31263 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECI'RICAI, PERMR NO.
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL 31263
BLITZING PROJECT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATI
3g ��irVEt�1
9WNSR'SNAME: ak PHONE: RACTOR'S NAME: LIC NO
NIC " CONTROL#
ASN Nt - ems— O 51 -
ARCHITECDhcoUll :ER: LIC NO: - ADDRESS: - •❑
CONTACT. - PHONE: BUILDING PERMIT INFO
pp
El Consultant Pecs Paid by Applicant(Initial) BLDG ELECT PLUMB ' MECH
W W.AQy'1. C, ❑ I� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY 'ELECTRIC PERMIT FEE
1 hemby affirm that 1 an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�'Z wish Senian]tXNry of Division3of the Business and Professions Cade,unJ mylicenu
RESIDENTIAL;
to
in full torment effect, PERMIT ISSUANCE .�.k
LL7 V ❑SFDWL ❑KITCHEN REMODEL
1�g..V�j License Class ial
Dan- APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE.PIPE
6
V)6 _ CContactor
�oe ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCNRAL
PANELS
1 understand my plans shall he used as'ImMic roods - MODIFICATION
0z . . UPT02DOAMPS ❑INTERIOR [I CHIMNEY REPAIR
9:4Hq...p Licensed Peofasmand - 201-1000AMPS IMPROVEMENT
SyX OWNER-BUILDER DECLARATION OVER IIXp AMPS DEATH REMODEUREPAIR [I DEMOLITION
yy�d RR'•66'' 1 hereby affirm that I am exempt tram the Comrselors License Law for the
WaMU following mason(Section]031.5.Bmmmamd Professions Code:Any city recomy SIGNS ELECTRICAL ❑OTHER l'
47 OFa which requires a pemit to construct,alter,improve,demolish,or repair any stmeturc PAV -K
�N.i prior mib issuance.also requiresahe applicant for such pcmit so fileusigned statement SPECIAL CIRCUIT/MISC. is e-&M S
!1} tbatheislicensedpunuammtheprovisinnsof Ne Conlmcmr's Licenm Taw(Chapter9 Q
p�apo (commencing with Section 7")of Division 3 of Ne Business and Professions Code)or TEME METER OR POLE TMST. COMMERCIAL
I1. e¢ mat he is exempt therefrom and the basis for tete alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ts, Section1011, yypp
1 banapplicant fora pemitsuemis the applicant w u civil peralry of POWER DEVICES
ny ❑TENANT ❑FOODSERVICE
not more than five hundred Dollars 15508. - ' IMPROVEMENT
Q
L3 1.as owner ofthe property,or my employees with wages as their vele compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not interdcA cr-offered for mile(Sm.71144.Business O ❑OTHER
nd
aProlamines Code:The Cmarmmer rs Lt..Low does not apply to an ownof OUTLETS-SWITCHES-FIXTURES .
p' property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or Offered for NEW RESIDENTIAL ELECTR SQ ET.
,.It.IL however,the building or imprwcaval is sold within meyem ofeampletion,the SQ.FL FLOOR AREA $(SQ.FT. '
ftuner-builder will have the burden of proving that be did not build or improve for or-
aseofaale,. p p' I D
❑1,m owner of the property,am exclusively convecting with licensed contractors to TOTAL'
bill
ommu the project(Sec.7044,Business it Pmfessinns Code:)The Conuacmrs Li-
sense Law does nal apply toanowneradproparty who builds or improves thereon,and QTY PLUMBING PERMIT FEE OCT who caramels for such projects with a contactors)licensed pursuant to the Contractor's _
License Low. PERMIT ISSUANCE
❑1 am esempt under Sec. •B&P C for this reason
Owner Dam ALTER-DRAIN&VENT-WATER(EA) CITY (JIiA
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
I hereby affirm under Penalty of perjury one of the following decimations:
❑I have and will mainudn aCerdBcateof Cometh to self-insure Tar Workers Compcn. DRAINS-FLOOR.ROOK AREA,COND. STORIES TYPE CONSTRUCfIOF
salon,m provided for by Section 3700 of the Labor Cade,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section -
37MoftheLabor Came,for the pcommance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My WorkS�ffgqCCgqmppff�gtts(� n Insurance carrier and Policy number am:
Certiev�a.Al. Policy No.: GAS-EA.SYSTEM-OVER 4IFA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRBASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section neeJnm be,completed ifthe permit is faros hundred dollars($Its)) GREASE TRAP '
or leis.) PLANCHECK FEE
Iem i"mm0s,perf.rumofthe work forwhich this permit is ism.ext,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject m the Workers'Comper- ENERGY FEE
Oz wobn laws of California.Date WATER HEATER WNENT/ELECI'IT
Q Applicant GRADING FEE
y NOTICE TO APPLICANT:If.after making this Cerifmatc of Exemption,you should WATER SYSTEM/TREATING
F became subject to the Workers Compensation Provisions of the Labor Code,you must SOILS FEE
en
forthwith comply with such previsions or this Permit shall be domed revoked. WATER SERVICE
Q
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Ff. 'PAID . Date ftoeipt#
LJ I far which thi thin thereis.
sued( eematuration len Jing agencyforthe performance of
the week Tar which mit perch is issued(Sat.3097,civ.C.)
C)I" Lenders Name TOTAL:
ltULT I<nder1 Address - TOTAL BUILDING FEE 1 certify that I have reed this application and state that the above information is
9h correct.l agree to comply with all city and county mdmunces and stale laws relating to QTY. MECHANICAL PERMIT FEE -
U building convection.and hereby authome mpresenaaives of Nis city to enter upon the SEISMIC FEE
above-mentioned property for mammon purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way memo against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO Mind CFM) MECHANICAL FEE
SOURCE REGULATIONS.
• AIR HANDLING UNIT(OVER 110,010 CFM) CONSTRUCTfONTAX
Signature o'ApplicanUConuacmr Date EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplieant or future building escapism stem or handle harnesses material HEATING UNIT(TO 100,1100 BTU)
as defirmd by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532mU HEATING UNIT(OVER 100,00)BTU) '
Yes ❑NO VENTILATION FAN(SINGLE RFSID) PAID
Date Receipt#
Will the applicant or furore building occupant use equipment or devices which ppILERCOMPI3HP OR 1W0p BTII) _
emit humanities co
nous air as d - ,
defined by the Boy Ama Air Quality Management s TOTAL:
-1Oistrict^ BOILER-COMPIOVER 100,000 BTU)
p Yes FJ No
I have mad Ne hav rdous materials sequirem et,anchor Chapter 6.95 of Ne Cali- AIR CONDITIONER ISSUANCE DATE
forma H.IN&Sefny Code,Sections 25505,25533 and 25534.I.Mdc M that if the NEW RESIDENTIAL MECH. SQ.FE
building does rot currendy have a tenant,that it is my responsibility to nudfy erre accupont
of the mquimmenu which must ba met prim to issuance of a Certificate of Occupancy.
Owner or uuthorittJ agent Date TOTAL: ISSUED BY:
OFFICE