31198 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL . PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 31198
BUILDING PROJECT IDENTIFICATION -
RUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
I I V LL oo A iZK W q
OW AME: THUS CON" �Cj[]R'ti NA 1.. LIC NO:
�I�A �V\ ���1 NIC CONTROL '
AH /E C E 1- ` J.IC I�'-(k'�� ADDRESS: { .❑
CONI'A PHONE: BUILDING PERMIT INFO
OF5j[) _ 224-770Z_ ❑ CoB1.10n1 Fees Paid by Applicant(Initial) BLDG ELECT P UM MCH
I1(••
LICENSED CONTRACTOR'S DECLARRATIION QTY ELECTRIC PERMIT FEE
I hereby affirm mat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�aZ with Section](KKUofDioision 3ofthe Bunincss and Professions Cdemnd my license is - RESIDENTIAL:
�� in lull f..candeflbet. PERMIT ISSUANCE.•
CWF - ❑SFDWU ❑KITCHEN REMODEL
EQ-U U Licence Class Lip.0
NQL Dale Contractor - APPLIANCES-RESIDENTIAL ,DADDITION El PLUMBING R&PIPE
ARCHITECTS DECLARATION C1 MULTI-UNIT ❑STRUCTURAL
ZOyz I undernandmy plamshall be used uspubliclenuds I PANELS MODIFICATION
OZ.-z L UP T021NIAMPS I []INTERIOR _p� ❑CHIMNEY REPAIR
[-ynLW Licensed Professional 201-100DAMPS IMPROVEMI,nJs pp.�y' '
SaYf OWNER-PUILDERDECARATION OVER1000AMPS BATH RE ODEUREPA CDEM1fOLITION
y C w Q I hereby from shut I am exempt from the Contractor's License Law for the
x 3 L U following reason.(Spai: 7031.5,Business and Professions Code Any city or county SIGNS ELECTRICAL ❑OTHER D
which t to em"'
prior
alter,int pair any s flPrtaw
oQ to i�is�issuanccealsore thea licum torsion Permit
1.File asi dmamaxid
y, Prtr 9 PP po g SPECLV.CINC IT/MISC.
f y tom heislicensed pursuant the previsions faf be t et 'sLsenala (Chapter9
�ap0 (wnnencingwlh Section]INN)1 fD"cin t fm li sa dProle,' ' sCnJc)nr i'CMP "1', OR POLE. 'BUY/-
a a p C mal he is exempt tbcrefr d th b u f Ih 11,rd a e d,h n Any {motion of ❑NEW BLDG/ADDITIOts*h V DEFIOLITIUN
X'^R• Section 7031.5 by any applicant fora permit subjeels the applicant a civil penalty of POW E ES
ly^m - ANT ❑FOODSERVICE
not more man Eve hundred dollars y employees
PROVEMENT
�ZO ❑ i.as owner of the property,or my employees with wages as their sole compensation. SWI NG ELECT— IsRIC
will dome work,and ma nmcw¢is not mtenJW orolfcrW for sale(Ser.]044,Ru'owss ❑OTHER.
u�l`m and Professions Code:The Contractor's Licemse Law dons not apply m an owner o UTLETS- 'ITCHr., XT ;S
a 3^ property who builds or improves thereon,and who does such work him¢If or through
his own employees,provided that such improvcmems are not intended or offered for NE S ENTIAL E SQ IT.
sale.If.however,the building or intpmvpnum issold within one yrs,if asmplminr,do SQ IT.FLOOR AREA VSQ.FT.
owrbuilder will have the burden ofproving that he did not build or improve for pur-
pose of s ,
ZA
C] 1,as owne owner of the property,,B exclusively contracting with licensed contractors m )
rase a does not (Sec.o an ecer of nM property
who hm Cmdp:) pro Gtmmcnv4 Li-
whocoawdocsnotupplymaswitha afpngeny wcenseddurst npmvice Contractor
QTY, PLUMBING PERMIT FEE
whncontrans for such pmjeas with a comractoKs)licensed pursuant m the Comraclor's -
License Law. PERMIT ISSUANCE
1 am exe pt ander Sec ,B&P C or this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
�..a
�Ot--:M ity o per) ry N Df Ne ful�loT tOg de 1 HACK FLOW PROTECT.DEVICE
MIhave J will maintain a Crtfcate al'Consent llinsu far Worker',Carter- DRAINS-FLOOR,ROOF,AREA,CONE). STORIES TYY' UCTION
,mina,as provided for by Section 3]tlo of dm Labor CMe,for the peHlnmarev of the
work for which this Permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of me Labor Cade.for the performance ofthe work for which this Permit is issued. GAS-EA.SYSMM.IINC.4OUTLETS , OCC,GROUP1PN
Cm Worker's Cnntpcnsalion Insurance anter and,Na.:number arc:
Comer: Policy No.: GAS-EA.SYSTEM:UVIiN4(CA) s
CERTIFICATE OFEXEMPTION FROM WORKERS'
. COMPENSATION INSURANCE GRE,SEANDUSTRL WASTE IM'ERCEPTOR
e DNG DI' ION FEES
(This ucnion need nm McomPleteA if the permit is formic hundred dollars fb 100) GRP.ASI?TNAP : I
or less) PLANCHF PI —
I employ
any that in me pay muse ace of the work for which this permit is issued Col shall
not<m to an - SEWER-SANITARY-STORM EA.200 FT.
p y y person m any manner a as m become abject m me workers'Compcn- ENERGY E
O Z vtion Laws of California.Date WATER HEATER W/VCNT/ELECfR
Z Applicant GRADING Iq?i?
% NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTE UTREATING
become subject tome Workers Compensation provisions of the LaMe CMe,you man SOILS FEE
forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
5z CONSem is acONLENnlNGAGENCY NEW RLlIDENT1Ahi'LMB. SQ.T7. PAID
CJ L for which
that Permit
is,red(Sti0nlending agency for the Performance of )me NeuiplM
Fthe Lanark for which this permit is issuW(Sec.3097.Civ.C.)
Lcnticr's Name TOTAL:
O V Leadce,Addmrs T
aL cutily that I have read this application and xwte that me above information is BUILDING F E �
(.F N cornml.l agree to comply with all city end county oNinanres and Stam laws mlating to QTY, MECHANICAL PERMIT FEE
J ,'Z buildingconamction.andherebyauthorizerepresentativesofthiscitytoenteruponthe SEISMIC FE Lj6at —
above-nicotined property for inspection purposes. PERMIT ISSUANC17 f
(We)agree to save,indemnify and keep hamiless the City of Cupertino against ELECTRIC IZ'
liabilities,judgments,cons and expenses which may in any way aceme against said City LTER OR ADD TO MECH. �
asequence of me gaming of this pcmtit. PLUMBING F. It
APPLICANT IERSTANDS NDWILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT(TO I(hINp CFM)
SO iRCERE ULA'1. MECHANICAL E
rAIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION' X
Aisaiuuc of ca
E t EXHAUST HOOD(W/DUCT)
BAZAR DODS MA'T'ERIALS DISCLOSU RE - HOUSING MITIGATI NESE
Will the npplicatarfuture building 0ccupual noncar handle bt,iroms mutmial UEA'1'I NO UNI I(T)I ogINNI BTU)
as defined by the Cuperino Municipal Code,Chaple,9,12.and the Health and Safety
Cade.Section 255321,)? HEATING UNIT(OVER 10(L000 BTU)
{]Yes VENTILATION PAN(SINGLE RFSID) PAID
Will thea applicant or future buildm m use n and or devices which E Da¢ Receipt p
OP 6rcche ea Air BOILER-COMP(JHP OR IW.gX)BTU)
emit harardnus air commitments as def nW by me Buy Arca Air Quality Management TOTAL:
Distract] BOILER-COMP(OVER 1)0,000131U)
❑Yea
AIR CONDITIONEk
L have read the hzvmdous materials nal immerav under Chapter 6.95 of the Cali- ISSUANCE DATE.
fnmie Health&Safety CMe,"Nom 25505.25533 std 25531.1 understand mm if the NEN'RESIDENTIAL MECH. SQ FT
building m not cum Y • thatil is my resp risibility tonin(,the occupant
of lbe qtr nl. to issuance oft Coni s Ge {racy.
evp{Owner amummil-. to Dam A ISSUED BY:
OFFICE