31445 (2) _ AFFLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOPCUPERTINO , - 1. ' BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT. PLUMBING-'MECHANICAL 31:445
BUILDING PROJECT IDENTIFICATION
BUILDING ADORI?SS: •'h - ,SANITARY NO' APPLICATION SUHMIT'1'AL DATIi
OWN V//NyyAME PI ZONE: RS NA :: hIC 0: a
/7�� '�S — 7e,,4/ �/_r 0 NIC _ -CONfROLx
ARCHITICUF.NGINELR:', LIC NO. A iSS. ❑
CONTACT: PHONE: BURRING PERMIT INFO
I,, ❑ Cnnsu_I nt Fees Paid by Applicant(Initial) BLLDDG slo la?CT PLUME, MECH .
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby atfi nt(hon ant Ecenxcd areae(nmsixions r.rehapmr 9¢+tm,mandng _ JOB DESCRIPTION. a
azz wtnS tum] tar v n3 of Ne Bu,ines. Pofcsin od tdm licemels
�OO y PERMIT ISSUANCE RESIDENTIAL'
In fug force a
W.
❑SPDWL ❑KITCEFN REMODEL
�F.UZU I.icen Ins, Lic.x _ '
N6L Ua(' Comramor /4 Ice-•_`� APPLIANCI?S-ItGSIDEMI'IAI. .` ❑ADDITION El PLUMBING RH-PIPE
ARCIIITECPS DEC ❑h1ULT1-UNIT ❑STRUCNRAL
PANELS.
zpr=/+7,. 'I understnadntyplan.ashallbe used aspoblic records dye MODIFICATION ..
Oz4 v Y , IIP T0200 AMPS
r 4 F{Oil Licensed Professional (]INTERIOR HIMNEY REPAIR
Y7� OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT
I hereby af.Tat that I ant exempt from the Comrul License Law in,the OVER IMX)AMPS - ❑BATH REMODELTEPAIR ❑DEMOLITION
ip O a U billowing reason.(Section 7031.5,Bmineis and Promoions Code:Any city or coumy r SIGNS ELECTRICAL - 'l(]OTI1E12
s�3 D•Iyr"�1 which requires a period to concoct,alter,improve,demolish,or repair any structure
FEs0 prim t ' Lso .th ,tic ttr.uch Permit to Li ngned:ttement } SPECIALCIRCUIT/MISC. r
vWvWlI p.•.•1l Ilia,he licensel,nuarru tt Ir, pm n:ultlt Conaraclar,License' 1-aw(CI pt J
atL'p0 (commarrugwith Secti6701)()ofDviio fthe 3oBu,mes d ProlesCode)
am, or I IMP.METER OR POLE INST. COMMERCIAL: - t
6 y e C that he is exempt thereGom and the hasis for the alleged exemption,Any violation of rt ❑NEW BLDG/ADDITION ..D DEMOLITION
i4t] 4 Section]031.5 by any applicant l'or n lwroul sohil tho npplieui0 ren civil penalty of POWER DEVICES"
on - - -•'r EITENANT ❑FOOD SERVICE
EZQnot marathon�ofthund party,ed rmars SSWloy IMPROVEMENT
❑lot w find property, y inter withoffered
agootheir
ee. ,Buricompensation, SW(hLMINGPWhIiLECT _
will do 1M1 k id the structuremime intended H dfnr sale(See.IDW,..su ss ❑OTHER
LLl, and Profession,Code:Th C tract is L L des not apply to an own r of fN TLI TS SWI'I'CHCS-Oil R S s
x property who builds or improves thereon,and who does such work himself or through
his own employ in,provided that such impmfenend are not intended or iAfered for NEW RESIDENTIAL ELEC f.
sal,If.hownveq pm baildmgnrlmpml,nmin ss,ld within wteyonrnf,arml0ort,the SQ.FL FLOORAREA VSQ.FT.
mamer-budder will have the harden ur proving that he Aid not build or improve for par-
pose of sole.).
I,a,owner or the en ,con gw T At,
❑ prop y,am extlnsivel tmetin llh licensed conWctnm m. e. �IIR ♦[l I
coal 11ie project(sec 9141,Business and Proressionx Code:)The Conalloa Li- b U
cense law does not applyto an owner mpropeny who builds or improve themon,anJ QTY, PLUMBING PERMIT I'EE C�Ir `o !
who contracts fmxuch pmjeax with a cncaraw, pI licensed pursuant tmhe Conlemans ur
License Law. - PERMIT ISSUANCE
[3I am exempt under Sec. ,B&PC for this reason - ,
Owner Date-
ALTER-TRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION '•' BACK FLOW P
I hereby alROTECT.DEVICE
n �G'71r7,•�
finn under penalty ofpenta,one mine following declaretinni:
IhobConsentCo.,.. D
❑ avcmalfimum for Worker's Com pe RAINS-
FLOOR,NOOF,AR II,GOND.
. STORIES TYPIiCONSTRUCTION
sation,m proandwillmaimamircunificamvided for by Section 3]1X1 of +d
the La Cc,fovlhe performuncc of the -
w_orkfo chthispermitixisaed. FIXTURES-PERT RAP
e
end will umintuin WorkKs Compensmion Haurnme as required by Section
,.. ,]Wof the Ltmr Code,bur the pcfnrntnnce of oho work awhich Pan pennitu s. e GAS INC,4 OUTLETS'
My Wn wirier end Po''(I�y/ OCC.GROUP APN
l
Cartie;Llp�l..�Y/q •e Policy Nd.:+liti,cri GAS-EA.SYSTEM NER 4(EA)
CERTIFICATE OF EXF.MP10N FROM WORKERS'. + GIt P.ASPIINUUS'1'It I.WAST'Ii INTF.ItCIifTOlt '
COMPENSATION INSURANCE BUILDING DIVISION F1 HS
(Thissectian need nm becompletediftheperoon isfnronehundreddollar,0100) GREASE TRAP -
nr less) PLANCHECK FEE
Irertibythut in the perf..all work I,,,Much this permit is issncd,Ishan SI?WER-SANITARY-STORM EA:200 FT.not employ any person in any manner so as to hcaome subject m the Worker.,Curacao- ENERGY FEE "
,Z an..Luwsof Calif..,..Date '
O Applicant WATER HEATER WNENT/EiLECTR GRADING FEE.~NI) NOTICE TO APPLICANT:If,after making ihi,Certificate of Exemption,you should WATER SYSTEM/fHF.ATING' -
a become subject to the WalCciinpernation provisions of the labor Code,you must - - SOILS FEE
forthwith comply with such provisions eethis perm,skull he deemed revoked WATER SERVICE ,
Q ,
CONSTRUMIONLENDINGAGENCY NEW RESIDENTIAL PLMB.- SQ.FT. 'PAID
U'
(hereby affirm that them is a construction lending agency for the performance 'of _ Date Recx
the work farwbich this pcna,xixsed(See.7097,Cl,C.)
Q U Lender's Name
G[I Lend(s Address TOTAL:
o y I n fy that 1 have .d this applicar a and that the h a informati n is BUILDING PER.
h cone t 1 g 1 comply ill II ly aide airy d curesanda t w,mlati bre Qq'Y. MECI IANICAL PERMIT 17EE
U ,Z M1uildingconslN<1ion,end hereby awhorize represemativcs of this city to ener upon the SEISMICFEE
'-' above-mentioned pmpeny it,,inspection Inrlm,es. PERMIT ISSUANCE '
(We)agree to retry indemnify;md keep harmles,the City of Cupertino against ELECTRIC FEE i
ludililics.judgments,costs andexpenses which may in any way zccme against said City' ALTER OR ADD TO MECI I.
in consequence of the granting of this Permit. - PLUMPING PUt
APPLICANT UNDERSTANDS AND WILL.COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO 10.0W CPM)
SOURCE REGULATIONS. MliCfiANICAI.FEE--ss,,
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
r Signature ar AppliconUContmamr - t Lae EXHAUST HOLD(WIDIICI) HOUSING MI'1'IGATIONi+EB
HAZARDOUS MA'ITRIAIS DISCLOSURE.
Will the applicant orfdure building«enpantsore or handle hazardous material HEATING UNIT(TO IW,O(XI BTU)
as derned by the Cupertino M 'poi Chapter L 12,and the Health and Safety -IT Scal 55. (a), HEATING UNIT(OVER I(XI,OW PTU) -
❑Yes VENTILATION PAN(SINOI.0 RESID) PAID
Den - - RecciprN
Will the tppl cam 1 r baddin p t equip nem or dm ccs wh ch ' BOILER-COMP(J1nP OR Ilt(LOIX113'I'U)
not
haz}vdous air contaminants as do by the Bay Area Air Quality Management TOTAL:
DisWm'❑Yes ;• 1 BOILER-COM 11(OVER IW.Ofp PTU) -
I have read the ran noz materials requirement,under Chapmr fi.95 of the Cali- AIR CONDITIONER ISS LANCE DATE(
romia &Sandy Code Sections 25505, 531 anJ 255J4.I undemmnd that if the NEW.RESIDENTIAL MECII. SQ.FE -
bu' ngdoe ecu dy hl enter,Nat itlxt 'revrymsibility mnodfy doe mcopanl
rhe poor.-:
Llre
nr euthari' age Date - TD'fAL. ' 'ISSUED BY; -
OFFICE