31296 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 31296
BUILDING PROJECT IDERTFICATION
BUILDINGADDRESS: 16 /t_- rSANITARY NO. APPLICATION
SUSUBMITTAL DATE ocyWGn CAJ 14-
OWNER S
NAME PHONE: q(/`,_ CO H)
CR'S NAME LIC NO',
5 r NIC COMROhN
ANCIIITIiLT/ENGINECR'. LIC NO: ADDRESS
AyW ❑
SS
CONTACT: •T jj tt, „�ry - PHONE: �> BUILDING PERMIT INFO
�oOJ �a�C.a�`{J71 o�7-r/J�� ❑ Consultant Feet Paid by Appli"alt(IrUdIrD HLUG ELECT PLUMB MECH
Q�T ❑ ❑ ❑
LICENSED CONTRACTOR DECLARATION QTY ELECTRIC PERMIT FEE
1 neasby danthat at 1 am Heen.m mulct Irn
ovi,ioof Chapter 9 Nenmm
aem ns JOB DESCRIPTION
WOO wiNSecton7")oNDivision 3 oftu Business std professions Cade,and my licimsea RESIDENTIAL
F�� full fonceand effect. PERMIT ISSUANCE
jut Ijcense Clev Ijc.0 ❑SFDWI. El KITCHEN REMODEL
NQS IAte Cmlmam APPLIANCES-RLSIDFFIAL []ADDITION El PLUMBING RE-PIPE
a' ARCI I I'rCCPS DECLARATION� ❑MUI.ThUNIT ❑STRUCTURAL h
Z,p n Z 1 ummJeruanJ my plem shell M uu.PublicsedPublicm
ic coNs PANELS MODIFICATION
OZ—o UP TO 200 AMPS ❑INTERIOR CHIMNEY REPAIR
Licenucl Pmfeuimel AH-10MAMPS IMPROVEMENT P
OWNER-BUILDER DECLARATION
C6 I bereby eR ftut l am exempt from Hoc Co..,&,Licehue w lara ILK OVER IUUOAMPS [IIIR
BATH REMODEEPAIR ❑DEMOLITION
�OaU fdlowipg reasan.(Savm]OJIS,Nu.irnv eN Rvfcssi«u Code:Any acoumy TRI
SIGNS ELECCAL [I OTHERslaish
tiny
prim to liPermit
ts issvavee,dsofeca rtl fileapplicant for ,alemi foriuch pvrrim to filee.ie«da met SPECIALORCUITIMISC.
fly that he is licemed puna ,to the provisions ofthe Contmctots License Law hao,er9
N,1 L (commencing with Section 7")of Division 3 ofthe Businav uul profeuim,Cock)or TEMP.METER OR POLE ST COMMERCIAL'
d nC 'ha be,is exempt therefrom end iM basis for the alleged exemphiun.Any viulatihm of ❑NE BLIX✓ADDITION [I DEMOLITION
M y Seelion 9031.5 by any apps-am for a Permit vuhjens the applicant or a civil penally of POWER DEVICES
m more dant five hmdnvl dollar,(SNNO. ❑TFAANT El FOOD SL'RVICE
I-�6 I,as owner of the propenY.hr,my empinym with xagomNcir ante cnmlrn him. SWIMMING I.ELECTRIC IMPROVEMENT
pW will ohttewat.Code:The
Cemis har'A iceerse Use
se do fi act
apply
to an Buniws ❑OT '
LL1—� art)eny I,a,b Code:The Cmtresvem."al Lewdm hwtapplytolf owner of Of1T1.E SWITCHES-FlXlURES
d 3— ptoPenr who bwld,m imptrvea ttemon,and also Docs s«h wort,led o r or through
Ns ram oweverme pr l,mi,tan such mens is said
arc not iyecMeJ m uffueJ fa NE hSIDF1lTA1.EIDCfR SQ
aale.If.hoxew,111hatee tioF«imlof xilim issoW Will.ain riete
build rimprovetfier the SU FT.FLOOR ARTA ESQ.FT.
pwon-budder will Wee the buNrn of graving tont he did rm build«impvve f«par-
neufnleJ. P A O
❑ L u nwnm of the grprny,acn exclusively nntneung with licen.cl antrslon m TOTAL
n,tmn the project(Sec.7IN4.Business,mxl Pmfeumima CNet)The Cmlmcmr's Li-
seLaw ciao not applyit)an owner of progeny who builds or lmpnrvav themm,and QTy. PLUMBING PERMIT FEE m y$p
whocmtreds forsuch pumiceswith aenmmcor(s)Ila:mal pursuant to the Contractor's DECRLU
License law. PERMIT ISSUANCE DEC
Ism exempt mde m Fe ,B&P C for rut hewn
Owner Due ALTER-DRAIN&VENT-WATER(EA) VI j VI VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
IWreby df ander perWly ofpenjury ave of the following deelararima: - ®Q
❑ IWveandwillnainWna Ceniftr dCrnsmtmm0-immmfm Workets Cr - DRAINS-FLOOR.ROOF.AREA.COND.
sarin,as pn idW fir by Section Ohl)of the Leber Code,for the perfmmurmce M the STORI[S TYPE CONSTRUCTION
ark for which this pun0t Is Isuncd. FTXTURES-PER TRAP
PJ 1 have aN will maintain Wader's Coro,maminn Insumnee.n rryuued by Section
37Mofthe Lahr Gds,f«the paAmnaceofhhc wont forwbich this perom ie kocacd. GAS-1A.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Wal 'n ohnPenseuon lnsumncc vnicranJ Pollcynyn�bcy 1-y,.
Canicr: A��Y Po ,Nn.: NWr' N.'1 J3 /d� GAS-KA.SYSTEM-OVER 4(GA)
CERT T EXEMPTION FROM WORKERS' 1
COMPENSATION INSURANCE $pp. II /YY GREASEIINDUSILWASTE 'RCEPTOR
Mins 4etioa hese rot be eompletel if tone pcmro is f«arc hmtJrtd dollen(SIM) BUILDING DIVISION FEES
car leo,) GREASETRAP PLANCHECK FEE
1 certify tut in the pmf«mnce of to work f newhich this pmdt is iaWGI.I stall
rot employ any person in any numter sr u on become subject to the Wortm'Compem SEW ER-SANITARY TORM FA.200 FT. ENERGY FEE
Q Z salon Lai California Dec WATER HFATF NEN`NELECTR
Z2 Applicant GRADING FEE
y
NO HCH TO APPLICANT.If,after making this Certf m of Exemption,you should WATER SY EATING
abecome subject to the Worker's Compemmim Provisions of the falwx Chale,you most SOLI S TEE
Lnthwitb comply with such proviaiuma or this permit dull M dermal resmod WATE- .ERVICF.
CONSTRUCT ins onear.ENDINGAGENCy N RF_SIUIiNfIAL PLFIB. 5
ION PAID
V Q Ihembyaff mo.a tort isacol(Sec.(N7.Cing agency fan the lcrGxnuna of Q�PC Receipt
N
C) thcwmt f«uitich this permit is ivwW(Sec.J09].Ci,C)
Q ImdeYa Name TOTAL
r feNetAddress TOTAL
I
F y ttnify tan 1 have rtwd prim epplieuion end sole then the shove infwnutioe is BUILDING FFE
A ectrect lagfce to canply with all cby am muoy ordinuea aN sure has misting to QTY_ MECHANICAL PERMIT FEE
V Z holding anuronim end hereby authorise repaesemu0vn ofhhis city to cnur upon the SEISMIC FEE
ebow mrnhi«tW pmpmy for in,ptYlion Purposes, PERMITISSUANCE
(We)agree m save,indemnify moil keep hmmkss the City of C.,moo against ELECTRIC FEE
Iwhili esjudgment,cues and expemcs which may in any way accrue aguins sold City ALTER OR ADD TO MECH. PLUMBING IPE
in con".,oce of Joe gr,-anfmg m this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO IL"CFM)
SOURCE REG(1LATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.M0 CF CONSTRUCIIONTAX
SignaNheof AppbscumUC teeter Date EXHAUSTHOOD(WOUCT) HOUSING MfrIGAT10N FFE
IV.7ARDOUS MATERIALS DISCLOSURE
Will the epplinm ce fwum building occupam sore or hark hnwAws msaml HEATING UNIT(TO 100,0008
an rle(wl by the Cu em o Munleipd Cute,Cbaptu 9.12and the Health aN Safny
Code,Smian 25532fa)] HEATING UNIT OVER 1 0
AB"fID
�Yn ItR1r
I� VENTILATION PAN( GLE RESIT) PAID hale Receipt N
N911 the applkom«omrc building ache Bi use At.
cut or fit,Mu n which
snit WrnNrus air rrntamihanl.as JefneA by the Play Arran Av Quvliry Mawgcncnt HOILL'R-COM E' POR 100.000 BTU)
Uistrinl TOTAL:
❑Yn �Na BOILER-C P(OVER IW,q)B BTU)
I have mad the hammed«u memo Eats narmimmvs under Chapter 6.95 d the Cali- AIR LO m0,N'ER ISSUANCE DATE
forma Health&Safety Code.Section,25505.25533 aN V 5Nf.I wderauoJ 1W1 if the
buiWingd«s.cannmaly have al<nanl.the it is my nes ramiNlitylo noify theoccupwu NE ESIHFNIIAL MECH. SQ.PT.
ofte whcbeal
=r iuwrce o(a CatF.,,•MOcape«y.
(Furcraauthodnd gen Date r TOTAL:
ISSUED BY:
OFFICE