31366 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I IBUILDING-ELECTRICAL. PERMITNIO ^.a
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 311 �{J{6 hV
BUILDING PROJECT IDENTIFICATION
+ BUILDINGADDRESS: - SANITARY NO. APPLICATION SUUBBMMITTAAL DATE
a 038 C GZ ( h^ E o'KJ�W
OWrtB''5 NAME: PHONE: CIINTR CTOR'S NAk1E: LIC NO:
X10 path IJ til " 5� N/C CONTROL#
1RCNITECf/ENGINEER: Y\ LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant FeesPaid Applicant(Initial) BLDG ELE PLUMB MECH
1-�oo��L 1���. 1800-Q ❑ � ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm Not I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Qa'Z thSection]000)ofDiviaidn3dfNe tlusiness end Professiore Cade.aril my license is RESIDENTIAL:
OO n1cutdree and cR ` PERMIT ISSUANCE
WFWUZF: Licersse Class d his# ( 0SEDWI. ❑KITCHEN REMODEL
N6 Do Colo. APPLIANCES-Rf:SIDENTIAL ❑ADDITION •0 PLUMBING RE-PIPE
> ARCHITECT-b DECLARATION PANE" ❑MULTI-UNIT ❑STRUCTURAL
Z O rgs❑ 1 undeismnd my plops shall be used as .hire rewords ^ MODIFICATION
OZ4 UPT02WAMPS fill [_1 INTERIOR El CHIMNEY REPAIR
Fit, Licensed Professional 201-1000AMPS IMPROVEMENT C
OWNER-BUILDER DECLARATION OVER 1000 AMPS O BATH REMODEDREPAIR DEMOLITION
yy 1 hereby affirm that 1 um exempt from the Contractors License Law for too
X 6 U following reason.(Section 7031.5,Business and Professions Code:Any city or countySIGNS ELECTRICAL ,OOTHE`R A
LLLL77 LLO which regains a gamut to conswet,alma improve,demolish.or repair anY sweturt ��E..t6�
pd.,in issuaned,alsa requirestheaplassnt far such permit to Meusigmd statement PECIAL CIRCUIT/MISC. -
} (com mingudpursti.n7 N)pfDisiorsoftf Conwnofs Liceme sion Chepter9 COMMERCIAL,
Op (comeisexe exempt
andth U osis or ofNleged exsendon,Anyavi Code)of TEMP.METER OR POLF.INST.
W`i0.5
Mao Section 7031,5 1,any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
1F...Zp. not more than five hundred dollars S50H 'IMPROVEMENT
CLQ 01,as owner ofthe property,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC
d2d2'' will dothe work,and the structure is not intended or offered for sale(Sec.7044,Business ❑OTHER
a 3 and Profexeimta Code:The Crundenta License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ ET
sale.TL however,the building or improvement is sold within one yearofcompletidn,the SQOR AREA LSQ.PT.
owner-builder will have the IwNen of paving that he did not build or improve for put. P� B
pose of are.).
0 I,as owner of the progeny,am exclusively connecting with licensed contructnrs a, TOTAL: ��
construct the project(gee.7r'134.Business and Professinm Code,The Camractar's Li- 8 199C
cense Lawdoes not apply it)an owerofpmpeny,whobuilds orimpaves thurmt,and QTY. PLUMBING PERMIT
who contractsforsuch Projects will,o contractors)licensed pursuant m an
the Commander;
' {�
License Lew, PERMIT ISSUANCE V�
O lamexempamal Stt. ,B&PCfor Nis.. Uf"try J)ry
ALTER-DRAIN&VENT-WATER E i) VALUATION
Ower Dme
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby afford under penalty of perjury one of the following declarations:
❑Ihave endwill meimainu Cenifcumdf GmsennosdGinsure fpr Worker's Compen- DRAINS-FLOOR ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
salon,m provided for by Section 3700 of the Labor Code,for the performance of the 9
work for which this permit is issued. FIXTURES-PER TRAP
0 I have and will maintain Worker's Compensation Insurance,as required by Section
3/00of Ne Labor Cade the pelf ormareedI the worky for which this permit is is sued. GAS-EA.SYSTIi IINC.4 OUTLETS OCGGROUP APN
My Wholdies Cm t asumree ramer yq "eq
Caries Puh A7— a� .o� GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF F.XEMPTIOM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not ed completed ifthe Permit is for one hundred dollars($100)or lees.) GREASE TRAP PLANCHECK FEE
I artily that in in,performance of the work for which Nis permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner sa as m become subject to the Workers Compete ENERGY FEE
0 z setion Lows of California.Date WATER HEATER WNENTMLECfR GRADING FEE
Z Applicant
arA NOTICE TO APPLICANT.IL aver nuking this Cenificau of Exemption,you should WATER SYSTES17REATING
[' become abjecno the Worker's Compensation provisions of the Labor Code,yon must SOILS FEE
G fnthwithromply with such provi...wca phis penid,liml he deemed revoked. WATER SERVICE
G Q
�) z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID Data Receipt#
V 0 Ihereby union that in a construction lending agency for the performance of
the work for which this pewit is issued(Sec.309].Civ.CJ
OL)IEg.
--' Unites Name TOTAL:
lender's Adders - TOTAL:
W0.
pit
[r I certify that I have read this application end star.that the eMve information Is BUILDING FEE
to career.l agree to comply with all city and county ordinances and state laws adding to QTY. MECIIANICALPERMIT FEE
V building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-orphaned property for in imerion pumoses. PERMIT ISSUANCE
tia—
(We)agree to save,indemnify and keep handless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accae against said City ALTERORADDTOMECH.
in ronsequence of the granting of this pewit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOU CE REGULATIONS. ,S
��JJ(I'.���]] a AIR HANDLING UNTT(OVER Ig11fl(1 CFM) CONSTRUCTION TAX
Sigva�iZart/C'ommcar Date EXHAUSTHOODONMUC i HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle luxurious material HEATING UNIT TO 100,000 BTU)
as defned by the Cupertino Municipal Code,Chapter 9.12.and Ne Health and Safety
Cade,Section 25532(e)? HEATING UNIT(OVER 100,000 BTU)
❑Vas CNo VENTILATION PAN(S INGLE RES RH PAIS
Dem , RccelptN
Will the applicant mon,a future building der the Bayuea Air nt or uality vinagemwhich
nt BOILER-COMP OHP OR 10a"BTU)
emit ict? ave air comaminanta as defined by the Bay Area Air Quality Management
Distrix? I - t
❑Yes ON. BOILER-COME(OVER I00,IXNI BTU)
Ihave mad the harradous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCEDATE
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET.
budding does not currently hove a unarm.that it is my responsibility m noify the dccup rd
of the requirements which must be mel prior to issuance of a Certificate of Occupancy. �us
Camerarauthorizedagent Dam TOTAL: ISSUED BY:
OFFICE