31324 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING•ELECTRICAL PERMIT NO. 31324
N A1 3 L 4 q/� a
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING MECHANICAL 3
BUILDING PROJECT IDENTIFICATION
BUILDINGADFS: iOr SANITARY NO. APPLICATION SUBMITTAL DATI
S A/e p
OW F:R'S NAME: P ONE: C ACI R'S NAME' LIC?O
P 0 2s3-a2 W a`1 9Cg/ 6s NIC CONTROL#
ARCHII ECT/M GINNER: LIC NO: AO N"S:
Q N
FCONTACP. PHONE: - BUILDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ ❑
y affirm that I am licensed under provisions of Chapter 9(commencing 1 ESCRIPTION
WB.f`Division 3oftue Business and Professions Codgondmy license i.s if'fedd effect. PERMIT ISSUANCE D�V ' Lie.N ❑KITCHEN REMODEL
s / Conwemr APPLIANCE -RESIDENTIAL
[]ADDITION ❑PLUMBING kGPIPE
ARCHITECTS DECLA Al'ION PANELS
f- res Iunderstandm lana shall be used as blit records ❑MDLTI-UNIT ❑STRUCTURAL.
Z OI�,�j- YP public MODIFICATION
OZ-� UPT020"AMPS ❑INTERIOR (_1 CHIMNEY REPAIR
1`, Licensed Professional 201-1"AMPS - IMPROVEMENT
OWNER-BUILDER DECLARATION
yy W 6 1 herby a1Brm tum 1 am exempt from the Contractors License Law for the OVER IM)AMPS C BATH REMODEVREPAIR C DEMOLITION
iq 3 6 F following reason.(Section 7031.3,Business and Professions Code:Any city or county SIGNS ELECTRICAL. COTHER _ —g
fi{ed1
MOOG w which requires a permit to conauun,alta,improve,demolish.or repair any structure .f
primo its ismanc p.ho requires theapplicam forsuch permit,,fileusignalstmemem SPECIAL CIRCUIT/MISC,
p�jtuet he is licensedpursuanrtn theprovisionsti the Contractor's License Lao,(Chapters)
O (commencing with Section71100)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. -
6 y o y that he is exempt therefrom and the basis for the alleged exemption.Any violation of C NEW BLDG/ADDITION C DEMOLITION
LLXl^'Wy Section 7031.5 byuny applicant foto permit subjects the applicom too civil penalty of 1'OWF;k DEVICES CTENpNT ❑FOOD SERVICE
not mane than five hundred dollars($500).
O ❑1,uowner ofrhe property,or my employers withwager ns their snkcompenmtion, SWIMMING POOL.ELECT RIC IMPROVEMENT
will do the work,and the slrvcmk is not imeaded m offered for sale(Set.7044,Business COTTER
and Professions Cade:The Contracnsrs License Law does not apply to an owner of OUTLETS-SWL'raim-FIXTURES
property who builds or improves thereon and who does such work himself or through
his own employees,provided that such improvements ere not intended or offered for NEW RESIDENTIAL FLEC11 SQ PP.
sale.If,howevcr.the builiingorimproverrant is sold within one yearof completion,the SQ.FT.FLOOR AREA $ISQ.
owner-builder will have the burden of proving that he did not build in improve for pur-
pose of sale.).
(D 1,as owner of the propcny.am exclusively contracting with licensed contractors to TOTAL ,41 PAID
conserver the pmjert(Sec.70,14,Business and Professions CWI:)The Contactors Li-
censeLawdoesnmapplytoanownerof property who huilds or impmvesthereon,und QTY. PLUMBING PERMIT FEF.
whocontracts forsuch projects with nmtnraaor(s)licensedpurxuanuothe Conwemrs ` OCTg [�t.1 J(I(��
License law. PERMIT ISSUANCE ��i o �
C lam exempt under Sec. ,B&PC forthis reason
Owner Date ALTER-DRAIN&VENT-WATER(EA) Gil Y V ATI CF
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO'IECT.DEVICE
I hereby arrive under penalty of pe jury one of the following declarations:
I have mW will maintain a Certificate of Consent o self-insum for Workers Cornim- DRAINS-PIADR,RODE AREA,COND. STORKS TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Latssr Code,for the performerve of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation lnsumnce,as required by Section
37M of the Labor Code.for the performance of the work for which this permit is issued GAS-EA.S YSTEM.I INC.4 OUTLETS �,u OCC.GROUP APN
My Warkerk und P
Com cnsahon mote artier olicy no -
Carriee Policy N..: � Q_ y� GAS-EA.SYSTEM-OVER 4(EA)
C tkfIFICATE OF HXEMI'DON FROM WORKER
COMPENSATION INSURANCE GRl,ASFJINDUS'IBL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be completed if the permit is for one hundred dollars(SI W)
or less) GREASETRAP PLANCHECK FCC
Loy any Phut in they my
nrof as he
Isskfot t to the Wisissueal aaaph_hot] SEWER-SANITARY-STORM EA.210 FT.
not employ any person in any manner so es m become subjecto the Warkeri Compen- ENERGY FEE
,Z ration Lows of California.Dore
C) Applicant WATER HEATER WNF.NT/f;1.L'CTR GRADING FEE
y
NOTICE TT)APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMIREATING
abecome subject to the Workces Compensation previsions of the Labor Code,you must SOILS HIS
UJ forthwith comply with such provisions arthis permit 0all W deemed revoked. WATER SERVICE
.0.7. Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.PT. PAID
UO l hereby offireuhat there is a construction lending agency lite the pfformonce of Data Receipt#
4. F the work On which this permit is issued(See 3097,Cie C.)
O U Lenders Name O TOTAL:
W Limner's Address TOTAL:
g>y I ramify that I have mad this application tad tome that the meet,information is BUILDING FEE
y7 torten.L agree m comply with all city and county ordinances and state laws relining to QTY. MECHANICAL PERMIT FEE
U G res
building construction.and hereby authorize representatives of this city wm
cnr upon the SEISMIC FEE
shove-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and kap harmless the City of Cupertino against ELF.CfRIC FEE O
liabilities,judgments,costs and expenses which may in anyway accme against said City ALl'ER ON ADD TO MIiCH.
inconsequence of the granting of this permit. PLUMBING FEB
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON- INT AIR HANDLING UNIT LTO 10,1X10 CFM) MECHANICAL PER
SOURCER A ONS /D
AIR HANDLING UNIT 10,(X0 CFM) CONSTRUCTIONTAX
Sig are of pplicun Commetor, IAte EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDDU 1ATFj IAI.S ISCLOSURIi
Will the applicant or future building accupant store or handle hazardous materiel HEATING UNIT(TO 100/000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
CWe,Section 25532(u)7 HEATING ON IT(OVER 1DOOR)BTU)
C Yes []No VENTILATION FAN(SINGLE RESID) PAID
Date - Receipt M
Will the applicant itcnor..tura building by the nt Bay
eea Air unt or deviceswhich
BOILER-COMP(3HP OR 100,(X0 BTU)
emit ice?Innuendoes air contaminenu as def mrd by the Bay Area Air Quality Management TOTAL:
District?
❑Yee F-1 No BOILER-COMP OV BR 100.000 BTU)
I have read the hazardous manrials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE /mss
fornia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECIL SQ.FT.
Wilding does not currently have a tenant,that it is my reslnmibility to notify me Occupant
of the requirements which most W mm prior to issuance of u Cemifcme of Diu,upancy,
Owneror authorized agent Dart TOTAL: ISSUED BY:
OFFICE