep harmless the City of Cupertino against ELECTRIC FIE
liabilities.judgments.costs and expenses which may in any way ammo all said City ALTERORADDTOMECH.
in consequence of the graining of this permit. PLUMBING :C:
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON['[*(TO IQ(100 CFM)
MECHANICAL.FEE'
SOURCP 8 LATIO.
C. � 'Q�• AIR HANDLING UNIT(OVER 10,(M CFM7 CONSTRUCTION TAX
S"humdo knpllwnl/ ter tar ��� Da r1 / EXHAUST HOODIW/DUM) HOUSING MI'PIGATION PEC
HAZAR GUS MAPERIALS DISCLOSURE
Will tbeappliwmor future huilding eccupnm store orhandleharmlO.S material HEATING UNI'1'(IIO 00,000 BTU)
its defnW by the Caperton,Municipal Cttdc.Chapter 9.12,and the Health and Safety
Code Section 2553200? HEATING UNIT LOVER 100.00D BTU)
p Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Date Receipt N
I Will the applicantntaminantures a building by the nt Bay Area Air mute or evices whichManagement
BOILER-COMP(3HP OR IW,000 BTU)
emit hazardous air contaminants as defined by the Bay Area Air QualityManagement ,TOTAL.
D1trin?
❑Yes E:)No BOILER-COM P(OVER IW,000 BTU)
I have resin the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fitram Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that 11 the NEW RESIDEN'1'I Al.MECH. SQ.FE
- building dt mom ly hal
v Lthmoismyet,ot a Carifimmdlythewcap:ml
hath rt u tet Prior to inmanueeaa CunlBe oa raft
mo
woOrtar aur 'zed agentDa TOTAL: ISSUED BY:
OFFICE