31226 PPLICANTTO
OF CUPERT L I TF.
INFORMATION WITHIN RED LINES-USE BALL POINT PENONLY
TYTRIGAI, reaK4rr No
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF,CHANICAI, - 31.226
BUILDING PROJECT IDENTIFICATION
ILDINGADDRFSS: 1 2t.' SANITARY NO. APPLICATION SUBMITTAL UATI
qYJNFJVS NAME: -T PHONE: ONTRACfOR'S NAME: LIC NO:
MP(r0 ^J PJ q SpF r P qZs N/C COMROLM
RCHITECT/ENGINEER: - LIC NO: KESS: 11tl I.Z Florwa W i
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby off rat mat 1 con licensed under pmvisinns of Chapter 9(c.mmenci^B JOB DESCRIPTI N
at0 with Section noddy of Division 3 of the Business and Promoiam Roe.and my license is
DO �a p PERMIT ISSUANCE RESIDENTIAL'
FyP
in and eBc�sr_3� z ❑SFDWL ,❑KITCHEN REMODEL
UUU License ClCle Lic.p
yea Date ��Comracmr �� APPLIANCES-RESIDEM'IAL ❑ADDITION ❑PLUMBING RP.PIPE
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT '❑STRUCTURAL
Z O n Z 1 and tend my plans shall be used as Public records MODIFICATION
0t�Z.. �" - UPT02WAMPS ❑INTERIOR ❑CHIMNEY REPAIR
CSN.l.W Lommurd Professional 201-IOWAMPS IMPROVEMENT
Y OWNEKU ILDT:R DECLARATION'
C
I hereby.(Seco on I rapt from the fesnuns Co e:Lothar,c Law for the
OVER Ifg111AMP5 ❑BATH REMODEVfiGPAIR ❑DEMOLRION
ippi55..�4V following rcewm(Section 7031.5,Business end Professions Cade:Any<iry or county SIGNS ELECTRICAL ❑OTHER
m++�O F' which requires a permit m comvuct,alcor,improve,demolish,c r repair any stmcmrc
prion.its nsuancc,tik.napdresthe applicant far such permit m file.signedsmtemem SPECIAL CIRCUIT/MISC.
QOthat he is licedmd pursuant o the provisions of the Contractors License Law(Chaper9
(commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.MET ER OR POLE INST COMMERCIAL:
eL n C that he is exempt thaefmm and the basis for the alleged exemption,Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
�w Section 7031.5 by any applicant for a permitmbjects neaPPlicam to a civil penalty of POWER DEVICES []TENANT ❑FOODSERVICE
t more than five hundred dollars(5500). IMPROVEMENT
Q ❑ 1,as owner of Ne property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
'S G do iss-
will do the work,and are strumure is not intended mothered forule(See.7(W4,Business ❑OTHER
f+l mo Professions Code:The Commemrs License law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
property,who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are,not intended or offered for NEW RESIDIW4 17'111 ELECTR SQ FT.
salt.If.hawevensbe building.improvementissold within ane year of completion.the SQ.FT.FLOOR AREA E/SQ.FT.
nwnerbuilder will have the hmden of proving that he did not build or improve Impair. ggsr��
pnseofsak.). IP A I
1,oa owner of the properly,am exclusively cnmmninwin licensed enmmmars TOTAL:
coconstructm
the project(S .7044.Business and Professionss Cale:)The Cnno- mU-
comm
.a, V
comm Law does not apply to an owner of property who builds or impravea thereon,and QTY, PLUMBI •R FEE
who contract for such projems with a canmamm(s)licensed pursuant to the Comractnr's.
License Taw. PERMIT ISSUANCE Cpy II[V u
❑1 am exempt under See. ,a&P C firths reach Uf
•Owner Date ALTER'-DRAIN&VENT-WAT: ION
WORKER'S COMPENSATION DECLARATION BACK: PROTECT.DEVICE
I hereby affirm under penalty of Perjury one of the following dcclara ions:
[I I have and will meircom.Comiflcam of Consent to sdGinsuu far Workers Compete DRAINS-FLOOR,ROOF,AREA,COND.
cation,as provided for by Section 37M of the Labor Code,for rte performance of the STORIES TYPB CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have odd will mabm m Worker's Campcdm.ian Ins tumor.as requircJ by Section
37M of the labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My W.rta Compensation Insmanc d Policy mm.hcr are:
/ Carrier. �\be_ „�rScatricPolicy No: I�S�o Q- GAS-EA.SYSTEM�OVER 4(EA)
ERTIFICATE OP EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE GREASU/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PEPS
(Thisetttion need nm M1erompletedif rte permit is for one hundreddnllars($pull GREASE TRAP
or less.) PfANCHECK FEE
I certify tat in rte pcommance of the work for which this permit is issued.I shall SEWER-SANITARY-STORM EA.2W FT.
rs
not employ any peon c in any manner as m became subject m the Workers'Comped- ENERGY FEE
ZZ sation laws of California.Dart WATER HEATER WNENT/ELECTR
Q Applicant - GRADING ME
y NOTICE TO APPLICANT:IL after making this Cenilicame of Exemption,you should WATER SYSTEMIfREATING
abecome subject to Ne Workers Compensation provisions of the tahor Code,you must - SOILS FEE
Lib f.nhwithcamply with such prosaions.,this permit shot]be mannedremked, WATER SERVICE
aO
�z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID Dam Rcceiptp
1 hereby atfnn thauhert is a c.nswninn lending abency for the performanre of
V O the work for which this pearth is issued(See.3007.Civ.C.) -
O U Lender:Name TOTAL:
Lenders Address
{Ll a BUILDING FEE
I ttnee nm I ply read this application end dint that the above ws eluding is
fZ crnx0lagrce uron,and with all than countyordinationof
stemlawsr upon gm QTY. MECHANICAL PERMIT FEE
' (] Z building construction,and hereby auth.rim reprtsematives of his city meter upon the SEISMIC FEE
oMwe-mentioned property far inspection pur,sim,. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamar s the City of Cupertino against ELECTRIC FEE
Iiobilkicamdgnom.......a andexpewes which mey toady,wuyiccmeag.instsaid City ALTER OR ADDTO SUCH,
in cm uca fence of use g.tidg of this proud. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CIM)
SOURCER GUTATIONS. MECHANICAL FEE
S-LL q AIR HANDLING UNIT(OVER IBfglfl CFM) CONSTRUCTION TAX
ipatuma App man/ nava Dare EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARI MATERIALS DISCLOSURE
Willneapplicom orf. wilding oecupum store orhandle lummoduus material HEATING UNIT(TO 100,000 BTU)
es defined by the Cupertino Municipal Code,Chapter 9.12,and me Health and Safety
Code,Sec0on 25532(o)T HEATING UNIT(OVER 11X1(100 BTU)
_0Yca 7 N VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment m devices which Dam Receipt g
emit hawdous air com...inims as defined by the]Lay Area Air Chalky Management BOILER-COM11P(3HP OR 1(q,000 BTU) 'TOTAL:
D¢mct^ BOILER-COMP(OVER 101.000 BTU)
❑Yes ❑N.
1 have«ml rte h:umdaus mamdals m under Chapter fi.95 of the Cali AIR CONDITIONER - ISSUANCE DATE
ryuirt
fuiliu building Jorh&Safmy Cade,Sminns 25505,25533 and 25534.1 o notify d mut if the NEW RP.SIDENTIAL MF.CH: SQ.Ff.
mhm dceemems rrentlywhich have h met Boat it is my res.f.C offlm e.fOrrOponcy. ..
of the t�uirementa which must be met pnonoiuuance ofaCenifcme ofOmupancp.
Owner emasmord.,urn Date TOTAL: ISSUED BY:
I OFFICE