31017 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IMILDING-ELECTRICAL PERMIT NO. 31017� O J
1
BUILDING DIVISION APPLICATIONIFERMIT PLUMBING-MECHANICAL
BUILDING PROJRC'1'IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMI ITAL DATE
o --_,5
OWN13
ARS,NA -071 PHONE: CONTH OH;S NAME: LIC NO:
S NIC CONTROLN
�ARCIII'IECI'/IiNGINEFiR LIC NO: G O HUD :,SS: - �o ❑
COCCJJ''J'J.•��5 Tj4-
PHONE: q/ / ...aaa''' Y/ -� BUILDING PERMIT INFO
M � l"G ^ Y( O (//O¢ , Consultant Fees Paid by Applicant(Initial) � BLI>G ELEM PLUMB MUCH
LICENSED C NTRA :DECLARATION QTY. ELECTRIC PERMIT FE
I hereby anmrt that 1 ain licensed ander provisions of chapter 9(commencing - JOB DESCRIPTION
C=z with Section l00o3of Division 3 ofthe Rosiness and Professions Cate,and my license is RESIDENTIAL:
F.WOO in full force and affect. PERMIT ISSUANCE
W F O SFDWI. O KITCHEN RI'MODIH,
�Qul I.icre cClass Li,# for APPLIANCES-RESIDENTIAL OADDITION ❑PLUMBING RE-PIPE
1n ARCHITECTS DECLARATION ❑MULTLUNI�' ® ❑STRUCTURAL
F O PANELS aI
oZ_Z I understand my plans shill be road.,Public records r1 �� MODIFICATION
1
UP TO 200 AMPS L (]IM1 EOR Cl CHIMNEY REPAIR
H�eF.W Licensed Pmfes,ioned 201-1(XOAMPS IM N�yjk�g..
OWNER-BUILDER DECLARATION OVER IIXXI AMPS OBA DF -ppegfEMOLITION
Q 1 hereby affirm that 1 am exempt from the Contractor's Liccme law for the �11I[�(�
�L�d 06 U following reason(Section 7031.5.Business and Professinns Code:Any city or county SICNS IiLECfRICAL I� ER
u13 W y which requires a permit to construct,alter,improve,demolish,or repair tory swnure Ur
E]LLO-5 on,to its osuance,alm mquimsthe applicant forouch pension filea,ignedsta¢ment SPECIAL CIRC 5 n((�
that he is licensed personnnothe provisions oftheCommonnessLiceno,Law(Chapter 9
s+:�CO (commencing with Section700(hof Division Ba.inessand Professinns Cssde)or TTvMP.MEI' LEI COMMERCIAL:
0.0. that he is exempt therafmm mol the Weis for the alleged exemption.Any vWatinn of O NEW BLDG/ADDITION O DEMOLITION
i+C ws Seedier tons by an,.pplicvm fin.pemdit subjects the applicant nru,vil lMnnhy of 1'DWGR DIIVIC
fed-Z Yt more than Five hundred dollars($5101. ROV [:I FOOD SERVICE
EMENT
SQp Ol.as owner f me progeny,or my employees with wages as their sole compensation. SWIhIDI1NG POOLE ELTRIC
pS�F.
will do the work andthc slowmm is nut intended or offered for sale(Sao 704,L Business ❑OTHER
{y 3 m and Professions Cede:The Contractor's License Law does not apply to an owner of 'IL['IS-SWITCHES-FI%TURES
progeny who builds or improves daemon,aad he does such work himself or mai l
his own employee,,provided Ihat such iinprovmnen¢are not intended or nRmed for NI?W RESIDENTIAL ELECTS SQ PT.
sale.If.however.the building or improvement is sold withinonc Yearafcompletinn,the SV.FT,FLOOR AREA $ISG.W.
owaser-larildiar will have the home.of proving mat he did nm build or improve for par-
Fl 1,as owner of the Property,am exclusively contracting with licensed ennuacans m �I(/�!!//
construct me project(Sm.7044,Business and Professions Code:)The Coronae/s t-
arose
Q
ase Law does.,it up,],In an owner ofpmpeny who taidds or imp..us fiance,and Q'TY. PLUMBING PERMIT FEE
who commal,Yon such Poiect w41,a pmlummoO licensed Pursuanuo the Coffman,"
License law. PERMIT ISSUANCE
1 um exempt tinder Seo. .B&P C far this reason
ALT12R-DRAIN&VENT-WATER IEA) VALUATION
Owner Data �X
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO]ECT.DEVICE 2 / MM
I&Irl I hereby Z.under penahy of perjury ane of the following declarations: TL I V LaCJ
I Wvesadwill mainmina Ccnificate mfConscnuo sdGinsuref Worker's Compcn- DRAINS-FLOOR,BOOP,AREA.COND. STORIES 'TYPE CONSTRUCTION
..tion,as provided for by Sedi... 39(10 of the Labor Code,for olio if ounce of the
work for which this permit is issued. FIXTURES-PER TRAP
o 1 have and will maintain Worker's Compcmatiun Insurance,as required by Section
3900.1 the Lahr,Code.Lorna,performance of the work far which this permit is issued. GAS-EA SYSTEM-]INC..OUTLETS OCC.GROUP APN
Me Worker's o pcnsntion lm ranee carrier and Policy. r :
Policy No.: U GAS-EA.SYSTf -OVER4(EA)
aredD CA 01'C-%. (TION FROM WORKERS' GRFASEINDUSTRL WASTE.INTERCEPTOR
COMPENSATION INSURANCE BUIL W ISION FEES
(This section need not W completed ifthe permit is formal hundred dollars(Star)) GRIiASB'1'RAP or to,,,) PLANCHECK FEE
(certify Nmin he performance of the wort for which mi>permil ie ismed.l,hall SEWER-SANITARY-STORM EA.200 FT.
not employ any Persson in any manner m as as become subject to the Workers Compcn- ENERGY FEE
Q Z eotion Law,.1 California.Dote WATER HEATER W/VENEMLECTR a—
GRADING FEE
z O Applicant
NOTICE TO APPLICANT:If,after making his Certificate of Exemption,you should WATER SYSTEMn REA'I'ING SUITS PEI:
? become subject m the Workeh Compensminn pnrvisimns ol'the L.Wr GXIe,you must
forthwith comply with such provisinvs or this permit shall be deemed revoked. WATER SERVICE.
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT PAID Da¢ 14C H
ectiti
V C) Ihereby a(finn than then is a construction lending agency for the Performance of
he work for which his lana is Issued(Sec.3097,Civ.C)
Lender's Name TAL:
L) LcnddvAddress 'ff TAL'
codify that 1 have mad this application and state that me ravve information is BUILD "'TUMNI
Ncorrect.l agree to comply with all city and county ordinances and state law,relating to QTY. MECHANICAL PERMIT FEE
(J z building construction,and hereby bubonic exprescmafivo of this city to enter upon me SEISM
arove ounti.ncd property fm impeeio.pnrpases' PERMIT ISSUANCE
I We)agree to save,indemnify and keep harmless the City of Cupedino against LLHCTRIC FE
liabilities.judgment,costa and esprnan which may in any way accrue against said City ALTER OR ADD TO MECIL
PLUMBING PBL
in .sequence of the granting of this pcmol.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO UX00)CFM)
MECHANICAL F.E
SOURCE REG' Ks
AIR HANDLING UNIT(OVER I0.00(1 CFW CONSTRUCflO. K
namm of A meacm Data EKHAUST HOOD(W/DUCI, HOUSING MITIGATIO Nr
HAZARDOUS .. ASCLGSURE
Will me applicant or future building occupant store m handle huallous material HEATING UNIT G 0100.000 BTU)
as defined by the C.pmins,Municipal Code,Chapter 912,and the Health and Safety
Code.Section 15532001 HEATING UNIT(OVER 1(10.0X)of
❑Yes ON. VENTILATION FAN(SINGLE.RF_SID) PAID
Will the a lira.t er fuel'a b.filio•mcau t me c t or devices.00h Dom Recci M
PP b Pan Area
n BOILER-COMP QHP OR 100,000 BTU)
..:hanrdous air contaminant a,defined by the Bay Area Air Quality Munagemem ,TAL:
Uisuietq
❑Yes Fl No BOILER-COMP(OVER Iotfor(1 B'GO)
I have mad he hromoss nationals requirements under Chapter 6.95 oldie Car. AIRCONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 255115.25533 and 15534.1 understand that if the NEW RESIDENTIAL MI CH. SQ.FI.
buildingdas nm currently have a tenant,had it is my responsibility to nmify rhe occupant
of the mquirement which must W met pno,1.isswar,of a Certificate of Occupancy.
Owrcronoummrized.gam Dare TOTAL: ISSUED BY:
OFFICE