31281 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO - - 1 - IIUBJHNO-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 31281
BUILDING PROJECT IDEM'IFICATION
BUILDING ADDRESS: ,
, SANI'T'ARY NO. APPLICAFIONSURMI'f1'ALDATF.
'LI"up SY owC \-,Vuk- Alva f;'3oo tb lC7 G
OWNER' NA I-O'li: �Q RACRIMS NAM P LIC NO:
�� V\ N/C CONTROL
ARCI ITECT/ENGIbyy:R LIC NO: ADDRESS: El
CONTACT:-- 11 t��\.•II�JJ� l 1�Na PHONE: ('� �(� - - BUILDING PERMIT INFO
�(.I/1_-j--1 Conan tent Fecs Paid by Applicant(Initial) BLDG -EL.Cf I MH - MECH
LICENSED CONTRACTOR'S DECLARATION - ❑
QTY F.LIECTRIC PERMIT FEE
I heresy df0rn that I tun fthe cd ander provisions On Chape. 9 teommensi ng IDR D85CRIPTION '-
WOZ with Semiun91NM1)nfUivision 3nfthe Business and Fmfnsiurm Ctde,and my license is RESIDENTIAL:
FyF in full force and effete. - PERMIT ISSUANCE ❑SFDWL „❑KITCHEN REMODEL,
�VUU I.icerrsu Clas Lla.11 APPLIANCES-kES1U1!NTIAL s
hZa Date Contactor ❑ADDITION,' ❑PLUMHINGRI.I'IPH
ARCHrfECPS DECI.ARATION '• ❑MULTI-UNIT El STRUCTURAL
Z o r,7,. I unJersmnal my plans shall se useJ os public regards PANELS, i MODIRCAI
OZ— " r,. UPT'0200AMPS CHIMNEY
W Licensed Profcssinnal , - ❑IMPIIOOR ❑CHIMNEY REPAIR
2111-IO,M)AMPS BATH R EMF.NT
aa� Oat I in
m the RAl Commod OVER 100)AMPS
y�W Q I herehy affirm that 1 an exempt from the Qm[acmrs License Low far the ��� [I BATH REMGDEDI2EPATR �DEMOLITION
LiyS O3,U fallowing tax snn(Section 9031.5.Business anal Professions Code:Any city m,ourtySIGNS ELECTRICAL ❑OTHER
W LL o ian which requires a permit to construct,ulmr,improve,JenndisM1,nr repair anY sunamre
��ti.4
proota its lso neximms the applicant( such permit rile a signed statement, SPECIAL CIRCUITIMISC.
r
'no,he licensed uporm 1 the p bion,of this C t t rsT Low(Ch pmr9
homarmadoin,won See an 7000)orDivision 3 f'he Beii nessond lmfea,ns Cs tutor •I LMP.MR I'6R ON POLI i INS"I': COMMERCIAL,.
L Qm y Ina,he is exempt themfmm and the hais for the alleged exemption.Any violation of •W BLDG/ADDITION El DEMOLITION"
.
Y• Section]031.5 hyanyupplicont forepcmtitiolba,t,ha.,fcanuua civil penalty,( POWER DEVICES
��Nnot mrc than five hundred dollars($503). - - ZeNT ❑FOODSERVICE
.
ZQ ❑1.as owner of the Oropany,or my employees with wages as theirs ole asmpebsautim SWIMMING POOL.ELECTRIC
aINT
will do the work,and the structure is not intended or offend forsule(Sec.9rif4.Business
and Pondoimts Cade:The Cnntmernr'n Licenw Law does not apply man owner of OU'I'LB'I'S-SW;'TCHHS-FIXTURES
progeny who builds or improves thereon,and who does such work himself or through p
his own employees,provided that such Improvements are not intended or offered for NEW RESIDENil AL ELFCTR .�. SQ ITC
sale.If.however,the building or impevemem is sold within one your of completion,the SQ,FT.FLOOR AREA $/SQ.FL
owns-builder will have the burden;(provorr,mo t he did not mild s improve far par-
ofcaI )
Kinard
owner of the progeny,tun exclusively contracting with licensed conmacmrs e TOTAL: _
o ewes Ne p ajem(SaJ044,,usinass and Professions Codod'Em Can—
come
anraoLi qq
c se Law docs not apply m an owner of property who builds or improves bacteria,add QT'Y. PLUMBING PERMIT FEE W,.4
wuson ho nmtraos li such'ejax,,wah.embactor(s)licensed'ursuantto the Contractor's
License Isw. PERMIT ISSUANCE'
0Inmxeer efers, . ,,&PCfrthi re
ALTER-DRAIN&VENT-WArER(IDO VA
Owne Date /x I� /W��1
WORKERSCOMI'I:NSATIONDFCI,ARAHON T RACK FLOW PROTECT DEVICE - �f�- `, A!
Ihereby ff under penalty of perjury one of the following decl Rn: _ /•N., .I
] Ihaveandwill maintain a Ccmficme of Consent to self insum for Worker's Carolina- DRAINS-FLOOR,ROOF AREA,COND. - STORIES TYPE COYSTRUCI'ION
taboo,as pmv'd,d fin by Section 39(10 of the Labor Cada for the ped, panic of the
work for which this permit is issue. FIXTURES-PERTRAP
1 nave anal will maintain Worker's Compenseion Insurance,m required by Section
3900 of the Lahr Code,for lne performance of the work for which this permit is issued. OAS-HA.SYXI lie-I INC.4 OUTLETS UCC.GROUP AIN'
My Worker's Compensation Insurance carrier and Policy number are: -
Carrier: Pal icy No.: GAS-EA.SYSTEM-OVER 4(EA) r
CERTIFICATE OF EXHMP1]ON FROM WORKERS'
COMPENSATION INSURANCE GREASEYINDUSTRL WASTE INTERCEPTOR
(This section need not he completed if the permit in fortune hunt dollars($IW) BU VISION Fl:-S
r odes.) s GREASE'I'RAP PLANCHECK I'.:
Icenify that in the performance of the work fnr which this permit is ismrd.ishall SEWER-SANITARY-STORM EA.20017.
not employ any permit in any manner so ms to become subject the Workers'Cnmpen- ,ENERGY fF.
Z infirm L roc.dl Culifmnim.Data
Z.Q Applicant WATER HEATI!Ii W/VEN'1IELECT'k GRADIN
ti N NOTICE TO APPLICANT.IL after making this Cenilicate of Exemption,you should WATER SVSTEMITSEATING "
NJboor aro subject m the Wnrke,Comgcncminn anv....or,of the Labor Code,Yon must - SOILS Fli: -
D.l r fmtnwith rmapty with such pnoisionsonhis .,,.but]Lee deemed revoked. WATER SERVICE
Q
7z -CONS'TRUCT'ION LENDING AGENCY:; NEW RI?S IDENI'IAL PLM,." � SQ.FC` PAID � - v•
U 0 l hereby affirm thmthee is a construeon lending agency forts,performance of De Rettip[M
Its E..t the work(or which this permit is issued(Sec.3099,Civ.C.) _ "
O U Lender's Name TOTAL:
Tenders Address TOTAL:
I trendy that 1 have read this application and mum that the none informm ion is BUILDING q E -
L. VV) sorest l agree to comply with all city and county ordinances and state laws minting to QTV. MECHANICAL PERMIT FEL'
L) building coms0uction,and hereb,modad ze representatives of thiscity nrenterurym the SEISMIC FEE
above-mentioned property for inspection proposal, ['It ZMI'I'ISSUANCE - ELECTRIC PP.
(We)agree m,cave,indemnify and krw•p harmless the City of Cupertino against t .
Iiahilines.judgments.costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
in consequence ddte grunting of this permit ' PLUMBINGFEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO BLOW CFM)
SOURCE REGULATIONS. MECHANICAL FE
AIR HANDLING UNIT(OVER 10,010 CI'M)I CONSTRUCTION TA
Signature of Applicanr/Contmcnu - Date EXHAUST'HOOD OYMUCD HOUSING MITIGATION 'EE '
HAZARDOUS MAL'ERIALS DISCLOSURIi �)
WTlffia.,licaat orfuture buildoo,cerupantsmn orhtudk havant......tonal DEAL[NO ON]L(TO 100.(NN)BTU)
as defined by the Caperton Municipal Code,Chapter 9.12,and the Health and Safety
Code,Second 25532p 1?' I IEATING UNI'NOVER 100,000 BTU) r ,
s ❑Ya ON. W PAID •
VENTILATION PAN(SINGLE RESID) Dote, Recmp a
I r Will the applicant or future building by the B use ea Air u or devices which -
emit hazardous air ammminams a Defined by the Bay Area Air Quality Management ItO1LF.R-CONI'(34P OR 1W,00a BTU)
/ 'aorta? - TOi
'-
F-1 Yes ❑Nn� � BOILER-COM I'(OVER 100.000 H'fU)s,..• .,
1 have mad the hazmdnus materials re,diremems under Chapter 695 of the Cali- AIR CONDITIONER IS ANCIe DATE
fomia Health&Safety Cade.Sections 25505,25533 and 25534.1 rnderoba d that if the NEW R[.SIDENTIAL M13CH.. SQ.FI'.
I
doe;mo¢urently have a[about,that it is my nO,var ibility m notify rhe oocupaat ,
of the requirements which must he met mor to lssaamr,of a Certificate of Occupancy.
Owner or amhmp,ad agent Date TOTAL: ISSUED BY:
OFFICE ;