31422 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
4BUILDING
TY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 31422
BUILDING PROJECT IUENTIFICA'1'ION
LDINGADURESS: SANITARY NO. APPLICATION SUBMITTAL DATE
22�� MAJesTic qAM WAY
Wys$S NgME: SM I� PHONE: CONTRACTOR'S NAME: LIC NO:
>t1Tlfd`/✓I& 55IIAI4
NIC CONTROL Or
ARC ? W EEV._H?_ iADDRESS:
vS VgZ'
CONTACT.
PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED that II am ON licensed
under
provisions of CON QTY F.LBCTRIC PERMIT FEE
QWZI hemhy anion Nm I am licensed under provisions.f Chapter 9(commencing JOB DESCRIP ION
won with Section 7000)of Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL:
WOO PERMIT ISSUANCE
s W F in fun force and effect. ❑SFDwL CHFN REMODEL
dUV License Class Lic.N APPLIANCES-RESIDENTIAL'
i <i Date Contmctor ❑ADDITION PLUMBIURAL PE
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL'
F D ret PANF.1,5
Z O v�Z I unJemanJ my plain shall he used as public arrnJs MODIFICATION
07,—p UPT0200AMPS
[I INTERIOR OCHIMNEY REPAIR
W Licensed Professional 201-IOW AMPS MPROVE ENT
www OWNER-BUILDER DECLARATION OVER IOW AMPS TH REMODEIJREPAI�L LITTON
¢ 1 hcrehy affirm that I am exempt from the Cmdractor's License Law for the ==�ti�iFFl�_��[`[ �`�
K'O d V following reason.(Section 7031.5.Business and Professions Cod,Any city or county SIGNS ELECTRICAL ❑OT Ek
m 3 w IF which require..a permit m construct.alma,improve,demolish,or repair any structure
E"�Og prior to its issuance.also requires the applicant An such permit to file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed purstuard to the provisions of the Contractors License Law(Chapter 9
ad 0 (commencing with Section 7000)of Division 31n the Business and Pmfessinns Code)., TEMP.METERORPOLE SL COMMERCIAL:
q q e K that he is exempt dmcrtfrom wd the basis fur Ne ell<geJ excmptioa Any violainn of ❑NEW BLDG/ADDITION ❑DEMOLITION
_Y• Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
t more than five hundred dollars 1551X). ❑TENANT [I FOOD SERVICE
IMPROVEMIiNT
xd ❑1,as.wncrkf the property,or is employees orowugesas rsaleinnle compcnsiness SWIMMING POOL ELECT -
F O will dothewons ands: he ctureCont is tors License offered does not apply o ass Business ❑OTHER
ad
and professions Cody.The Contractors License law Jac.not apply m m owner of OUTLETS-tiW13'CHES-FIXTU
q 3 property who builds or improves themun,and who does such work himself or through
his own employees.Provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR 4FTa,s
sale.If,however.the building or improvement is sold within one year of completion,the SQ.Ff.fL JROEA LSQ.FT.
owner-builder will have the harden of proving that he did no build or improve Output- P PNS Q1
pilot sola).
1,as owner of the property,am exclusively contracting with licensed contractors to T
cnnswct the project(Sec.9044.Business and Professions Cow,)The Contmctor.Li- 121996
cense law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE NOV07
whoomadctsforsuchprojeas with on costs)licensed pursuant to the Contractors
License La PERMIT ISSUANCE
la undc .B&PC fa thieve n CITY ur GUrtHIwU
• ALTER-DRAIN&VENT-WATER(EA) VALUATION
Dam �r
WOKE '. E. '
OMPATIONDECLARAGON BACK FLOW PROTECT.DEVICE 2�v �
1 hereby affirm under penalty of perjury one of the following dslamtions:
❑I have and will maintain a Cmdricatc ofConsenuo self-insure for Worker's Compen- DRAINS-Fl.00R,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section TIM of the Labor Code.Toro the perltmnance of the
work for which This permit is issued. FIXTURES-P13R TRAP
1 have and will maintain Workers Compensation Insurance,as required by Scenen
3900 of the LaMar Code.for the Performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance cancer and Policy number are:
Comer: Policy No.: GAS-EA.SYSTEM-OVER J(EA)
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASFIINDUS'TRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thisxedanneedism he con mplctedifmhcpernhls lormnchundreddoll.,($100) GREASETRAP
car less.) PLANCHECK THE
I certify that in Ne pmfomanccm the work for which this permit is issued,Isbell SEWER-SANITARY-STORM G.200 FT.
nut employ any person in any manner an as to become subject m the Workers Compen- ENERGY FEE
0 .inion Laws of California.Dae NATER HEATER WNENT/ELECTR GRADING PEE
Applicant
h NOTICE TO APPLICANT:B ancr making this Ccalmeme of Exemption,you should WATER SYSTEM/TREATING
a �'t aM1 atm the Workers Com nsotion f the labor Cute,you must SOILS FEF,
ecome s
j i, Provi.sinnxo
� fnNmwiN comply with such pmvi.aom car this permit shall he deemed invoked. WATER SERVICE
5z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH SQ.FT. PAID Dam
UC) I henhyaffirm thadthem iso Ornamentalhadingagency for the perfrmance of
h the work for which this permit is is issued(Sec,30)9,Civ.C)
QLenders Nano 'TOTAL:
r IVtJ Lenders Address BUILDING P'.
I cenify that 1 have read this application soil state Nat the above information is trill
f^' Iso comet.l agree to comply with all city and county ordinances and sate laws relating in QTY. MECHANICAL PERMIT FEE
building construction,and hemhy authnnm representatives of this city to enter upon no SEISMICF
above-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indenmily and keep barnJes.s the City car Cupertino against ELECTRIC FEC
liabilities.judgments,costs and expenses which may In any way accrue against said City ALTERORADDTOMECH.
in consequence of the scanting of this pewit. PLUMBING Flili
se
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.018 CFM)
MECHANICAL 'E
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 18.1100 CFM) CONSTRUCT )NTAX
Signature of Applicart/Contrucmt Data EXHAUST DOUG(W/DUCT) HOUSING TIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle heaardnus material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code.Scetion 25532(a)? HEATING UNIT(OVER 100.001)BTU)
• ❑Y,s ❑Nm VENTILATION FAN(SINGLE RESID) PAID In in Re s
Will the applicant or future building occupant use equipment or devices which
emit Instead...sir communism,mam,us defiu
ned by the Day Arca Air Quality Management BOILER pHP OR IfNI.OIp OTU)
TOTAL:
Dmnct) BOILER-COMP(OVER 100.00)BTU)
Cl Yes ❑Nn
1 have read the haeardous materials milmo ments under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
mmia Health&Safety Code,Seetinne 25505,25533 and 25541 I understand Nat if the NEW RESIDENTIAL MECH. SQ.Ii'.
building dines not arrently have a tenant,that n is ony resgmsibility It,notify the iccupnnt
of Ne requm m'is which omen be met prior to issuance of a CenlOcam of 0ocupancy.
Owner or amhunmd ager Date TOTAL: ISSUED BY:
OFFICE