31165 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBNG-MECIIANICAL
BUILDING PROJECT IDENTIFICATION 31165
BUILDINGADDRESS: SANITARY.NO. APPLICATION SUBMITTAL GNU
o857 GJo(F l
OW ERSNA PHONE: CO ACTOR'S NAME: LI NO:
. s Tf�Cl�o 11 \ /Z Z /an N/C CONTROL#
ARCHITE v [NB& LLIICNO:' ADD vg ✓ l.0 ❑
CONTACT:, PHONE: - BUILDING PERMIT INFO
L�0377 -2—(d 6 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLU G H
Imo'
LICENSED CONTRA(cPORS D✓ECLARATION ' QTY ELECTRIC PERMIT FEE
I hereby affirm thin I am licensed u,a. ,powisions of Chapter,9(commencing JOB DESCRIPTION
WOOOaZ with Section of Division 3 of the Businss'anil Professions Code,and my license is RESIDENTIAL•
wm PERMII'ISSUANCE
WOO
in full force anJ effect.3 . -\ - -
�k) License Class 1J LiaN - ❑SFDWL - [I KITCHEN REMODEL
MUatc 6—[iiia—97 Cr-f#a APPLIANCES-RESIDENTIAL. ❑ADDITION El PLUMBING RF,-PIPE
ARCHITECT'SDECLARAA N., El MULTI-UNIT ❑STRUCTURAL.
�Oa - PANELS
ZO'-Z lundcmad my plans shall 6e used upubic rtcords' MODIFICATION
OZ— \ ti UPTO 2WAMPS El INTERIOR CI CHIMNEY REPAIR
f;4�k44 LicemmdProfessionil s 201-IARAMPS - IMPROVEMENT
•] OWNER-BUILDER DECLARATION
W 6 1 hereby affirm ohm 1 am exempt from the Contracior's Lic� Law for the OVER that AMPS D BATH REMODEUREPAIR D DEMOLITION
JqS Oy U following reason.(Section 7031.5,Business and Portal..'Cade:An ty.or county SIGNS ELECTRICAL OOTHER
t+l a 4 rrl�� which reyuires a permit m conswel,alter improve,demnlixh;or rep ,atruaure
prior to its kominc,als,ralm...thcii,iemo kora hpe.... to file asigncdamiemem SPECIAL CIRCUIT/MISC.
vWvW��Y that he is licensWpursuunt tot he provi,mmsof the Contractor's license law(01sBater9
C i (commencing with Section 7") of the Business and Professions Co`d�l er TEMP.METER OR POLE INST. COMMERCIAL
6 p`,m pE ohm he is exempt therefrom and vhe basis for the alleged exemption.Any violation f' - D DEMOLITION
LiDC 0. Sellion](I31.SM1 Meant for t.suhmts the ashram to u civil ye El
„sy by permi j Ip penult oF5 POWER DEVICES - F:NANT ❑FOOD SERVICE
not more mhos flue hundred dollar(SSW). '_
FO ❑has owner of the propcny,or my employees withwages astheirsole compenmti..n. SWIMMING POOL F.LECIR�C IMPROVEMENT
will do the work,and the structure is not intendedoreffired forsale(Sec.70DI Business OTHER
3� and Professions Code:The Contractor's Liceneo Lim&us not apply to an owner of OUTLETS-SWITCHES�FIXTURES
property who huilds or improves thereon;and who does such work himself or through
his own employees.Provided that such improvements are not intrnded or offered for NEW RESIDENTIAL ELECS'R SQ FT.
sale.If,however,the building or improvement is sold within one year of completion,the s„� SQ.FT.I!OOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he didnol build...improve farina-
pose of sale). ; '-
D 1,as owner of the property,am exclusively contracting with licensed contractors to \ ��� TOTA k '
construct the projest(Sec.704 ,Business and Professions CWc:)The Contractors Li-
anaLaw does not apply toanowner(if ptapertywhoholds...improves thereon,and QTY. PLUMBING PERM IT FEE
who contracts for such projects with a contractoo s)licensed pursuant in the Contractor's sAm • 1
License law. - PERMIT ISSUANCE\
as
D I um exempt under Sec. ,B&P C for this minion
ALTER-DRAIN&VRd DT -WAI'F.R(EA)
Owner Dae VALUATION
WORKER'S COMPENSATION DECLARATION x
I hereby (firm under It of e'u of following declarations BACK FLOW PROTECT'.DCVICE
a penny p H ryenco g
D ltiuve and will maintain Cettilicmeof Consent o self-insnrc far Worker's Comlem DRAINS-FLOOR,ROOP,ARCA,CON���'f �\i
sotion,es provided for by Section 1]W of the Lahnr Code,fur the performance of the - STORIES TYPE CONSTRUCTION
w kfmwhieh Nis perannisissued. APPPrM
y�s/.I have nn0 will maintain Worker's Compensminn Insuruncc,as require)by Section 1
7]Igof cLabor Cod,for the performance nfthe work for which this Permit is issued. SETEM-I INC.40UTLETS, \ �„
OCC.GROUP APN
orpCryh utstytm mer J,il Pollnher � ��pp �T • •Carrier:]'g Og-y�o/'(,layN Y DZSEW aO1C QCCERTIFIC EOFEXEMPTIONFROMWORKERS' n tunCOMPENSATION INSURANCE ? 4h 'nll� I1111LDING UIVISIDN FLi('Reissu'tian need not be c,ngrlelnl il'thc permit ie Rsnms hundrad dollars($1W)nrlesxJ OI COPLANCHECK FP?I3I«nify that in the Performance of line work for whim this permit is issued,Ishan - `kQENERGY FEE
OZ sotion Lawsof Cdinmiu.Date O4Vv ,V
..z O Applicant GRADING ME
FN-m NOTICE TO APPLICANT:If,after making this Cenificare of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Gds,you must Obf da SOILS FEE
UJ fanhwith comply with such provisions or this permit shall he deemed revoked. ' - ER SIiRVIC \,
0. Q
z CONSTRUCTION LENDING AGENCYNE SQ,FT PAID2
L)C) I herchyaffinomotthere is o comm ion lcndingngency far he performance of \4 Date Receipt
the work for which this, 'tiai ' d(Set.3(4),Cm C)
u” H Lender's Name - ` '
Ll Lender's Address \'`• TOTAL
GP certify that I have mad this application and.state that the above information isILDING FRE
tq Anse..I agree m comply with an city and muntyoNin...r,undsmm luwsrelatingmo MECHANSacq FEE
U z building construction.and hereby mnhorize representatives of this city to enter upon the SEISMICFPE
above-mentioned pmpcny for inspection purposes. ' . PERMIT ISSUANCE
(We)agree to save,indemnity and keep handless the City of Cupertino against ELTRIC FEE ,
I lubilities,judymetns,costs and expenses which may in anyway accmaagmnst said City ALTER OR ADD TO MECH.
in consequence of the groom,of this permit. PLUMBING FEE '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH LL NON-POINT AIR HANDLINGUNIT(TO 10,"CFMI
SOUR - GULATIONS. MECHANICAL FEE \�t
:l n. / p NRtIANDLING UNIT(OVER I(1,0(III CPM) CONSTRU ON TAX
Sm ofAp icanas
uVontraaor - (I/ Un T EXHAUST HOOD(W/DUCT) HOUSING MITI 1 N E \
HAZARDOUS MATERIALS DISCLOSURE
Wil l theapplicamorman material HEATING UNIT(TO 10gWtI BTI])
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety r \
Code,Section 25532(.)? HEATING UNIT(OVER 10i,()(1)BTU)
❑Yes r-1 No q
VENTILATION FAN(SINGLE RESID) A7�
Will the applicant or future building occupant use equipment or devices which Q k iptM
.emit hazardous air contaminants as defined by the Bey Area Air Quality Management BOILER-COMP QHP OR I00,000 BTU) ..
Distils? TOTAL:
❑Yes No BOILER-COMP(OVER I00,001 BTU)
I have read the heodova macddsall AIR CONDITIONER ISSUANCE DAT
requiremrnts under Ch tmfi95oftheCdi-
foanin Health&Safety Code,Sections 25505,25533 and 25534.1 understood that if the NEW RESIDENTIAL MECH. SQ.FT.
bmilJing docs nm cuoently have a renonr that it is my responslhility to nodi,the acen,al
mf the rnquiremems which must be and prion,ismunce of a Cenifir.n of Occupancy.
,Owner lar nuth,nzed agent Date - TOTAL: ISSUED BY
OFFICE