31132 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PMMRNO. 3^ 1132
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
i o X35 A-710-12 �Q
ER'S NAME �./J ��/f PHONE: ONTRACTOR:S NAME: ///�� .t /LIC NO:
III C �I{�/-1 :�gr'r— t E -Erin/ �C�� ZZO NC CONI'HOLp
HCHITECHF.NGINEEH: LIC NO: A�3"O ¢ S- �.d s E]CONTACT: PHONE: f P BUILDING PERMETINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
,r� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensedBu ander and
Pmfim of Coder 9 Bmmmeneing � JOB DESCRIPTION
�aZ with Scctiectind 0)ol Division3 of the Business and Rofessions Code.and my license is
F�� in full(orce.nJ efleut. /� p-T PERMIT ISSUANCE RESIDENTIAL:
a U V Liccme.S�I� v I is p �`� / Z Z D ❑SFDWL ❑KITCHEN REMODEL.
<UU Dare-; s 2� Cnnmwwr ,mss 1`11n1-1- APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCyITELTS DECLARATION
MULTI-UNIT ❑STRUCTURAL
Z p r=/r m ➢ r;tupd my plans S M used m public recorQ TRACT'S MODIFICATION
p2-, .LCIli — UP TO 20D AMPS 0INTERIOR El CHIMNEY REPAIR
F�.f.W Licened Professional ` 201-IIHk1AMPS IMPROVEMENT
y� UN.-BUILDER DECLARATION OVER l0k0AMPS ❑BATH REM EUREPAI D-MOLITION
C�< 1 hereby affirm tropt limn the CommOer's Licence Law fur aha
K3 d U fallowing reason.(Section 7031.5 cBr sins we]Professions Cwle:Any city or county SIGNS BLECTRICAL []OTHER
W a Nwhich ruluirca o q�ania m<orowca,alter,improve.demolish,or repair any structureF LL'01 prior to its issuance,also maluirestheapplicant f9rsach permino flea signedsmumrn SPECIAL CIRCUITIMISC.
ythat he is licensed pursuant to me pminm visof the Contractors License law(Chapter9
I�+I�QO'O (commencing with Stolon 90D0)ofUivisianJ ofthr Business and Pminsions Carel ar TEMP.METER OR POLE INSTs COMMERCIAL:
0.a p C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDTT10N ❑DEMOLITION
ySrctio. 031.5by any llcant ter a puov
asubjeetc he epplicmann a civil penvhynlPOWI7R DEVICES
❑TENANT ❑FOOD SERVICE
FZ ehundred dollars 1851q.
IMPROVEMENT
=Q ❑L thestorvd the pro pery,mmylmplended wi owages for
lei(See compensation,
SWIMMING POOL ELECTRIC
will do me won,and e,The Contractor.,
is tot intended oro fered w it., ..apply 1.an,Business HER
W 3 m eM Pmfemions Csde:The Contranors License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pmperty who builds or impmves menti and who does such work himself or thmugh
his own employees.provided that such improvements are not intended or offence]for NEW RESIDENTIAL ELECTR SQ PT.
.sale.If,however the building or ims
provcnnt issold within one yearofcumpletiun,the .AFUODRAREA gISQ.Fi'.
owner-milder will have the burden ar proving that he did nm build or impreve for lam-
,or
ar- {{//
;ext eaf sale,. AFAR �g
I,as owner of me property.em exclusively contracting with licensed contractors to TOTAL: ��seen��ss
combat the project(Sec.7010.Business end Professions Code:)The Conavmurs Li- RECp
c sc law docs not apply I...owner,of property who builds or impmves thereon.amt QTY. PLUMBING PERMIT FEE V `s
who contracts for such projects with a co marta(s)licensed pursuant to the Contractor's Ur
License law. PERMIT ISSUANCE L�+'tH 17N0
I an exempt under Sec. .B&PC for this reason _
Owner Mute ALTER-GRAIN&VENT-WR'I'ER IEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under pcnahy stiffener,one of the following declarations:
I have and will mainmin a Certificate of Consent to xlGinsure for Worker's Compen- DRAINS-FLOOR,ROOF.AREA.COND. STORIES TYNECONSTRUCION
when,m provided for by Section 3900 of the Labor Calc,for the permanence of the
work for which this Permit is issued FIXTURES-PER TRAP
❑1 have and will maintain Worker's Cmnperstoom Insurance,as required by Section
3700ofthe lather Code,far the perfomnmee of thework for which this permit is iswcd. CAS-EA.SYSTEM-1 INC.4OUTLETS OCC.GROUT' APN
My Worke' Com pcforya Insurance carrier and Polly man
Guricr: Ay Insurance carrier
Policy N.NwLa_ _5 GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSA'T'ION INSURANCE OREASrANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(ThisserimOoedma be completed ifthmi
e pert is forunc hundreddollurs(51(10) GREASETRAP
or less) - I'fANCHECK FEE
I certify that in the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-NIORM Eh 200 FT.
m
not employ any person in any manner so as become suhjen to the Workers'Canapes- ENERGY FEE
O Z ad..Laws of Calimnu..Dam WATER HEATER WNENT/HLECTR GRADING FEF.
Z 0 Applicant
NOTICE TO APPLICANT:IC after making this Certificate of F,acmpdon,you should WATER SYSTEMA REATING
a become subject to the Workers Compensation provisions of the Labor Code,you must SOUS FEE
W forthwith comply with such provisions or this permit shall be deemedev
roked. WATER SERVICE
A CONSTRUCTION LENDINGAGENCY NEW RESIDENTIALPLMB, SQ 14. PAID
Ihcreby.flirm mat mere isannsammion lending agency for the performance of Date Receipt#
the work for which this permit is issued(Sec.3099,Co,CJ
H. U Lcrall Name TOTAL:
V Leader's Address TOTAL:
> a 1 certify mat 1 have read this application and state that the achieve information is BUILDING FEE /a
iFi h curer,l agree to Comply with all city and county ordinances and state laws relming to QTY. MECHANICAL PERMIT FEE
U Z huilAing caastmrinn,and M1arcby vumaira reprwcnmtivcs of this cltymcmuruNm the SEISMICFEF,
aMrvnmemioned property far impenion purposes. PERMIT ISSUANCE
lWe)agree to save.indemnify and keep hatmlcss the City of Cupertino against ELECTRIC PHE
liabilities,judgments.costs and expenses is Inch may in any way accrue against said City ALTERORADDTOMECU
m consequence of the gmmin, limit, a. PLUMBING FEE
APPLIC 1UNDERSTA S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,1%111 CFM)
MECHANICAL FEC
SOUR[ R V ATION.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION'PA%
Signamrrnf Applies actor Dam EXHA11F'I'HOOD(W/DUCT) HOUSING MITIGATION FEE
HA H RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havardom material HEATING UNIT CID 101"BTU)
Am defined by the Cupertino Municipal Code.Chapter 9.12,and me Health and Safety
Cade.Section 25532(.1' HEATING UNIT(OVER 100.000 BTU)
❑Yes ON. V ENT]LATION FAN(SINGLE RESID) PAID
Dec Er"bila#
Will she aElilecont or frmrc bull,[,.,ocempmm use equipment or devices which BOILER-COMP(3HY OR I W.WU BTU)
emit hazmdous air contaminants m defined by the Bay Area Air Quality Management
L
❑No BOILER-COMP(OVER 100,gp BTU)
l the hmardaus mAIR CONDITIONER ISSUAN ,DATE
Safety Code Sections 25505,25533 and 25534.1 andmstand mut if the NEW RESIDENTIAL MECII. SQ.FTt coastal e a moan.that it is my r Nmsibility to notify mmx,upot
r a o bnmet Ima,I xvmmeotaC�s cral anI re Date TOTAL: ISSUED BY:
OFFICE
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NIAR 2 6 1997 : C. t�£2av (VIA
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BLDG.INSPECTION DEPARTMENT Q-114 / -4 10,
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CITY OF CUPERTINOOFF* ORB C" r F„( : 44,-V 318
DATE Job No.
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Des4n By ConsuRing Engineer
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