S 4311 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL. S 4311
IIt II1,DIN(,.i'RO3F.LT II11tNTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNeERuu'$$N~~^^AME: ONE: ` CO ACTOR'S NAM': LIC NO.
ARCHITECT/E,N`G,INF.E -. LIC NO: V gDORBS :c� \�C�\'` !;%
% �` 7 O N/C CONTROL#
" A red �� ❑
CONTACT, PHUNIc BUILDING PERMIT INFO
VciN Lot3_�� q in E] Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ECH
❑ ❑ "❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QOZ with Section 7000)ofDivision 3ofthe Business and Professions Code,and my license is RESIDENTIAL:
F 4 in Nil force and efiec O PERMIT ISSUANCE
0ADWL OKITCHEN REMODEL
Q U U License Class Lic.N
irtQy Dated meq--Comments APPLIANCCS-RESIDENTIAL ❑ADDRION ❑PLUMBING RE-PIPE
'� �� `ARfHITECTSDECI.AR TION ❑ IT []STRUCTURALMULTI-UNSTRUCTURAL
PANELS
zoo✓r Z 1 understand my plans shall be used as public records MODIFICATION
OZ^� UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
F.4.t; Licensed Professional 201-1000AMPS IMPROVEMENT GSWIMMING POOLS
�+1F OWNER-BUILDERDECLARATIONCe Conte ON OVI:RIW AMPS O BATH REMODEUREPAIR 0DEMOLITION
C C� 1 hereby affirm that I am exempt from the Contractors License Law for the
'nK'3eV follmwing reason.(section703--5,Business and Professions Code:Any city or county SIGNS IiLECI'RICAL OOTHER
LL LL which requires a petmit to construct,.Iter,improve,demolish,or rcpaif any structure
0 prior to its issuance,also requires the applicant for such Permit o file asignednatement SPECIAL CIRCUIT'/M.
E;!I} that he is licensed pursuant to the Provisions of the Commim's license Law(Chapter 9
(commencing with Section 71#10)of Division 3 of the Business and professions Code)or TEMP.METER OR PO14*1 COMMERCIAL:
X m that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
LL--y Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES 0TENANT ❑FOOD SERVICE
F Z as not more than five hundred dollars($5006
SpE]1.as owner ofthe property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
$aF ❑OTHER
will Mine weak,and thenruute istintcndedmeffercd forsale(See 7044.Business
nno
Irl ro and Professions Code:The Contractors;License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who dors such work himself or through
his own employees,provided that such improvements art at intended or oflercd for NEW RESIDENTIAL ELEC R SQ ET.
sale.If.however,the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA VSQ.FT.
ncr-builder will have the burden of passing that he did not build or improve for par.
pose of sale.).
0 1,as..or of the property,em exclusively contracting with licensed contractors to TOTAL:
c9nswm the project(Sec.744.Business and Professions Cak:)The Comrucrors Li-
cease law does not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a conuamat(s)lio nscd pursuant tothe Contractors
License law. PERMIT ISSUANCE Q
0 I am exempt under Sec. ,B&P C for this mason
Owner Dae ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby aRnn under penalty of perjury one of the following decimations:
❑l have and will maintain a Certificate of Consent to self-insure for Workers Compen. DRAINS-FLOOR,ROOK AREA,COND.
.tion,as provided far by Section 37M of the Labor Code,fm the performance of the STORIES TVPE CONSTRUCTION
week for which this permit is issued. FIXTURE-1'FR TRAP
0 1 have and will maintain Workers Compensation Insurance,as requited by Section
3700ufthe Labor Cale.forthe performance ofthe work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLET'S OCC,GROUP APN
My Workers Compensation Insurance carrier and Polity number art:
Carrier. Policy No.: GAS-EA.SYSTEM-OVER 4 H;A)
CERTIFICATE OFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(This section need not be completed if the permit is Enron hundred dollars($100) BURRING DIVISION FEES
or les") GREASE TRAP PIANCHECK FEE
I certify rho in Ne peefurtnance afthe work fmrwhich this peemit is issuedlshall SEWER-SANITARY-STORM EA.201 FT.
not employ y n in any manner so as ro hccume subject m the Workers'Compcn- ENERG E
zZ action Laws ofmiaDa WATER HEATER WNENTIELECTR
0 Applicant -MCL:— 4+- l' GRADE E
y NOTICE TO APPLICANT:If,after linking thilyarrificason of Exemption,you should WATER SYSTEM(IREATING
a ; become subject to the Workers Compensation provisions of the Labor Cede,you must SOILS
r forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE
a
CONSTRUCTION LENDING AGENCY NEW RE5IDEN TAL PLM. SQ.ET. PAID JulJ
V Q l herebyaffrmthvuhere isite norwriun bndiagagency Emile pcdnrrainotof Date ec Ipt
GLs Hthe work for which this permit is issued(Sec.3007,Civ,C.)
Lender's Name TOTAL:
Lender, ddres
's As
W
T
1 certify that 1 have read this application and score that the above information is BUILD
tFi V) correct l agree mems with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
V Z building emexamcticn,and hereby authorize represemmives of this city to eructation the SEISMIC HE
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep hcrmlcssthe City of CuNrinn against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accme against said City AITERORADDTOMECH.
in consequence of the graining of this permit. PLUMBING FEB
APPLICANT VNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,010 CFM)
SOURCE REG IL TIONS. I� 1� [� fff•••���111 MECHANICAL FE
��fl Ilay,.1' ,-'� —k NA AIR HANDLING UNI"f(OVfiR 10,0(IIICFM) CONSTRUCf10NTAX
Signature ofCCAApppllicicunUConwcctror�-yt-_"YY Dwc \ HXHAUSTIIO0D(W/IIUCT) HOUSING MITIGATIO FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingeccupvnt,tare or handle h...oh animemil HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? IH3A'I'INC,UNIT(OVER 100,000 B'rU)
O Yes 0No VENTILATION PAN(SINGLE RESIT) PAID
Data Receipt#
Will the applicant or tutors building occupant use equipment or devices which BOILER-COMP(3HPOR I(X),00013TU)
emit hazardous air cnntaminanls es defined by the tluy Arca Air Quality Management OT
District?
GYes ON. BOILER-COM P(OVER IIN1,1X10 RTU)
I have read the hncommsmatc,Wareulrementa under Chapter 6,95 of the Cull- AIR CONDITIONERy p I$SUADATE /k
fomia Health&Safety Code,Sections 25505,25537 and 25534.1 m dromad that If the NEW RESIDENT Al.MECH. SQ.FT. (/�/ 7
bnildingdore vohichan vevtennm,thol it is ny responsibility notify lho nccupnm i
oRhc rcquircm t..licit muxt le,met 'nmist 'teofaC nifcncu
Owner car amhorized agent Mute TOEAL: ISSUED BY:
OFFICE