31255 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO- ' ' 'BUILDING-ELECTRICAL. ' - PERMITNO. 31255
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATF
OWNE 'SNA :: PHON t__� NTRACIOR'SNAh1E: LICN
/I 0 i y ��i
NIC CONTROL 4
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RRCHITECf2NG NEER 1 RESS: l• ���
CON ACr: N I P ye:�� / ��.^/ L C9—(�� ,S•� BUILDING PERMIT INFO
•�•�( ❑ Consultant Fees Paid by Applicant(Initial) B ELECT PLUMB MECH
YL
LICENSED CONTRACTOR'S DECLA A N _D QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(corromming JOB DESCRIPTION
OZ wit Section 900X)of Division 3 ottbe Business and Professions Code,and my license is TI
,OZ in full Fairmont]effect. I'FiPMil ISSUANCE
Cul F L ❑KITCHEN REMODEL'
QUV Liiense Class Lic.# - APPLIANCES-RF,SIDENTIAL -
y¢W Dom Conuanor ❑ADDITION ❑PLUMBING RE-PIPE
Fay ARCHIIECf'SDECLARATION PANELS ❑MULThUNIT ❑STRUCTURAL
Zpyn
Z I haderstndnry pbunhall be usudaspurd
bi,acos MODIFICATION
OZ--q - UPr0200AMPS ❑INTERIOR El CHIMNEY REPAIR
F.y,E"W Licensed Profexsiood 201.10000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OYER IUW AMPS ❑BATH RF,MODEVREPAIR El DEMOLITION
C C Q I hereby affirm that 1 rein exempt from the Contractors License Law Ins the
ca3 a F following reumn.(Section 7031.5.Business and Professions Cora:Any city ar county SIGNS ELECTRICAL 0OTHER
F O y which requires a permit to construct.alter,improve,demolish,or repair any suuaure
prior to its issuance,also requires the applicat for such permit to file a signed statement SPECIAL CIRCUITIMISC.
thm
fes} at he is licensed pursuant the Ross loans of the Contraclnrs License Law(Chapter 9
tat='00 (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST COMMERCIAIr� pp
d C c,C that rte is exempt therefrom and the bods for the alleged exemption.Any violation of ❑Nr.w BLDGIADDfffAN 0 qq Y DEMOLITION
W�H Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
=Q not morn than five hundred dollars IS50% IMPRO
(] IS
Las owner of the propcny.or my employees with rages as their sole compensation, SWIMMING POOL ELECTRIC 11 OTHERa�V JQQD
F. will do Ne work,and to structure is not intended or offered for sale(Sm.0011.Business �
W 3 an and Profusions Code:The Contmmor's License Law dces not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who docs such work himself or troughV f• `Ur
his awn employees,provided that such improvements urs not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however the building or improvement is sold within one year of completion,
SQ.FT.FLOOR AREA ESQ.ET.
ower
n -builder will have the harden of proving that he did not build or improve for par-
opsse of eul
1,as owner Of the property.ata exclusively cantmeting wit licensed contractors to T
mosboct Inctpnj,,,,Icc,9814 Bmina,and P f.. ns Code)The Comment_ Lf-
censcL does notapply l of prpeny who bund,or improves tharvion,and QTY. PLUMBING PERMIT FEE
whocontractsforoich) ] I:with a vo,firsholsoI' sed pursuant o the Contractors
License Law. I'lilt Ml'1' 'U9CNCF. s•
❑ I ant exempt under Sec. ,B A PC fo tkovin,
Owner Date AUER- ENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACKAW PROTE •VICE
I hereby afimt under penalty of perjury one of the following declarations � �) I �3 �
�C1 I baccand will maintain a Certificate of Consent to self-insure for Workers Courtlier, DRAINS-MOOR,BEEF,A&CO STORIES I TYPECONSTRUCTION
,anon,as provided for by Sectio 3700 of the Labor Code,for the performance of rhe
work for which mi+permit is issued FIXTURPS-PE R P
❑ 1 have and will maintain W'orker's Comparison..Insurance,as requirul by S
3700.f to Labor CCeosle..ff..On edomwnce of me work for which this permit is issueJ. GAS-EA.SYSTCMf I C LETS PICC.My GROUP APN
/I Cart r�k�wNfsM tT'hlryuQvFe earticroli Policy uptbcr,ar: / p9 GAS-I:A.SYSTEM OVERa
/ (rests Policy No.:
CERTIFICATE OF EXEMPTION FROM WORK RS'
COMPENSATION INSURANCE GREASP/INDUSTRL WASTE L C R
(This section need not be,completed if the permit is for one hundred dollars(S I01) RUII DIV ON FFFS
GREASETRAP ��
- or les'.) PfANCHECK FF.
toy any that in the mine ymaranceafts t becomork r%objech tto permit isissued.'Com]shall SEWER-SANITARY-STORM EA.200 FT.
not employ any perms in any manner m as to become subject m the Workers'Compete ENERGY FEE
Z ,Z 'atsm Laws of California.Dia WATER HEATER WIVENT/ELEC R
Q Applicant GRADING FIiE
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING SOILS IFF,
a , become subject to the Workers Compensation provisions of the Labor Code,you must
L11ti forthwith comply with such pmvisinns or this pennift.11 be deemed revoked WATER SERVICE.
a q ,
C(INhereso1'PON LENDING AGENCY NIiW RF.SIDIiNTIAL PLMN, SQ.FT. PAID
z {. Unto Rcceip
1 hereby ullirm that there is u construction lending agency for the perfnrmuncu nl
W.U � the war,far which tls purnat is issued lticc.3097,Civ.C.)
C) �' LaMer's N..oc TOTAL:
Leader,Address T IIUII qE r�
I hemi,that 1 have read this application and,state hot above information ix
F h commis l agree m comply with all city and county ordinances and state laws relating In QTY. MECHANICAL PERMIT FEE
U z building conslmcticutnd hcrchy aclum,n eprcsioarives U rb,caytoemer upon the S'. FEE
0.6
movcmentioned property for inspection purposes. PERMIT ISSUANCE
(We)ugree ,,save.indannify and keep harmless the City of Cupemnoagainst LI ICFP: v
Iiabilities,judgments,costs and expenses which may in any way scant against said City ALT'ER OR ADD TO MECH.
in asequence Of the Seating of this permit. PLUMBING/Eli 2 t p
APPLICANT UNDER.TANDS AN WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT OQ 10.000 CFM)
S U CE REGULATI 5. MECIIANI.AL FEE
wL� AIR HANDLING UNIT(OVER ID.00DCFM) CONSTR CTIONTAX
/ tg sure Of ApphcanVC m to Dole EXHAUSTHOODIW/DUCT) HOUSING 11TIGATION FEE
IIALARD MATERIALS DISCLOSURE
Will the applicant or fm ebuilding Occupant store or handle hasardous material HEATING UNIT(TO IW.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade.Section 25532(x)? HEATING UNIT(OVER I W."BTU)
❑Yes C]NO VENTILATION FAN(SINGLE RESID) PAID Dara. Rcaeiptas
Will the applicant or future building occupant use equipment or devices which
emb hazardous air contaminants as defined by the Bay Area Air Quality Mourgunnear BOILER-COMP(3HPORIWAWBTU) TOTAL:
Drorict?
C]Yes [J No BOILIiR-COMP(OVER I W."BTU)
I hnvc rcaJ the h:a;udous ma¢riaB requirements under Chapter fi 95 of the Cali AIR CONDITIONER ISSUANCE DA
femia Health k SafctyGde,Sections 25505,25533 and 25534.1 understand that it the NEW RESIDENTIAL.MECH. SQ.FT.
building dn Ic urcinly have a huraid,th t it is my ra,qxOnsibilify to notify the occupant
of ihe cquirchicas wInch mar,be fuelprio to issuanceofaCertificate f Occupancy. -
1-41
Owns truth 'trial atical I [)are. T ISSUED BY: v a+ -
OFFICE