31538 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 31538
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGAIIDRESS: SANITARY NO. APPLICATIO SUIT IITALDATE
Io�be OL L— � . bled 2zo G� >a((No /2 S�5lo .
OWNER'S NAME: PHONE: 44 O. ME: LIC NO:
A o o ikl m--3 N-468-136% 1 6 NIC C�OSNTROL a
RCHITECI'/ENGIN .R: LIC NO: )DRESS:
' al(n tl ooO"•a
CONTA : PHONE: BUILDING PERMIT INFO
E3 consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUINQ. MECy
LICENSED CONTRACTORS DIECLARAI'ION 9 QTY. ELECTRIC PERMIT NEB Vrl_-p✓ IIrCJA
1 hereby alarm Nm I in licensed order pcmisions of chapter 9 a tmmeacing JOB DESCRIPTION
FODWZ with Section 7")of Division 3 of the Business and Professions Cade,and my license is RESIDENTIAL:
O infall face wd effect. PERMIT ISSUANCE
�U 1I(F.- �.- License Class Lic.a ❑SFD W L ❑KITCHEN REMODEL
Pzw Date Contractor APPLIANCES-RFSIDPi IAL ❑ADDITION pp r E)PLUMBING R&PIPE
ARCHI'D[Cr'S DECLARATION T N p❑MULTI-UNISTRUCTURAL
F h PANELS
Z O 1 understand my plans shall he used as public ,cards MODIFICATION
UPT0200AMPS ❑INTER(1�AJJ��qq 0 C IMNEY REPAIR
Gyf"tOi1 Limnu4lsmfeuional 2UI-IOW AMPS I.MPROFFAO� 13
E•.1 OWNER-BUILDER DECLARATION RR��r�lIrr��s���
OVER IUn11AMPS ❑Holl RE MODEUREPAIR'iM33vfOLITION
I hereby affirm that 1 am encmpO from the Contractor's License Law for the }��
xOdU fallowing mason.(Section]031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL- �O
F µ0� which requires a pcnnh to construct,alter.improve,demolish,or repair any structure l kb H I IN()
prio a itsiaaancaalvorequiren the applicant wrmm fneb pet file aligned aawmert R T
yNet he is licensed purxuam m Ne provisions of the Cnmdemr's Liccnsc Law(Chapwr 9
MEMO (aommcncirg with Smt...... IB of Division3of the Business and Professions COdO or TEMpjMFh<OR POLE INST. COMMERCIAL,
a. m e Ohio he is eacmpt therefrom and the basis far the alleged exanprion.Any violation of ❑N' BCUG/ADDITION ❑DEMOLITION
Sectio,III Ll by any applicant fora permit tahjcae the applicant m a civil per.hyd POWA DEVICES BNANT OFOOD SERVICE
(-, tot more than live hundred d.11...($500), IMPR EMENT
Q I]1,as owner of the propcny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
O W Aothewons and Neswctureraccia Licenvo Law does
applyoan,Business OT
yIm coed Professions Cede:The Cnnaanors Licenu Law Jas not apply m an owner of OUTLETS-SWITCHES-FIXTURES
I 3 property who builds err improves Merton erd who Jas such work himself or through
his Own however.
the
pmvidW that such improvements are not intended or oOereJ for NEW RESIDENTIAL ELECTR SQ FT.
sale.ILhowevccthhave the
burden improvement issoldhe didnoneymroRnmpletion.the SQ.PIT.MOOR AREA $/SQ.FT.
tar-builder will have rhe hurJen of proving that he did not build nr inspmvc for pnr-
poseafsaleJ.
I,as owner of the property.aexclusively contracting with Brei d comments to O
m
construct the project(Sm.9044,Business and Professions Code:]The Contracmr
tensas Li- gOO SQ 1
Law does not apply to an owner of property who builds or improves thereon.and QTY N PLUMBING PERMIT FEE \ 1
whocontracts Rvsuch projects with ocammctonolicencedpica anuorM1e Contractors
�� License Law, PERMI'1'ISSUANCE
4 0 1 am exempt under Sm. .B&P C for this reason
o Owar Date ALTER-DRAIN&VIEM'-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICEQ too 13 I hereby affirm under Penalty of perjury ane of the following dsclaretionr. v to
]I have and will maintain a Certificate of Consenuo self-insure for Worker's Compel- DRAINS-MOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
sat ion,as provided for by Section 3700 of the Luba Crale,for the perfsmnnce,of the
work for which this Permit is issued, FIXTURES-PER TRAP 0916 ��
F1 1 have and will maintain Worker's Compensation Insurance,az required by Section ��t
JT00 of Ne lobar Code,for the perfnmance of the work for which this permit isissued GAS-EA.SYSTENIA INC.40UTLETS OCC.GROUP APN
My Works(.C�'o((..ppcc� uon Inpumnce artier and Policy n bcr ore:
/ Cartier. OUIb.F P_\(L-s' Policy No.:�kIG �_ GAS-[A.SYSTEM OVER 4IEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'a
COMPENSATION INSURANCE GREASUINDUSTRL WAS'f1E INTERCEPTOR
(This section need not he completed if the Permit is for one hundred dollars($1 W) BUILDING DIVISION IBES
GREASETRAP 0
or less.) PLANCHECK FEE a
I cenifythat in the perfnmurce ofthc work for which this permit is issued,lshalt SEWER-SANITARY-STORM EA.200 F4.
not employ any person in any manner so as to became subject m the Workers Compen- ENERGY FTE
z,Z anion Laws of Califomia.Dae WATER UEA'rER WNENTMLIEC R
Applicant GRADING FEE
fin
NOTICE ID APPLICANT:IL alter making this Certificate of Exemption,you should WATER SYS'fEM?REA9'ING
a ; become subject m the Workers Compensation provisions of the Labor Code,you most SOILS FLEE
forthwith comply with such provisions or this permit shall be dttmed revoked. WATER SERVICE
a �
5z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ,FT. PAID Date n ok
UInam,affrnlhalftime is.sam.amclion leadin,agency forthe ncrfonnanceof
the work for which this permit is issued(Sec.3097.Civ.C,) Owl V. I ori Name TOTAL' G 3.
L) Lenders AJdrcss T
} W� BUILDING FEE
F' I eenify Ihet 1 have read is applicaoinn and arum the the aMve information is
h conmo.I egmemmmplywith cloy and county oNinanees and sum laws relating to QTY. MECHANICAL-PERMIT FEE way jy�
C.) building con.amction,and beret umono,reprcamlmlvna of this city center upon the SEISMIC PEE
,hove-mentioned propery for i pecnnn purposes. PERMIT ISSUANCE.
(We)agree m save,ind unify and keep tactless the Cory of C.,nino against ELECTRIC FEE
Iiabilities,judgments,costs an apenses which may in any way accrue ugaimt said City ALTERORADDTOMECH. -I'
in consequence of the grnitin fthis permit. PLUMBING FEE
APPLICANT UNDERSTA YS AND WI IPLY WITH ALL NON-POINT AIR HANDLING UNIT 10,WO CFM)
SOURCE REGULATIO S. MECHANICAL E
AIR HANDLING UNI'1'(OVIER I0.000 CFM) CONSTItUEl TAX
ignaareof anVCon 9 oc EXHAUST HOOD(WIDUCO HOUSING MITIGATE HIE
0-7
11,
HAL+ US MATERIALS DISCLOSURE
Will the applicant orf rebuilding acupam arum ahamlle hauNous materiel HEATING UNIT(TO 100,000 BTU)
as defined 11 the Cupertino nicipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(.)1 HEATING UNIT(OVER NX),000 BTU)
-DYes No PAID
VENTILATION PAN(SINGLE RESID) Date Receipt#
Will the applicant or future building Occupant use quipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
emir havrdsms air comaminams as defined by the Bay Arte Air Quality Management
TOTAL:
DistrictT BOILER-COMP(OVER 10f,"BTU)
❑Yes ❑No
�J
I have read the havNnaa materialsrcyaimmem..ander Chapter fvus of One cwt. AIR CONDITIONER
ISSUANCEEP
(omit Health&Safety Cale,Senors 25505,25533 and 55TL 1 understand that if the NEW RESIDENTIAL MECIL SQ.FT. Y)
building does,am currently have a wand,that it is my responsibility to amity the racialism
of the requirements which most be rat prior to issuance of a Cenifcave of Occupancy.
Owner or authorized agent - Elate ISSUED BY:
OFFICE