31535 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATIONIPFRMIT PLUMBING.MECHANICAL. 31535
BUILDING PROJECT IDENTIF'ICAT'ION
BUILDING ADDRESS - /s ' SANITARY NO. A11'PLICAI'ION SUBMI'ITAC DATE
cmpG�
O 'SNA PHONE: CONTRAAACCTO•ORS NAAAM_E: LIC NO: s•� 6
11111MNIC CONTROL�#fg
AR i1TTiCf/ENGINE Len
'C. 1,41 ADDRESS:
C ACT. PHONE: - BUILDING PERMIT INFO
r(Qe�q ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
\�WMrIk LICENSED CONTRACTOR'S DECLARATION o . ELECTRIC PERMIT Flili M
affirm ❑
I hereby Nat l am ed licensunder provisions of Chapter 9(commencing QTYJOB DESCRIPTION
OCz with Section]IXMI)of Division3ofrhe Business and Rofesxions Cude,anJ mylittnse is RESIDENTIAL:
00 PERMIT ISSUANCE
in full force and effect.
QUZ�j License Class Lia# ❑SFDWL r]KITCHEN REMODEL
Dmc Contractor APPLIANCES-RMIDEM]AL ❑ADDITION [I PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS '❑MULTI.UNIT ❑STRUCTURAL
OZ91 Z I understand my plans shall be,used as public records MODIFICATION
, _ UPTO211a AMPS ❑INTERIOR [I CHIMNEY REPAIR
P 41- Licensed Professional 201-100OAMPS IMPROVEMENT
�Fd OWNER-BUILDER DECLARATION OVER I"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
y C I reasonereby
that 1 vas exempt form the Cnnhns Co e:LoctprocAny c ty o for the
x 0 W V following reason.Permit
to
7031.5,Business and improve,
de Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
F LLO which requires v permit m canmrvm,alma improve,demolish,orfile
repair any structure
that hor oitsisauanccrEontto rte Novisiosofthesuch Pcount ctors LfleaeLaw(Chapters SI'ECIAP.CIRCUITI SC.
} that me cttnsed Section Ne pmvisioorof the Conuamor'sness nd Professions
Code)
0.
(commencing is ixemwith therefromon it us Divisiun3 oft heegedsAampli'n.Any
or TEMP.MFTR POLE INST. COMMERCIAL
d d n ty Sec io is exempt therefrom and Ne basis fns the allege)exemption.Any l Penalty of ❑ EW BLDGIADDITION ❑DEMOLITION
-,H Sectioneth 7031.5 by any handle dollars S500)niuubjems Ne applicant to.civil peachy of POWER I3EVP S
not more than Ove hundred dollars 15500). #ANT ❑FOOD SERVICE
��< I,as owner of the n,brm to ccs with wa es as theirsole con oration. SWIMMING POOL ELF: IMPROVEMENT
❑ props ct YcmP Y 8 Fe
Sawill do the work,and me structure is not intended ondferW for nate(Sec.]014.Business ❑OTHER
a vZ
and Professions Code:The Conaamm's License Low docs not apply to to owner ofis
OUTLETS-kwfT ES-FI%' r'
property be builds or improves Nereom,vad who does such work himself or through
his own employee.,provided that such improvements me not intended or offered for NEW RESIDF16IdiL.KEQA SQ 1T.
sole.If,however,the building or Improvement is sold within one year ofcompletion,the SQ IT.FLOOR AREA .$/SQ.f ..
o�wneer,builder will have no burden of pmving that he did not build or improve for par,
�#f,Poor nssowne
r of the pmpeny,am exclusively convecting wird licensed n:mwcmrs to �tfiIv O
tract the project(Sec.7144,Business Ad Profession Cade)TTre Cmumemea Li- ,^( v
cense Law does not apply to an owner ofprolcny who builds or improves hemor,and QTY, PLUMBING PERMIT FI7C - '!;
who contracts for such projects wird u commctm(s)licensed Pursuant to the Contractor's
License Law, PERMIT ISSUANCE
❑ l am exenpt under Sea ',B&P C for this mason - .
ALTER-DRAIN&VENT-WATER(CA) W e VALUATION
Owner aDvO a
WORKIik'S COM RATIONDECLARATION BACK PLOW PROTECT.DEVICE
1 hereby affirm under penalty of Perjury one of the following declarations: ,
❑ Ihvve and will mninminn Cenifca[e of GmsenOoselhinsurc lar Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND.
xatiun,as provided for by Section 3700 of the Unfair Calc,for the perfomnnce of the Ec "f(MIJ TYPE CONSTRUCTION
work for which this Permit is issued FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Immuntt,as required by Section VV
3700ofthe Leben Code,fonhe pedarmanceofthe workforwhich this permit isissued. GAS-EA.SYSTEM.)INC.4 OUTLETS
My Worker'sCompensation Insurance carticr and Policy number vie: p .GROUP APN
Carrier' � Policy No.: GAS-EA.SYS'1'EM-OVER 4(I A)
CERTIFICATE OF F.XEMPUON FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUS'IRL WASTT.INTERCEPTOR _ fl ILD) :1 VISION PEE.l'
Obi. Bion account Mcumpletd ifthe penult is forooe hundreddollars($100) GREASETRAP
m leas.) PLANCHECK FE
toy any forhatm the performance
erof Nework become subjech ct
to perthe Wokesuul,I shall'A- SEWER-SANITARY-STORM EA.21X1 FT.
not employ any person in any manner so as to become subject m the Workers'Compen- ENERGY FE �
0Z satins Lawn of California.Dow _ WATER I[EATER WN ENTBiLECTR
Applicant GRAVING
Z pr' NOTICE TO APPhICANP.IL.Torr making Nis Cmifcate of[xemprion,you should WATER SYSTEM/TREATING
become subject o the Worker's Compensation provisions of the Labor Code,you must SOILS TIV
{la Iti forthwith comply with such provisions or this pemtit shall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RIi51UF.NTIAL)'LMB. SQ.FT. PAID
L) 0 work
by which his
there issued(Sec.30 leading agency for the performance of Da Receiptp
w l-+ Le wnrk for which Chia permit is issued(Sm.309],Civ.C.)
I-t Lender's Name TOTgh:
r W Lender's AJdress TOi'AI.:
y I certify that 1 have read this application and sen¢that the above information is BUILDING FE �•
Fh correct.l agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
Orz buildingeon.uuction,and herebyadhoree represenmtives ofthis city in enter upon the SEISMIC FEE
r arove-menioned property for inspection purposes. I'F;RMIT'ISSf1ANCE
(We)agree to rave,indemnify and keep harmless the City of Cupcnino against ELL'C'IKIC 1' B
liebilities,judgmcnta,costs and expenses which may in any way acarus againn wiJ City ALTER ORADDTO MECH.
in consequence of the Scanning of link permit. PLUMBING JEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('1'010.g10 CPM) MECHANIC LFEE
SOURCE REGULATIONS.
' AIR HANDLING ON]]'(OVER 10,000 CFM) CONSTRUCT T'AX
Signvttam of Appfc.mJC.nmwmr Dare EXHAUST HOOD OVIDUCT) HOUSING MITIG ON PEE
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicanr or for.m buildingavcupent smoemleddle hazardous material HEATING UNIT(TO](in."BTU)
as defined by the Copenime Municipal Cade Chapter 9.12,vAd the Health vad Safety
Code,Section 2553200? HEATING UNIT(OVER 100,000 BTU)
)
❑Yes Vs VENTILATION PAN(S INGLE RESID) PAID
r
Will the applicant or futurefuturebuilding occupant use cgaip tom or devices which 1 ate Re 'pl A
emit t hazardous air contaminants as defined by the Day Area Air Quality Management BOILER-COMP UBE OR 100,000 BTU)
AL:
District'
BOILER (OVER 10d"BTO)
❑Yes
1 have read Ne hmardous materials AIR CONDITIONER
rtquiremcntx under Chapter 6.95 of Ne Cali- ISSUANCE DAT
Brain Health&Safety Code,Sections 25505.25533 and 25534.1 understand not if the NEW RESIDENTIAL MECH. SQ.FT.
ofN�build on es not re sly n'tbornant,th:nitismyecafa hility ui notify the
;rc sew must be met prionoissuance ofe Ce�ificaCk�pan�.
Owner or vmhodudagem Date DT ISSUED BY:
OFFICE