31419 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I BUILDING-ELECTRICAL PERMING 19
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3 314 4
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATE
O l PA)P�4 ll-e416
OWNE '"N �M ONE:' CONTRACTORS N, LIC NO:
NIC CONTROLq r
XRCHITEUUhNGINLEK: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
r� .❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am liccnsed under provisions of Chapter 9(...warming JOB DESCRIPTION
FGOO with section 7")ofnivision3ofthe Business and Professions code,and my license i, - RESIDENTIAL
OO in full force and eRect. PERMIT ISSUANCE
FW_ ❑SFDWL ❑KITCHEN REMODEL
ZZW License Class Lica APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
F Q Dam Connector
ARCHITECT'SDECLARATION' ❑MULTI"UNIT [-]STRUCTURAL]
FOrz PANELS
2ONZ lundersfand lay plans shall be_useJ ns politic,ecoMi MODIFICATION
OZ^o UP10200AMPS ❑IN'TF;RIOR ❑CHIMNEY REPAIR
P:ntW Licensed Professional 201-1000AMPS IMPROVEMENT
Y OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH RF,MODEUREPAIR C1 DEMOLITION
C C
k O Q 1 hereby affirm that I am exempt from the Commemos Licence law for the
LL7 3C U following reason.(Section 7031.5,Business and Professions Code:Any city.,,early SIGNS ELECTRICAL []OTHER
Y,c' which requires a Permit to construct,alter,improve,demolish,or repair any slmcture
� prior to anissuance,also requires the applicant such Permit to file a signed statement SPECIALCIRCUIT/MISC.
that he licensed pursuant theprovisions fIh Contractor's L Law(Chapter 9'
C�� Tram g eth Srcli 9W0) [Dwislon3 fill IS tercn dPmfc::ion.v Calc)pr TENIP ME'I'ERORPOLF.INST. COMMERCIAL:
that he is exempt Ibereliom and the hinds for the alleged e+empvom.Any vinlalina of _ ❑NEW 61.DG/ADDITION []DEMOLITION
W Section]031.5 by any applicant for a permit subjects file applicant to a civil penalty of POWER DEVICES
^A ❑TENANT ❑FOOD SERVICE
t mom than five hundred
porry, rrmyem). OT14ERVIiMEM
ASO ❑Lo,ne owner
work,and
propeuctremycmntended witffered a,their(sole compensation, SWIMMING POOL ELECTRIC _
p. will do the work,anJ thestmcmreis not intended proffered forsale(Sec90Yt.Business ❑OTHER
W 3 and Professions Code:The Convectors License Law does not apply to an owner of OUTLETS-SWITCHES
-FI%TURES
Property who builds or improves thereon,and who dor,such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ
'dr.If.however,the haddingnraa,m,,mmm iv anld wihinnneymrofcco,atior. he: SQ.I LODRykRFj(k $/SQ.FT
cr-builder will have the borano of proving Thal he did sol build or improve for Aur- r ((��
Ane ofsale). I
• TOTAL Not Q
1,as owner of the progeny,am exclusively contracting with licensed contractors to oO
consumer thmjmt e p (Sec.IIHJ.Business and Professions Cade:)The Contractors Li-
sena Law does not apply to an owner ofpmpeny who build or improves Barren,and QTY. PLUMBING PERMIT FEE /k��VVC
who contracts(or such projects with a centimeters)licensed pursuant mm
o Line Contractor �lry
. (fI-
LicenseLaw. PERMIT ISSUANCE hut' yw
❑ I am excn;under.Sec. MPENSATION IIHCLAR- .B&PCfnr lhisreaum jNO
Dam -
ALTER-DRAIN&VEN'L-WA'I HR BEA) VALUATION
WORKS COATION BACK FLAW PROTECT.DEVICE I�
ser I hereby affirm under penalty of Perjury one of the following deductions:
�L7 l have and will maintain a Certificate of Conscm to self-moan for Worker's Cont DRAINS-FLUOR,ROOF AR BA.COND.
smion,as Provided for by Section 3700 of the Labor Cale,for the performance of the STORIES TYPE CONSTRUCTION
work for which this Permit is Issued. FIXTURES-PER TRAP ,
C] 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 ofthe Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-i INC.a OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier: - Policy No.: GAS-FA.SYSTEM OVER 4(HA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE.INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be rompletN ifLhe pcnnil is(Drone hundred Jpllars(S100) GREASE TRAP
or less.) PI-ANCHECK ME
I cartrythm lathe performanceofrhe work fpr whichrhn Amaral,is issued,l shall SEWER-SANITARY-STORM EA.200 FT
not employ any Person in any manner sn a,m heccme subject m Line Worker'Compact- ENERGY FEE
0Z saran Laws of California.Date WATER HEATER WNENT/ELECTR
Z.Q Applicant GRADING FEE
ti NOTICE TO APPLICANT:If,after making this Cenifcxm(if Exemption,you should ''WATER SYSTENVIREATING
C become valance,it)the Worker's Compensation proFEB.
visions of the Labor Code,you must SOILS FE
forthwith comply with such provision.,path;,permit shall be deemed revoked. WATER SERVICE
UJ 0
= Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,Flt( PAID
U O l hereby affirm that hem is a construction lending agency for the performance of Dam Receipt#
LL,L. he work for which this permh is v..ed(Sec.3099,Ci,C.)
Lenders Name TOTAL:
V Lcadce,Address TOTAL:
F41 cinim bad l have read this ppiscI d state Ihl the have f m i, BUILDING MH
LO correct.I agreet comply with all city and county ordinances and state laws mitaing to QTY MECHANICAL PERMIT FEE -
V Z build' g nstrtivion.t din rebyamhorize rep ,cntmnrspffl ,ciymemerush
pt e SEISMIC FEE
above-mentioned px wry for inspection purposes. PERMIT ISSUANCE
(We)agree to rave,indemnify and keep harat the City of Cupertino against CLEM IC FEE
liabilities,judgments,costs and expenses which may in any way interum against said City ALTER OR ADD TO MECH.
in asequence of Linc granting of this Permit. PLUMBING FEF.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 0.0a)CFM) CONSTRUCHONTAX
Siynamre of Applicam/Commcmr Date MiAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
•HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle Interactions material HEATING UNIT(TO 100,000 BTU)
as demand by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(.)' HEATING UNIT(OVER 100,000 BTU)
sk . ❑N
VEM'ILA]'[ON FAN(SINGLE RESID) PAID Date Receipt#
Will he app.,' mine bauldingoost,ant use topormato,desire,whish BOII.RR-COMP(3HPOR 11X4fXXIB'IU)
ntif h J :at,cont soot,a,defined by Ili Ila,Area A Q in,Management IOTA[:
Drat tP BOILER-COME(OVER 100.000 BTU)
-0 Ycs i]No
I have read the IurmJous materials requirement,under Chapter fi95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
(prat.Health&Safety Cale.Sections 25505.25533 and 25534.1 understaml that if the ,NEW RESIDENTIAL MECH. SQ.Fl.
building does nm currently have a moan,that it is my responsibility m.,fly rhe rmcopant
of the requirements which must In met poor to issuance of a Cenificme of Occupancy. .
loseOwnia,m.rnnomd open, Dire t TOTAL: ISSUED BY:
OFFICE
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