31441 f
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRLCAI, PERMIT NO, ^ Jf
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J( 4
6UII.IIING PROJECT IDENI'LFICA'L'IQN
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
ZlG 5 T 1 1 1 Lt Q
OWNER'SNAMIL I IONS: TRA 'U ' AMIE: - ICNO',
b^� JL O N/C CONTROL#
A CHISEC1/ENGINEER: LIC NO', RES S: TIS ❑
D
CONTACT. PHONIi: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG MECH
Jrd� LJ ❑ ❑
LICENSEDCONTRACfOR'SpIICLARA'r10N QTY. ELECTRIC PERMIT PEE
I hereby aRrm that l an licensed unJer provisions or Chapter 9(commencing JOB DESCRIPTION
n tafZ with Set 7 1)nfl) 3ofthe Businessa Profess,.Ona Cod dnrlicensees
�0O Y PERMIT ISSUANCE RESIDENTIAL:
in Intl Tose )
tY Jki ❑SFDWL ❑KITCHEN REMODEL
a V k] Lic =1 Lic. NC
P
APLIAES-RESIDENTIAL.
� D Conm.ct ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS D[ A El MULTI-UNIT ❑STRUCTURAL
7 n PANELS
Z 1underamnJ my plans shall be used as public rccoNSW�q` M ION
OZ.-0 "" ol/ upT02g1AMPS ❑INTIiRION CHIMNEY REPAIR
f=4CW Licensed Professional - 201-10011AMPS IMPROVEMENT
�+42; OWNER BUILDER DECLARATION '
C W Q I hereby amrm that 1 am exempt front the Contractors License Law for the OVER 11X111 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
3 O 6 V following reason(Section 7031.5,Business and professions Cale:Any city m county SIGNS ELECTRICAL DOTHER
0.ya which requires a permit to construct,alter,improve,demolish,or repair any wucmre
pd.,to its issuance,also requires theapplicant for such permit.file asigredstamment SPECIAL Cl RCUIT/M ISC.
�y that he is licensed purannom 10 the provlsion.s of the Contractor's License Low(Chapter 9
�QD (mmrnmemg with Section 7000)of Division 3 of the Business and Professions CMc)or TEMP,MIOER OR POLE INST COMMERCIAL:
G m n' that he is exempt rhemfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
h
Section 7031.5 by anyapplicant fora permit subjectsthe applicant to It civil penalty of POWER DEVICES
zF. p., out more than five hundred dollars(3500). ❑TENANT ❑FOODSERVICE
X C ❑ I.us owner of the property,or my employees with wages as their sole conipenumlon, SWIMMI NO POOL ELECTR IC IMPROVEMENT
will do the work,anal the tecore is not intended or offered for sale(Sec,POW,Business ❑OTHER
3 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTIJR
property who builds or improves thereon,and who does such workkhinnelf,inj magh
his own employees,provided that such improvements are not intended or offered for NEW RGSIDENTIALELECfR S
sale,If,however.the building or improvement Is sold within one year of completon,the SQ.FP.FLOOR AREA 3/SQ.Fr.
owner-builder will have the burden of proving that he did not build or improve for put. PAID T�
Poscofetle.). P P1 D
❑1,es own r of the properly,am exclusively ennuening with IicenseJ nmtmnors to TOTAL:
construct the project(Sec.7644,Business and Professions Code)The Contractor's Li-
censeNOV Law ones not apply to an ownerofpmpery who builds or improves(hereon,and QT'Y. PLUMBING PI7RMIT FEE
whomntram,for such Tommx with a contractors)licensed pursuant to the Contractors
License exempt
PERMIT ISSUANCE CITY
�7
I '-Uf LuraMll I
❑I am exempt under Sec. - ,H&P C for this reason
ALTER-DRAIN,F VENT-WATER(EA)•
Owner DoVALUATION m
WORKER'S COMPENSATION DECLARATION BACK FLOW PNOT[CI'.DEVICE /�ZQ
1 herehy affmn under Penalty of perjury one ll the following Workersdeclarations: 7
m.asI have and will for
eCeni icate37M of]he LiduoCods,1rreforcIfimprs Qhmpen- DRAINS-FLOOR,ROOR AREA,COND. STORIES TYPFCONST'RUCI'ION
cation:as provided for by Section 371X1 of the lnMr Ga1h.for the performance of the '
work for
have
ill traircu is orker. c' FIX'1'URBS-PER TRAI'
37 I hath and will m Iv,for Workers Compensation Insurance.as required by Section
37W of the lnhor C,uk,for perfnrnwney uftnewI which this emit ie issu GAS-EA.SYSTEM-I INC.40UTLCTS OCCGROUP APN
MyNnr C. r s mrond Pnl' r are: GAS-EA,SYSTEM-OVF,R 4(EA)
Policy
CERTII'ICAOMPE SA (TION PROM WORKERS'
COMPENSATION INSURANCE n GREASFFIINDUSTRL WASTE,INTERCEPTOR
(Hassled ion toed to,he mnlPletal if the Per mhls l'anmhhundred dollnw 131(X11 BUILDING DIVISION FEES
mless.) GREA$ETRAP
1'LANCHECK PEE
I certify Phut in the performance o as t work for which this peedl is issue,,.,,all
not em le any Person nannerun en Po become subject Workers'Cnm em SEWER-SANITARY-STORM F.A.200 FIT.employ Y' p IiNERGY FEIi
,Z, Applicant
California.Date
O WATER HEATER WNP.NT/ELBCTR
Z O Applicant GRADING PIiF.
ti NOTICE TO APPLICANT:If,after making this Cenificom of Exemption,you should WATER SYSTEMTREATING
a , become subject to the Worker's Conhpmentiun provisions of fire Labor Code,you must SOILS FEE CIA
(31 forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
5z CONSTRUC'T'ION LIiNDING AGENCY NEW RGSIDEN'l1AL PCMB. SQ,FT. PAID
U O IherehY amnm that ixawnswalion lending agency for.he performance of Date
I.T.
H the work for which this permit is issued(Sec.3097,Cie C.)
O Lenders Name TOTAL:
WLenders Address TOTAL:
FC4 I certify that 1 have rend this;iFtewntinn and state that the above information is BUILDING FEE
Cil correct l agree to comply withal]city and county ordinances and sem laws mining'. QTY. MECHANICAL PERMIT FEE
U I� building constructiooand hereby aathorim reprevandives of.his city III from upon the SEISMIC FEE
`y uhove-mentioned Properly for inspection purposes. ,
(WO agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabll'nies,judgments,constant expenses which may in tory way.,me against said City -
ALTER 012 ADD 10 MIiCH. PLUMBING PEE
incit yu ce of the granting of this penmi..
All A r U D.RSTA' S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TIO 10,000CPM) MECHANICALFEE
S JI CP Er TION
/_ AIR HANDLING UNIT(OVER 10,IXNICFM) CUNSTRUCf10N TA%
Signa mOfAPp'mAZA to, am EXHAUST HOOD(W/DUCT) HOUSING MRIGATION FEE
HAZA tures MATERIALS DISCLOSURE
Willy t applicant or future itiat Co e,Climber
or handle Health ad Safe,, HEATING UNIT TO IIXI,IXIII N'ITl)
as def Sect by the Cupertino Municipal Code,Chapter 9.12,and the Health ad Safety
Code,Section 255320)7 HEATING UNIT(OVER 100,000 BTU)
El Yes ❑Na 'PAID
VENTILATION FAN(SINGLE RESID) Date Receipt Will the acorom minmof from building occupant use equipment or devices which BOILER-COMP THP OR 100,0011 BTU
emit Factories,air ll asmaas as,eOneJ by the Bay Aren Air Quality Management )
District? TOTAL:
ED Yes [-I No BOILER-COMP(OVER 1!1!1,000 BTU) -
ve must Phe harnrdo o mammals mryimmcnts unJer Chapter fi 95 of the Cali AIR CONDITIONER
ISSUANCE DATE
I { hh&Safny CsJc,. Pions 255!15,is my and 25534.1 understand.hat if Nc NEW RESIDENTIAL MECH. SQ.FT.
I i Jces nn rte tenant that iP is my responsibility mnOtify Nesrcupum -
oT �whis Ir1I e spoor n issuanw oz�rif a fOq�ryy.
Owner ot- e0 in �atja TOTAL: ISSUED BY:
OFFICE