31110 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
31110
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL
BUILDING PROJECT IDENTIFICATION
s4UILDINO ADDRESS: (fll'plrld� 'Is --0 Jj IL16 '1 SANITARY NO. APPLICATION SUBMITTAL DATE
21 To )o . Ind -c RiOfip . �CJ e 3—r `-q(
)WNE SNAMF.: PHIGNE I CONTRACTOR S NAME: LIC NO:
,323— 00 liwe CON Tkol.a
`-9W IARCHTECT/ENGINEER: LIC NO: I ESS: — ❑
N't S rJ liluash f. 0
CONTACT: PHONE: BUILDING PERMIT INFO
- ` C $.-�T6_�g g.� 1:1 Consultant Fees Paid by Applicant(Initial) BLDG ALF . PI.D H ME
LICENSED IU CONToec tinOR;,DECLARATION ro QTY ELECTRIC PERMIT FEE
1 hnrehy m7mm ma Into lmeacd ower Prorisians ar enapte.9(mmtmaodng 70B DESCRIPTION
aw�Z with Senian]BW)of DivisionJofthe Business end Pmfccin.,Code,avd my license is RESIDENTIAL:
[ '_ infullfurmindefTen. O �.t._ PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
<ZU I;ac .Class Liatt > APPLIANCES-R11SIDEN1'IAL ❑ADDITION ❑PLUMBING REPIPEi--a6 Dale 7 Conlraclnr_
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
1 underwand my plans shut]be used as un lic record. MODIFICATION
Z O m
OZ.SUP'r021NInMPS [3 INTERIOR El CHIMNEY REPAIR
r�L' W Licensed Professional 201-1000AMPS IMPROVEMENT'
.aa. f,; OWNER BUILDER DfCLARA N OVER I"AMPS ❑BATH REMODEL/REPAIR [I DEMOLITION
C a 6 I wrehy aflirm that 1 am exaum from the Carl bar's License Law for the
°• a U following rcawn.(Smion 7(IJLS.Business and Prmfcssi CWc:Any city or county SIGNS ELECTRICAL
❑OTHER
3 4 y which requites a permit m construct,alcor,improve.demi ism,or mpair any swaurc
prior to its isstamee,alcn myuires the aPPlicatn fornuch pert it to file a signed statement SPECIAL CIRCUIT/MISC.
thatbeis licence)pursuanuobhe provisions of tM1e Contrnnnr'c License Lins Chapmr9
W 0 (commetmiogwitbSttdon7"lofDlviclon3ullhe Businexsand Pmfeuions Cmde)or TEMP.METER OR POLE INST. COMMERCIAL:
6y�d c,nn that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION ElDEMOLITION
W^, Section 71031.5 by any appllcin l for I pertmib.objects the applicum to a io.1 penally of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not mom than foe hundred J.H.(85(X)).
F Z Y IMPROVEMENT
=6 p Ras a sok,,the progenamemyemntended with wages as.lei(soft c0mpemmdon. SWIMMING PWLELEtTRIC
f�C will dmhewmrk,and the he Cianisnms intendedordoe, sale(Sec 1.movsinesv [-]OTHER
lata] coact Pndessiom Cede:ina C ev thermic
is License law does not apply to an ownerof OUTLETS-SWITCHES-FIX'NRIiS
1�'_ pro,my who builds or improves thereon,amt who does web work M1itrsul(or bhmugh
his own employees.provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ FT.
sale,If.however,the building or improvement is sold within tine year ufcompletion.theSQ,FT.FLOOR AREA b/SQ.FT.
ouser-builder will have the burden of proving that he did not build or improve for put. 15—
pose of sale). PAI
'
0 I,a owner of the property,am exeladma
vely contracting with licensed arras tit TOTAL: I_ N D
construct the project(Sec.7094.Business and Professions Code:)Hat Contmemrs Li-
cence Law does nm apply to an owner of pm,my who builds or improves themon.and QTY. PLUMBING PERMIT FEE sewj'� RE
C,
hansom pmj.mswitha enumselms)licensed pursuant to Oe Coa
ntnm's RA 18 {/E(1
Li.mae law'. \ PERMIT ISSUANCE 14.b
❑I sm exempt under Sec. .H&P C for Nis reason
O Date
ALTER-DRAIN&VENT-WATER([M) r VEffPNtO
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE �l I IIY
1 hereby affirm under penalty of perjury one of the fallowing doelinationic
•�l here and will maintain a Cenilicutc ofComentto.self-imare,for Worker's ComPen. DRAINS-FLOOR,ROOF,ARECO STORIES 'rYPECONSTRULTION
Indian.a-Provided Tot by Section)71X)of the Unfair,Cade,for the performance of the
which this permit is issued. \ FIXTURES-PER TRAP
;; have and will maintain Worker's ow an Insurance,sex required by Section
3700n1'the Labor Cwe,(tar lh• color a e 'ark for whicl>,dtis permit is isaued. GAS-NA.$YSTEM-I INC. TLETS JI
OCC.GROUP APN
My Workers Cotp ens n tanPocopy ¢
Carrico: Pali Policy dl� GAS-EA.SYSTEM- (EA)
CERTIFICIMH OFEXEM ION FROM WORK17RS'
COMPENSATION INSURANCE GREASIAN U. L S'fE "RCEPR)R
BUILDING DIVISION FEES
(This section need not be completed Rahe permit is forms,hundred dollars(SIM)
or IecaJ GREASETRAP PLANCHECK HE
I cenify that in the performance ofthe work for which this Permit is iswed,l slash SEWER-SANITARY-STO 2W
not employ any person in any manner w a to become subject to the Workm Compen- ENERGY FEE
QZ nation laws of California.Date WATER HEATER WNENT/ELEC GRADING PER
z Applicant
NOTICE TO APPLICANT.If,after making this Cenifcme of Exemption,you should WATER SYSTEM/TREATING
become mbjcenm the Worker's Unia,mi.two provisions of the Lahr Cade,you must SOILS FEE
forthwith comply with,amb.......innsorihis permit shall be deemcdoe,1cd. WATER SERVICE
�
z CONSTRUCTION LENDING AGENCY NEWRGSIDEN SI
ALP B SQ FT. PAID Date Receipt.
L) work
rwhich rte that cord,
is.consSo.3097,Cm agency for the performance of
the work iia which this permit u issue)(So.311Y],Civ.CJ
D" U Lenders Name TOTAL:
W Lender's Address TOTAL:
I tinily that 1 have read this a."re.ii i mnJ.ame that the above information is BUILDING IEE
F' H torr eL I agree m mmpty with all city andco my oNin.n'es and state laws belating to QTY. MECHANICAL PERMIT FEE
C.) ,Z builJing construction.and h<rtby nuthodur re¢nmtives of thiscity menterupon the SEISMIC FEE
amen-mentioned prapeny for Inspection put ones'. PERMIT ISSUANCE �
(Nle)agree w save,inJAND
p harmless the City of Cupeninu against ELECTRIC FEE
liabilitios.jud,anuma.msnsanh maymmyway.m.cagainsuaid City ALTER OR ADD TO MECH.
in asequence of the grantinPLUMBING FEE
APPLICANT UNDERSTAN .COMPLY WITH A L N
SOURCE REGULATIONS. )N-POINT AIR HANDLING UNITUO IQIXXICFM)
MECHANICALVE
3 I AIR HANDLING UNIT(OVER IB,(XM)CFM) CONSTRUCTION'
Signawreof APPlicart,"gencmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS M IAL,DISCLOSURE
Will the applicant,or fmurc build': cupantsmsre m handle hit doses mated.[ HEATING UNIT(TO 10LOM BTU)
as declined by the Cupertno Municipal Co ,Chapter 9.12,and the Health and Stubby
Cade.Section 25532(a)? / HEATING UNIT(OVER his,"LOU)
p Yes `nY'd VENTILATION CAN(SINGLE RESID) PAID
Doc Receipt a
Win the applicant or future building accepts use equipment or devices which
ma,hasandous air cumaninams as Mfined b the Bay Area Air Quality Management BOILER-COMP IMP OR I00.0B BTU) TOTAL:
DomielI BOILER-COM P(OVER 101,1X1)RTU)
❑Yes
I have read the hazardous material. aquirrineur under Chapter 6.95 of the Cub. ARCONDITIONER ISSUANCE DATE
forma Health&Safety Code.Sections 25 )5,25533 and 255]4.1 uwctatand that if the NEW RESIDEN UAL MECH. SQ.FT.
Wilding does and currently have a tenant, ]ibis yiesparsibih o notify the ematerm
of the rcyuiremenU which must be nuance n(e C ou,p0
w4..
Owner or audmdzcd.gems w)) Date ISSUED BY:
OFFICE