31161 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECFRICAL MR"f"N° 31161
BUILDING DIVISION APPLICATION)'PERMIT PLUMBING MECHANICALi BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APMICNOONN SUBMITTAL DA'IT
OW ER'S NAMB: PHONE: COMRACIDH'S NAME 4 LIC NO
/ NIC CONTROL Y
•ARCI{ T iINFP LICN ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consullaal Far Paid by Applkanp(Inhial) BLDG PLUMB meC
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE ❑ /�yc5
1 hereby affitm Thu 1 am li nsd undo provisions of Chair,9(commrming JOB UESCR ION
1 DMZ with Sutiun9g10pol3iviaionJoftM Bwincxv and PrvLxdms Rrl,aW my liattu is RESID NT
nfull face and PERMITISSUANCB . �-- HAAs:
O O_ ./
to
�L/f63L� ❑SFDWL El KITCHEN REMODEL
F�F-Z, Lmctssm Ctl=" lice
NQa Uatc Con uwtar � APPLIANCES-RFSIUE.NTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F-'<vs ARCHfIEM DECLARATION I'ANFlS ❑MN.TI-UNIT ]STRUCTURAL
Z O t2 7- I andmound my pL nx nM1all be shed as public mcnnty MODIFICATION
O Z UP TO 200 AMPS
1-viE-��M]] Liccvud Pmfcruimel _ ❑INTERIOR ❑CHIMNEYREPAIR
Oa f] OWNER-BUILDER DECLARATION 2111-HXb6AMIS IMPROVEMENT
2O 66V�� 1 hereby aRnn Thu 1 on exemq from the Caev.emis Licens<Law fir the OVER I"AMN ❑BATH REMOIR DEMOI.I
p(3 d Nlow'ing maran.(Section 7031.5,Rusini end Pndeviona Code'.Any exy m eimmy SIGNS ELECTRICAL ❑OTH17R_
4411 4. which maim.pcmtit w cowlrvn,.1mr,iittprov<.clson isft,or reps,any structure
such pe
0.mr,oi
price to it.i... rts the ygliemt for mul to fleesig^M smrcm<nt SPECIAL.CIRCUIT/h115C.
dFthat he is li¢ttuJ punuw0o the pmvi.ionr afthe Cunlmnor'a Licen,e law fCh,ler9
.+DO fcom
metriog with Sttticoi700)of Di,6.3 of the Basircq se uPmm P.fnsirCode)m TEMMETER OR POLE INSE COMMERCIAL_
dp.es CC Unit he Is eu<mp,therefrom and tk basis for Ihm alleged exemption.Any violation of
x�4 Sutton 7031.5 by any at for a psori,wbjwu¢Us,epplkanl me dull pmn.l,y ofNEW PoWER DEVICES ❑9FN/C�/ADDITION NT ❑DEMOLI ION
WZ} trot mom than five hundd dolen(1]o0). FOOD
—6 1,a owmr of the❑
5N'IMMINGIWLEI.ECCIIIC IMPROVEMENT pmpeny,nth my cmpltryesw wish wagca vs their.00e compenanion.
l C will dolhmwuk.Corti: swcwrtisuwsi, isemaaf.does on.,I".to
❑OTHER
W ad Pmfnsions Corti:The Comahere land w no doe.tax apply to if r dner of OUTLETS-SWITCHES-Fl%TURFS
hiAer,s own wk)huida or imprnvcs thcmrxl and who. rush wM h ani or ar mnsagh
M1u own unpluyee.,baildor, Wu such Impmvntld aR troth iy,wr or oRe,d for NEW RESIDENTIAL F1ECDt SQ
sale.ILbowcvwill Ube Into,
ft iuso of ootnt issoldhwi,hinnsWild or fr,,A,,nian,the SQ.FT FLOONAREA 3/SQ.FT.
wr-builJcr will have Ihm iutskn of poving thou he�hd rxx build m improve fuPur-
pou M alma).
❑L a.other, Ihm See 7 ul.,aively corfi oo ng wild:)'meed charter',,i-
csxuauct the profs,(.Sac.71U4. voter.cs and rty w1asiau Code:)The ei,s ft.,
, Li- 1" q 1 p
ecnseltwdoes each linjees ithactnimelonywcvho hu Jsuitnt loves Cont,,ortl Q7y. PLUMBING PERMIT -
who shiner fh vucM1P JecH with nenn,nnur(y lic,mwd pursuant CnnaxeN.
Lmcmmlow. PERMIT ISSUANCE DIF'- 3
❑ l em esemq udc see ,B&PC for tM1ix mown
ALTER-DRAIN&V EXT-WATER(EA) VALUATION
�owtt> ova (/r
WORKERS,undeCOMPENSATION,or DECLARATION PACK FLOW PNOTECI'.DEVICE ����HfINQ
1 hetrby.r0rm ander p<wtr of Tedmr nth of the following declenliwa: -
❑Iluv roal%ill nuincdna Ccnif roof Comma mmlf-iwurt Gs-Wu es'.Conye^- DRAINS-FLOOR ROOF,AREA.COND. STORIES WPECONSTRUCHON
anion,as provided for by Semon 9700 of the Wbur Code,tin,the pa,,orana of the
auk fir which this prrmil is ward. FI% RES-PER TRAP
❑I have and will maintain Worker',Compertwtim Imran .at,ro uimd by Sm,ion
370()IIfthe I,N,,Check,far rte perfoo..oftim wod for whK thin permll isiowd. GAS-EA.SYS -d INC.4011TLFTS
My Workcfj C° atimt carritt W
"'y2=.34
blicY n OCC GROUP APN
Cmrier:_[I//A(.xPnliry Nn.: GAS-LA.SYSTiM-0VER4(PA1
CFRTIIICATB( % ITIONIROM WbRKER.S'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE IN ERCEPIOR
19 his rection rmcJ not hamnipind ifthuo is Grate hundml dols,,I INo BUILDING DIVISION HES
or 1v.) paha GR ssSETRAP
PLANCHECK HE
I cs a n,tfe.ilibn perfixmnorso to to he for whichthis pis,Wordi Cerro - SEWER-SAND'ARY-STORM EA.Np FT.
not employ vny person in any manner v�ns to hernme vubject w Ihm WMeri Comprn- ENERGY FEL
O Z anion Iowa of Califunit.Due WATER HEATER WNI2IJTIELECIR
O
AMU.1 GRADING FEE
h NOTICE TO APPLICANT:If,after o iog Nu Cenifieue of Fa nth Tian,you sdwd WATER SYSTE UTREATING
F ^ bcean a wb*1 to the WM<r's Com anion provisions at teem Calc,you must SOILS FEB
forsh oh comply with such Provisions orNis Permit Jtall be od<emed mvekd. WATER SERVICE
yWin
D CONSrRUCUONLINDINGAGENCY NEWRESIDEN-HALPLMB. SQ.FT PAID
V O 1brreby df that them is a umxtruction lending agerey for the perforttw,ac of Due Rcceipi
r de wmk fm which this puna,is issaeJ(Ss.J(197.Ci,C.)
U d
leerr.Noo
L.J IsdsY TOTAL:
Addho. TOTAL: -
I emify that I have read dirk x,plicatih and state than the abos inrorntvaon is BUILDING HE
VJ 'r""O I agmc to comply with all city mod cantly md'marce.and slam law,mlwing m QTY. MECHANICAL PERMIT FEE
V Z building conswc,ion,end thereby atidxxize reprtsmtativn of this city to cyto upon the SFJSMICFV
above-treaevocd property for inspection pugw..es. PERMIT ISSUANCE
I WO agme Io.ave,idenmmthe
0y rind ksp haneca City of Cupertino against Pd.ECTRIC FEE
liabibfi ,judgonso ,eosts.nd aspe¢.rswbich tttay in way aecwe ugainw slid City ALTER OR ADD TO MECH.
ma
n eaerl.nf,U grontrin,of thin lc non, PLUMBING FEF, .'
APPLICANT UNDERSTANDS Al.WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNR(TO 10.1100 CFM)
SOURCE REGULATIONS. MECHANICAL FF.E
AIR HANDLING UNIT(OVER 10,000)CFM) CONSfRUCIIONTA%
Signature of ApplicanuCommnh Due E%IIAUS HOODIWOUCI') HOUSING hI1TIGATION FEE
IIA%ARDOUS MATIRIAI S DISCLOSURE
Nell the,appliemt u future building nor t nnrt or haadli,haznNous ttuterial HEATING UNIT CID 100,000 BTU) .
ria definer]by the Cupertino Municipal Code.CTtapp..9.12,ad the Ilwlth tml Safety
Code.See ih 15532(ri)° HEATING UNIT(OVER 100.000 BTU)
❑Ye E]No
VENTILATION FA N IS INGIR RESID) PAID pate Rccet M
Will rte nppli.t m None,building acvlvnt me egiii moi h devim which N
,nd,hoz ., is eontvminants u dertrcd by the Bay Arra Air Qwlity Ma ,,.i BOII.ER-COMP(3HP OR W,00 BTU)
Dovia7 TOTAL
❑yes• FI No BOILER-COMP(OVER I Ml)(s)BTU)
I lave and the M1uranlus inti C'hvper AIR CONDMON17R - ISSUANCE DATE
rt,1553 cats un5. 6.95 of the Cali-
Hca1N&Safety Cul.Sm on 2SNtt i is ry ,s 255.H.1 undanmnd ram if the NEW RESIDENTIAL MECH. SQ.IT
iuillin8 do nx artently have t tenant,tint it in my rtyrttsihil'dy to miry re ucupunt
dote uw h roar be rota prlofb iaslutre Orr'Caui ofOsu
,� .o"imi
Ower m euthonzed eget Date TOTAL: ISSUED BY:
OFFICE