31046 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNG 31046
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAI.
BUILDING PROJF,CI'IDENTIFICATION
BUILDINGADDRE9S: SANITARY NO, APPLICATION SUBMITTAL DAI
tf �T@ipRD g ""Z�p l o q *7
•OWyER'S NAME � p� PHONE: CUNTR OR' eNAM � arm LIC NO:
(ll..``..//VV11 6 U OY N/C CONTROL#
ARCHITECINENGINEER: LICNO: ADDRESS: ��A
CONTACT: PHONE: VV BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLUG ELE f PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ � ❑
1 hereby affirm that I ant licensed under provisions of Chapter 9(commencing JOB DESCRI TION
WoZ wiN s«tion 7000)of Div;s;onJofthe Business, Professi n,Co dmylicer,co R - ID
I-�- ;n fullforcc and a PERMIT ISSUANCE NTIA
aUU License Class, Lia.# c - OSFDWL D KITCHEN REMODEL
yea Dare--_�Cn fmcmr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
R HI'I'ECI'S DECLARATION D MULTI-UNIT D STRUCTURAL
O Z 4-0 1 andersmnd my plans,hall he aced as public record, PANELS
UP TO 2W AMPS
RMODIFICATION
E' I Licensed Professional D INTERIOR D CHIMNEY REPAIR
f; OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT
W¢ 1 hereby affirm and 1 am exempt Gum the Contractors LicenseLaw for the OVER HO AMPS D BATH REMODEUREPAIR D DEMOLITION
O t1 U following reason.(Section 703 IS.Business and Professions Code:Any city of county SIGNS ELECTRICAL D OTHER
LL O y which rcyuires a permit to construct,alteruc
,improve,demolish,or repair any samre
F•�C) prior to its isomeric,also requires lheapplicnnt formahpennino filea,i,rad,tammem SPECIAL CIRCUIT/MISC.
> that he is licensed pursuant o the provisions of the Contractor's License Law(Chapter 9
ma00 (eOmmencing with Section 70IXB of Division 3 ofthe Business and Pordes,ion,Code)or TEMP,METER OR POLE(NST. COMMERCIAL,
L 4 pC that he is exempt therefrom and the basis for the alleged exemptiva Any violation of
X N ION
S«tion 9031.5 byany applicant for a pennitmbj«uthe...beannov civil penalty of POWER DEVICES D WBLDG/ADDITION DFOODS RVI
WF Z_Y (more ],tot frva hundred dollars($500), TENANT ❑FOODSERVICE.
Q ❑I,as owner nfthe propcny,army employees wish sager u,thcirsole nimpcnmtion. SWIMMING POOL ELECTRIC - IMPROVEMENT
_ wife.the work,and the.,arm is not intended-fo(freed for sale lSce.70.14,Business DOTHER
W 3 m and Professions Code:The Contractor's License Law does nor apply to on owner of OUTLETS-SWITCHES-FIXTURES
Property who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR S IT.
.t�q
sale.It;however,the buildingor improvememis sddwithin tole yearuf completion,due - SQ.FII FLOOR AREA $/SQ.ET.
nenbuilder will have the burden of proving that he did not build or improve for put,
pascofsale.).
D 1,as owner of the property,am exclusively contestant,with licensed contactors m TOTAL: y
consaum the Project(Sea 70414,formals and Pnd"olux Code,)The Comment,'I Li. ��
cense Law it.not apply toren owner ofp..Perry who buim,or improves thereon.and QTY. PLUMBING PERMIT FEE � � O s�_�
who contacts for such projects with a contactors)licensed pursuant to the Comment ts �1J4L.
Law
0
License an excu PERMIT ISSUANCE
❑lam exempt undcr5«. ,B&PCfur this reason
Owner Date AIJTER-DRAIN&VENT-WATER(EA) VAL A
f WORKER'S COMPENSATION DECLARATION BACK FLOW PRO'FECr.DEVICE
I hereby affirm under penalty of perjury one of the following declaation,
D I have and is llneirmin a Cenifcee of Consent m.wllamure for Worker',Con cm- DRAINS-FLOOR,ROOF,AREA,COND.
scion,to provided for by Section 37M of the Labor Code,for the performtmce of the STORIES TYPECONSTRUCfIOt
work fit,which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker'.,Compensation Insurance,a,required by Section
37M ofdre Ldbm Cole.for he perhormrrecofth,work far
hiin thi'sjpe�tnt/Ni�t is i„ (If GAS-EA.SYS TEM-I INC.4 OUTLET'S OCC.GROUP APN
Ca Work{�j.Cwyp�gyrlian}_iryrrKl icrand olcy No.Y� J'�/'� r��s„ GAS-EA.SYSTEM-OVER 4(EA)
Camey. ZI1C I C r VN
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE.INTERCEPTOR
(This section nett not he Completed iDhe permit is former,hundreddollars S100) BUILDING DIVISION FEE$
or less.) GREASE TRAP
1 candy that in the performance of are work for which this PLANCHF,CK FEB.
pcnWorkre CrashaO SEWER-SANITARY'STORM EA.200 FT.
not employ any person in any manner en m m M1«nme subject m the Wurkeri Compcn- ENERGY FEE
2 sedan Low
O J9t J��p WATER HEATER W/VENT/I:LECfR
z O AOT I ant ..#1L1� GRADING FEE
NOTICE,TOsubject
APPLICANT:Worker,ll�Curr making this Cisions of of E abor o d you should WATER SYSTEIAGREATING
F h becomea compl oche uchoCnons or
is Permit
of the Labor Code,you must
a+ � I'orthwiNcomply with such provisions or this permit shall be deemed revoked. SOILS FEE
4 Q WATER SERVICE
az CONSTRUCTION LENDING AGENCY NEW RES IDENTIAL PLIOIL SQ.ET. PAID
U0 (hereby affum that there is a construction lending agency for the pefforrince of Date R«eipt#
f'
he work for which this permit Is issued(Sec.3097.Co.C)
O U Lender,Name
W Lender's Addmsa 'FOTAL *TITALy 1 cenify that I have read this application and stare that theaboveinformation is ESEISMIC
E
y mrrcn.l agree n,eompty with all city dna cmamy,rmnraneo,and,mm tows remtmto QTY, MECHANICAL PERMITZbuilding construction,and hereby adumnu representatives ofthis city to enter upon the FEL above-mentioned mpery for hepatic.purpos. PIiRMIT ISSUANCE(We)agrea to sma,Indcmnify and keep lmroleesthe City of Cupertino agaimt
Iimilines,judgmenu,mstaandexpemes which may in any way accmeagmn,t said City ALTER OR AUD I'O MECH.
in consequence of the granting of this normae.APPLICANT UNDERSTANDS AND WILL COMPLYWITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. p
3 (O -I� AIR HANDLING UNIT(OVEN 1(1,(XXI CFM) CONSTRUCfIONTAX
Signature ofA li VContacmf Dam EXHAUST HOOD(W/DUCTT
iAA AR'0"MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applies..offumrebuildi ng occupunl store or handle ha moons material HEATING UNIT GO 100,0X0 BTU)
as defined by the Captain.Municipal CMB Chapter 9.12,and the I Iealth mW Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,0 XI BTU)
DY Vo
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future budding occupant use equipment or devices which Date Receipt#
emit hneurdous tar contaminants as delated by the Buy Area Air Quality Management BOILER-CONT(3HP OR 100.000 BTU)
District?
❑Yes Fl No BOILER-COMP(OVER 100,WfI BTU) TOTAL.
1 have read the hmuNnus mmerinls requirements under Cbapmr 6.95 of the Cali- AIR CONDITIONER
Forms fleaah&Safety Castle,Sections 25505.8533 and 25534.I understand Thal if the ISSUANCE DATE
L"
does not currently have a tenon,that it is myreTensibility to ramify the«cupam NEW RESIDENTIAL MECH. SQ.FT.
ofthe requiremrnts which must Ferret Poor to is
oft Certificate of Occupancy. - /)
Owner nr outhonred agent Data TOTAL:
ISSUED BY:
OFFICE