31108 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 31108
y� 1 1
BUILDING DIVISION VISION APPLICATION/PERMIT 1'LUAi111NC-MF.CIIANICAI. - 3 y y O H
BUILDING Pe DFIX7 IDENTIF'ICNI'[ON
DIN ADDRESS: g - 5 NYI'ARY NOY APPLICAFION SUBMITTAL DA'1'p
9 r -«
X N' AMI": aPHI ii: T1AlZOHy NAME: LIC NO:
`- l6..�-JJ��JJ•VV.� -•N/C CONTROLp
�ARCIII'IEC'/L GI I?IIR: LIC NO— "' ADDRESS: ❑ ,.
COMPACT: - PDONE: • - BUILDING PERMIT INFO
'❑ CansultanI Fees Paid by Applicant(Initial) BLDGELE PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby ul cart that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
az with Section 7(XXBof Division Sot he Bmmess end ProfeWons Code,and my license i, PERMIT ISSUANCE' RESIDENTIAL:
F full focused effort.
'Wzr<UU License Class Lic.p - - OSNDWL ❑KITCHEN REMODEL.
H7W Date _ Contractor RESIDENT At, ❑ADDITION C1 PLUMBING RI PIPE
cs
ARCHITECTPANT?IS
S DECLARATION - ❑MULTI-UNI'T OS'FRUCTURAL
F�
OO Z . 1undersmnd my plans shall be used us public recoNs MODIFICATION
g d❑ following houb, (Section 7031.5.n .ann e a and 1'e Cmutens u',License
Law for county OVR 2W AMPS y w „ .
rr-s4 t' Licensed Professional "O INTERIOR OCHIMNEYRHI'AM -
G OWNER-BUILDER DECIARA'1'ION 20I-i(XX)AMPS _ IMPROVEMENT -
LL t 6 y uY Y SOIGNS EBLLCFRICAI. O BATH Rn,4`�P�C}DfjyO �/1
Dd3 UOOTH13R�
B2a 0.0 which,it,o a permit to construct,the alms improve,demolish,t or repair any suumurc _ _
pot heissiawunce,ufanam toi rex theapplicant for such Contrator chle a eese Laos(Chapter
SPECIAL CIRCUIT/MISE. .r
�} thmhe islicensedpurslionM)IofDisions of the ContractorsLicensePro Luw(Chapmr9
a� (commencingwith Bection]Eap of Division3oftheBusiness and Professions Code)nr TEMP.METER OR 1411.E INST. COMMERCIAL '
that he is exempt therefrom and the hasis for the alleged exemption.Any violation of O NEW BLDG/ADDITION O DEMOLITION
14 Suction 7031.5 by any applicant lit a permit subjects the applicanun a civil penalty of POWER DEVICES []TENANT OFOOD SERVICE
� iy+ not marc than five hundred dollars S500). - IMPROVEMENTI] I,asawner ofthepmpeny,army cmph w
layees witogesax theirsvle compensation, SWIMMING POOL ELECTRIC
will Jo the work,and the stanctum is no intended wondered far sale(Sec.71144,Business ❑OTHER
m and Professions Code:The Contractor's License Law d,ws not apply to an owner of OUTIX7S—SWITCHES—FIXTURES
n' property who hulldc or improves thereon,and`who does such work himself ter through -
his own employees,provided that such improvements are not intended or offered for NEW RESNI?NTIAI.ELF.CTR SQ PT
kala.If,however.the btildingor impu'eaunt issold within oneyearmfcompletloa,the SQ.FT.MOOR AS LSQ.ET.
ter-[builder will have the huNenof proving that he dad not limbdor improve for form g'� a D
pose of sole). / T
I]I,as owner of the pmpeny,nm exclusively comracdng with licensed contractors rt -
m'rect the project(Sec.7044,Enables,and Prof as Cade:)'Ibo Contractor's Li. -
censelawdoesnatappaytoanownerofprope )wholildeoriarpowe,deamr,'and QTY. PLUMBING PERMIT FEE MAR
ohm mmmets for such projects with a<nm to ofca collar rs the Contractors
Licence Law, 1 a PERMIT ISSUANCE - -
Ej funder Sea • B for his reason ' "UIatK INC '
ncr Dat ALTER—DRAIN&VENT WATER( VALUATION
WORKERS COME SATION DECLARATION - BACK FLOW PROTECT DEVICE Iyy'I^^�\� '/•T/FQ
Ih by ff u Jer penalty pepury n of the following d clt s I ,
�❑11 d 'll anclintrin aCoati F t f Consent toself—insure for Worker's Cmpen- DRAINS—FLOOR,ROOF,AREA COND,
satian,ate provided to'
by Section 3]00 of them 1-ahCode,herdic performance of the STORIES TYPE CONS'I'RUCI'ION
work for which this permit is issued. FIXTURES—PER TRAP
❑I have hw will maintain Worker's Cmnpensation Insurance,us required by Section
3704)of Ne Labor Come.for the Performance ofthe work for which this permit is",stied. GAS—FA.SYSTEM-I INC.4 OUTLIGS OCC GROUP UPN•
My Workers Compensation Insurance carrier and Policy number arc:
Carrier: Policy No.: GAS—BA.SYSTEM OVER 4(EA)
CERTIFICATE OF E- ?MPTION FROM WORKERS'
_ COMPENSATION INSURANCE GREASIVIN_DUSTRI,WASTE INTERCEPItlR
�•P (Thi ,achunneednot hensmplemd ifrhe pvrmatis(crime hundreddoulac(sIW) BUILDING DIVISION FEES
or leo.) GREASE TRAP 1'IANCHECK FRE'
[,entry that in the performance oftheworkfar which,his permit is issued,l shall SEWER—SANITARY—STORM EA 200 PC
not employ any person in any manner so as to became wryject to the Workers'Compcn- - ENERGY FEE
Z station Lows of California,Date WATER HEATER W/VGNT/ELECTR
Q Applicant GRADING FEE
tl NOTICE TO APPLICANT.If,uBar making this Certificate of Exemption,you should WAIE"ASYSTEMGTEATING -
became object to the Worker's Compensation provisions of the Ichor Code,you must SUITS FEE n_
w forthwith comply with such Provisions or this permit shall he deemed revoked. WATER SERVICE
az CONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL PMB. SQ PAID
UQ Iherehy affirm that there is a construction lending agency for the perfulance of Dale eceipt It-,.
,� t•+ the work for which this permit is issued(Sec.3097,Civ.C.)
Q U Lenders Name 'TOTAL:
Landers Address TOTAL.:
0.WI" 1 oenify that 1 hove tend this application and state bad the above information is BUILDING FE l
N correct.l agree to comply with all city and county mdiaances and shite lows elating to QTY, MECHAN[CAI,PERMIT' FEE -
U ,z [building constmetion.end hereby authorise rcpresemmives ofthiscity benmrmpnn the SEISMIC FEP '
above-mentioned property for inspection purposes. -
(We)agree to one,indemnify and keep[brimless the City or Cupamnn against PERMIT ISSUANCE ELECTRIC Ffis
liabilities,judgmems.costs and exyeaks which may in anyway aecme again,"said City ALTIiR 01RADDTOMECH. PLUM9ING FET?
in asequence of the granting of this permit,
APPLICANT U TANDS AND WILL 1 'WITH ALI,NON-POINT AIR HANDLING UNIT(TO 10.0100,"
0.01%1 CPM) M[CHANICALF'i
-
SOUR ER LTR JS"
AIR HANDLING UNIT(OVER IB,(XEICFM) CONSTRUCTfON A%
Sign urea pplicanu orkat Date EXHAUST HOOD(W/DUCT) HOUSING MRIG TION FEE'
HAZARDOUS MA'Z'E ALS DISCLOSURE
dlthe upplicum mfuturc building occupant stoic or handle hazaNnus'material HEATING UNI'I'(TO IBO,OIX)B'1'U7 " f as defined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
Carle,Section 25532mo? HEATING UNIT(OVER 100,000 BTU) ,
E]Yea No VENTILATION FAN SINGLE RFSLD) PAID
Dam Recei p r
Will the applicant or its auture buildingytheoccupant use ea Air Qu of devices which BOILER—COMP(3HP OR 100,000 RTU)
emit hurardnun air ammminants as defined by the Bay Arca Air Quality Management 'TOTAL:• 00-District^ '•
❑Yes Otho BOILER—COMP(OVER 100,000 BTU) — .
I have head Ne haznNous materials requiremnmde
eunr-Chaptei 6.95of the C.E. AIR CONDI'1'IONEN ISSUANCE DATE
f mix Health&Safety Code,Section,25505 25533 and25534 I understand not tithe NEW RESIIJENTIAI.MECH. - SQ.FT.
h tiding does not curie sly he t sant.that t. .rynsihbdyt tfy th occupant
f dte mrements which mostbe pen an ofa Cen Fc fOcupancy. I
_
+
net ora a agentDme. TOTAL: ISSUED BY:
OFFICE