31316 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ^
CITY OF CUPERTINO. BUILDING-ELECTRICAL PERMIT NO, -3 310
BUILDING DIVISION - APPLICATIONIPERMIT PLUMBING-MECHANICAL V
BUILDING PROJECT IDENTIFICATION
BUILDWGADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
66 q. PPw 14 b yz = 21
OW 'SNAME: PHONE: CONTRACI'UR'S NAME: . LIC NO
S-YI -I � N/C CONTROL# ,
ARCHITIE=NGINEER: LIC NO: ADDRESS: ❑
CONTACT:. PHONE: BUILDING PERMIT INFO
f//yJ,# 1 Q,�.�•// �a__� L���I�I+ ❑ Consultant Fees Paid by Applicant(Initial) BIPG, ELECT PLUMB MUCH
1J(r`rf � 1.-1c1 K1�/7� fly—xl� ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION m QTY ELECTRIC PERMIT FEE
I hereby forthat 1 m licensed p mne
s of Chapter 9(comeng JOB DESCRIPTION
"Z wnM1S t ]INII)dDi 3 Tobe Basin rid Pmf aionsCWe and my hccnec is
WOO ,'PERMISSUANCE RESIDENTIAL:
FW full f d fl'wt. C ❑SFDWL ❑KITCHEN REMODEL.
�UF LicenseCla Li
c.p
l—Zw Cmra APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE PIPE.
ARCHITECTS DECLARATION STRUCTURAL
Z O y Z
❑MULTI-UNIT ❑I understand my plans shall be used as public records PANELS MODIFICATION
O Z, UPTO 200 AMPS
Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
201-IIXNIAMPS IMPROVEMENT
Oat I am exempt
from
m Ce RKHONContractor's
- OVER HXO)AMPS ❑BATH REM01 AIR' EMOLUIONa
C Q 1 hereby nfErm that I am exempt from the Coniracnsr'a Licen nw for the �'
yxj3,F followingream,.(Section]031.5,13m,mraxand Professions Cud oycitymcounty SIGNS ELECTRICAL ❑OTHER _
a y which requires a permit m constma,ober,improve,demoli n repair any swmurc
F�Og prior issuance.also requires She applicant for such iuo 0leasigneJ sammeot SPECIAL CIRCUIT/MI
$�} that he is licensed pursuanvo the provisions ofthe gaaor's License law(Chapter
W e500 (commencing with Section 7000)of Division 3 the Business and Professions Code) TEMP.METER OLE INST. COMMERCIAL:
a q o that he is exempt therefmm and the hast, r the alleged exemption.Any violation or ❑NEW BLDGIADDITION ❑DEMOLITION
W-.y Sectmn)03 LS by an}applicam fora trot,,mnjena the upplicam m a civil pemdry of POWI7R DEV 'S ❑TENANT ❑FOOD SERVICE
Fz} not more don Bv,limadeddollar 510). IMPROVEMENT
�Sp ❑Lasowne w'dopropeny myemployces with wages as their sole compensation, SW'IMMI POOL ELECTRIC
F will do the work,and the s tore is not intended or offered for sale(Sec.7011,Business ❑OTHER
a3= and Professions Code: a Contractors License taw does nut apply ro an owner of OUT S-SWITCHES-FIXTGRFS
property who build f tmpmve.Ihemon.and who does such work himself or through -
his own emplo s,provided that such improvements are not in¢ndctl cur o1krcJ for W RESIDENTIAL ELECTR SQ FT.
sale lL how• sthc huilJingnrimprovcntem is sold within enc ycmefcomple...a the SQ.PT.FLOOR AREA S/SQ.IT.
eolor a will have the burden of proving that he did not I del or improve ar fur- -
poser, ale.), y
as own r of the property am exclmivelY conuactin6 with licensed conuanon m TOTA
no a the project(See 7014.Business and Professions Cod,The Conm...i
c mLowdoes not apply to an ownerofpropcny who builds or improves thereon.and QTY. PLUMBING PERMIT OCT. p�k
whence Lacrs for such projects with aconu.mogs)Ocensed pursuant to the Commaor's - #� V11996
License Law. PERMIT ISSUANCE - OC -
Fl I um exen:ft under Scc. ,B&P C for this tsars, `
Owner Dae n ALTER-DRAIN&VENT-WATER SEA) VALVTIpRsI
WORKER'S COMPENSA'T'ION DECLARATION BACK FLOW PROTECT.DEVICE (>I '(- UrCTk1"•
1 hereby union under penalty of perjury one of the following declarations: rD
.C)I have and will maintain a Certificate of Consenuo self-inwrc for Workers Compew. DRAINS-FLUOR,ROOF.AREA.C D.
otion,as provided lin by Section 3701 of Labor Cale,for the performance of the STORKS TYPE CONSTRUCTION
.
work for which thin permit w o;...d. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Scetom '
.. 3710nfdw Latin Ctsle,for the peormaxace of the work far which this pc mut is issued. GAS-EA.SYSTEM-I INC OUTLETS OCC.GROUP APN
My Workcr )m-n# ypn ns T/G>-?uantt corner and Policy nom urtoC
Carries +� Policy No.: lZ J• /I—SG GAS-HA.SYSTEM- ER J(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASP/INDUST WASTE INTERCEPTOR
_ BUILDING DIVISION RifS
[1hls 4ClinnnwJ not be con:plcmA if,,hepemnt is fa nnchs tlollu¢($IIN)1 GREA$13 TRA
nr leas.) PLANCHECK PE13
Hoy any Person
int he furfomranccorthe wow�kofr wuichthis the Work,,'Conifer-
SEWER- NITARY-STORM F.A.200 FT.
hall
not employ eny person in any manner so wnfbccomc subject m the Worken'Compen- ENERGY FEE
ZZ cation laws of Califomia.Date WATE EATER WNEJUDELECTR
Applicant - _ GRADING FE
N NOTICE TO APPL :If,after making this Certificate of Exemption,you should W' .R SYSTEM/IREATING
became subje the Worker Compensation provisions of the Labor Code,you must SOILS FE
LkI lonhwi ,mply with suchprovWon,orchis permitshell be deemed revoked. AI CR SERVICE ,
PAID
5Z CONSTRUCTION LENDINGAGENCY NEW R1351UENTIALPLMB. SQ.FT. pate Receipts
V I herebyarfrm that there is a construction[endin�+K�''yfo/r She perfommnce of _
the wort for which this pemar is issued(Sec.309 v.C.Cf )
lenders Name : TOTAL:
O Lenders Address - TOTAL:
1 certify that 1 have re is application and nate that the above mandealon is BUILDING F.
R. snrmctingrce nr nnnp .th an nry:and aounry oNinnnms:uulsmm lows relmingm QTY. MECHANICAL PERMIT FEE
V Z building onamcft unit hereby is cat
ofthis city to enter upon the SEISMIC E
above-matin Doi for inspection puryases. PERMIT ISSUANCE
agree m save,indemnify and keep harmless rhe Cdy of Cu,mr .gains,, ELECT C FF.F.
II Iiabiliues,judgmems,costs and expenses which may in any way acme against said City ALTER OR ADD TO MECH.
in cousequence of the gmming ofthis permi,,. PLUM LNG FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ALR HANDLING UNIT(TO 10.01100 f)
SOURCE REG NS MECHANICAL FEE
/4/1
2AIR HANDLING ON]r(OVUR ,WO CFM) CONSTRUCTION TAX
Signature of Applicant/Coneanm Date EXHAUST HOOD(WMU ) HOUSINGMITIGATLON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant acre or handle hazardous material HEATING UNIT(TO X000 RTU) -
as defined by the Cupenino Municipal M,Chapter 9.12,and the Health and Safety,
Code,Section 25532(e)] HEATING UNIT BR HX).1010 BTU)
EYw - VENT ILAI'l FAN(SINGLE RESID) PAID
Date Receipt
Will the applicant m e I building a c. uaa equipment to devices which
t haeawous sr cnnumimsnts as d Y the RaY Are.Air Quality Management ROILEH OMP(3HP OR 1 W.IXXI BTU)
District? TOTAL:
E]Yes No BOLI-. -COMP(OVER IW,000 BTU)
I have read the bawdous amm�als rcquiremems a after 6,95 of the Cali- A CONDITIONER _ ISSUANCE DATE
fomia HenIW&Svrety Code,Sestinas 255115,2 nA 255]4. undustwd thm it 0n NEW RESIDENTIAL MECH, SQ.IT.
building does not currently haveamnan ala my re'reas hilif,touch ythe avupam
of the mlaitements which moa teem m osmose of.Certiaeae of Occupancy.
Owner or autho` agent Date TOTAL ISSUED BY:
OFFICE
1�
o \ V R
W 1 V
UU1o oZow
Z V �t � O
m �l
TF-
N
� , G
'�11ff��VV N °�' y duo`� •p o V v
V�27 Q r'n✓ D � o