31456 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. ^ /A
BUILDING DIVISION APPLICATIONIPERMIT PLUMB NG-MECHANICAL JK FVa
BUILDING PROJECT IDE.N'FIFICATION
17 S BU�DIONG ApD SS� �\ ��� �- //L� SANITARY NO. APPLICATION SUBMITTAL OATt
rA
OWNER" ME: PHOhlp: Jr CONTRA OR'SNA E: LIC NO:
_4111
TVJ ` N/C CONTROL#
•ARCHITECTAEll: L/NO. ADDRESS: 1 L / / ❑ I�ta�^
CO ACh: PH NE: BUILDING PERMIT INFO
/O 337 ❑ Consultant Fees Paid by Applicant(Initial) BLDG E v1.UM MECH
Al S—
I.ICENSEDCONTR-A ', DECLARA ION QTY. ELECTRIC PERMIT FEE
1 herby vain he,1.m Tlrmnsed ander o vi it s of Chapter 9 Qmmneneiag ]OB DESCRIPTION
aW0Z hSection W00)of Division 3 ofthe Business and Professions Coda and my licemcis RESIDENTIAL,
F�-�� ntfull home and effect. PERMIT ISSUANCii
rel— ❑SFDWL C3 KITCHEN REMODEL
aVZV
License Class Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
r IF<E Dae Convector
.'a,br�w ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT C]STRUCTURAL
OZZ-Z 1 understand my plans shall he used as public records ,�pyr��ODUICATION
yO UPT02MAMPS L1 INTERIOR �LJ CHIMNEY REPAIR
Licensed Professional 201-IOOOAMPS IMPROVE'M�E�NT�ta
w m a I hereby of irnt that
I am exempt front he Contractor's tr
License Law lot he OVER IIXO AMPS- ❑BATH RErvlygoyytEJs1I�E'IKdfNfy.ITION
GYyS CIE V following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL / ❑OTHER �+� �� /1 (�V U
t++
3"0 y which uyuims a permit to conswct•dash,improve,demolish,or uwif any mature
F_ -5 poor to its ismance,also requires me applicant fm such Permit o file a signed mm„ncmSPECIAL CIRCUIT/MISC. �. CITYUYCH I INU
} that he is licensed pursuant to the provisions of the Comment's License Law(Chapter9
GE (commencing with Seminn9IXNpnf Division Sof the Business and Professions Cod,)m TEMP.METER OR POLE INST. COMMERCIAL:
d 0.p that he is exempt therefrom and the hasis our the alleged exemption.Any vmImmm of Q&W BLDG/ADDITION ❑DEMOLITION
12 y Section 9031.5 by any applicantfor a permitmbjece,Ne applicant to a civil penaltyof POWER DEVICES ANT ❑FOOD SERVICE;
not mom hon five hundred dollars(5500).
IMPROVEMENT
y< �Lmowner night proTenY,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC
f..,� will do he work,and the structure is not intended cautioned for sale(See.]Ofl,IT.,,,1s ❑OTHER
and Prolescions Cade:The Contractors License Law does not apply to an owner of )UTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who it..,such work himself m through
.. his own employees,provided door such imprommrc int
ents aant ended or aRcred for NEW RESIDENTIAL ELECfR SQ FT.
sale.If,however the building or immiaso
proveent ld vindicate of. led.n.the SQ.FT.FLOOR AREA SIS3yPT.
er-builder will have the burden of Timing that he did not build m improve for put- [`7,
you,I sale.). 17
❑1,as owner of the property,am exclusively convecting wish ice contractors ro I v
comswe Ne project(Sec.]044,Business and Professions CalI:) ma 1,is Li-
censeLawdoesnotapplytoanownerofproperywhobuildsorimprosr,thereon,and QTY. PLUMBING PERMIT FEE
whoeondzeesfarsuch projects with.contractors)licensed p 1.at in the Contractor's
License l..w. PERMIT ISSUANCE.
El I undcr5 ,B&PC (his reason
rexc ALTER-DRAIN&VENT-WATER(EA) VALUATION
a WOR 'S C M1 PENSATION IIECLAB AT)ION BACK FLOW PROTECT.DEVICE `fes 6
I hereby afirnt under penally of perjury One of the following declarations: •7 VVV ��
.�l have and will maintain a Certificate ofConsenno.self-insure for Worker's Compem DRAINS-FLOOR,ROOF,AREA.COND' STORIES TYPE CONSTRUCTION
stolon,m provided for by Section 3910 of the Inbor Cale,for Ne performance of the ` �S
work for which Nix permit is issued. FIXTURES-PER TRAP SU
1 have and will mutation Worker's Compensation Insurance,as required by Section
39IX0ot he Lahr Code.fur he pert'......sof the work for which his permit is issued. GAS-EA.SYSTEM-(INC.4 OUTLETS OCC.GROUP AI'N
My Workers Compensation Insurance carrier and Policy number am:
Cartier: Policy N..:-- GAS-FA.SYSTEM OVER 4IEA)
CERTIFICATE OI'EXEMPTION FROM WORKERS' GREIISFIRMUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thowation nccdnat Istat lncA if the pcnnit is funmulnmdred dallua(Elllfq GREASP,'IRAP
or less.) PLANCHECK FEE
I Certify Nat in Ne performance of Ne work for which this permit is issued.lood SEWER-SANITARY-STORM EA.200 FT.
not employ any Teruo in any mmh
manner m as to become subject to e Workers'Comps.- ENERGY FEE
O z station Laws of California.Dae \ WATER HEATER WNENT/ELEC R
Q GRADING FEE
A,Ie m
N NOTICE TO APPLICANT:If,now,..king or,Certificate of Exemption,you should WATER SYSTEM/TREATING
become subject to Ne Workers Compcnmbon provisions of the Labor Cale,you must SOILS ME
{aA forthwith comply withxuch provisions or Nis penin ull be deemed revoked. WATER SERVICE
Q
z CONSTRUCTION LENDING AGENCY NEW RE5IDENTIAI.1'LMR. SQ.FT. PAID
out eceiptn
U� IM1crcby eftirm thm there isaconarvnion lending agency hr the perfonnunce of
f•" the work for which this pnmit is issued(Sec.309].Civ.CJ
Lk, Lenders Name TOTAL:
U Lenders Address JP
a 1 certify that I have read This a,,]ec tion and state that the above information is BUILD(
i5 5
M correct.l agree to comply with all city and county ordinances andsmte laws calming to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby anatomic tepresentativesof Nis city toenter upon the SEISM( F.
—0r2 IF
above,mentioned pmileny for inspection purposes. PERMIT ISSUANCE
(We)agrae to save.indemnify and keep hamlem the City of Cupertino against ELECTRI EEE
hidditicsjudgm ns,osts and axpcnac..which may in any way accme agmina sail City ALTER OR ADD TO MECH. PLUMBING I ��
in naequarm •granting of this permit.
APPLICANT IS DS AND WILL COMPL WITN All NON-POINT AIR HANDLING UNIT ITO Ih000 CFM) MECHANIC FEE
SOU' RF "ION. /W
_ � AIR HANDLING UNIT(OVER IO.000CFM) / CONSTRU NTAX
m ppm ✓ vac nr Date ESHAGS'1'I100D(W/DUCT) HOUSING MITIGA ON FEE
kIA RDOUS MATERIALS(DISCLOSURE
Will the applicant or future building ove.panutore or handle ha¢mdeas material HEATING UNIT CFO 100.000 BTU)
as defined by one Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Calor Scnion 25532(u)7 HEATING UNIT(OVER I(0,W0 BTU)
E]Yes Fl No VENTILATION FAN(SINGLE RESID) PAID Date ceiptM
Will Ne applicant or before budding oceupam use egaipmem or devices which BOILER-COMP(3HPOR 100,000BTID
emir harradme,air conmmlroome as defined by he Bay Area Air Quality Management TOT
Distria'f❑Ycs ❑Nn BOILER-COMP(OVER 100,000 BTU) L Oct e
l have read the hazmdcamtmrmmsrtqudc
unr Chzprcr 6.95 of the Cali- AIR CONDITIONER ISSUANCEfisD
uim
building
gHealth does&Safety Cade,Section 25505,25533 and 25534.1 to notify
that if the NEW RESIDENTIAL MECH. SQ.FT.
of the re dors not currently have a tenet.,hit.is my responsibility of a Ctatty hr notify Ne occupant
o[the myvimments which man To mm prior m isamnce of a CertiOeamuf Occupancy.
Owner.,aathsuiudagent Dat, L ISSUED BY: /
OFFICE /