31045 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' BUILDING-ELECTRICAL - PERMIT NO. O
BUILDING DI VISION APPLICATIONIPERMIT45
PLUMBING-MECHANICAL
BUILDING PROJECT'IDENTIFICATION
ILDING ADDRESX - - SANITARY NO. APPLICATION SUBMITTAL DATE
Ior3r
8y1zKF 4vu: ec 5�rro 3 I aq�
NEIL' NAME: - �PF�O CONTRACTOR'S NAME: LIC NO:
N/C CONTROL It
CHITECf/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Od'Z witection 7000).Mivisfun 3afthe Business and Professions Code,and my license is RESRESIDENTIAL,ts100 h SPERMIT ISSUANCE
FF in full fame and effect. ❑SFDWI, ❑KITCHEN REMODEL
QUU License Cl.s Lic.N gPPLIANCFS-RESIDENTIAL DADDITION ❑PLUMBING RE-PIPE
z W Date Contracmr
InQy GMULTI-UNIT DSTRUCTURAL
F+Oy ARCHITECTS DECLARATION PANELS
z b n 7 l understand my plans,hall bevscd as public meant, TO UP200AMPS ❑INTERIOR D MODIFICATION
CHIMNEY REPAIR
Licensed Profcssional 201-1000AMPS ,IMPROVEMENT
PPP6000 ',� OWNER-BUILDFR DECLARATION OVER ItI(IOAMPS
e; [IBATH REMODEUREPAIR 0DEMOLITION
6 I hereby affirm that I oro exempt from the Connacmrs License Law for the D OTHER
W ar 0.V following teas..(Section 7.369,Business andmp ve,demolish,
Code:Any city m county SIGNS ELECTRICAL
i4-a Y. which rtyuirca n permit to conxtm<t,altcq improve,demolish,nr repair any xWnure
F!�O� prionoim issuance.also requircnthe applicannfor such pemduo files signed statement SPECIAL CIRCUIT/MISC.
In'
} that he is licensed purmaramilic provisions oftbe Contrommirs License Law(Chupter9
In' (commencing with Section 700X))uf Division 3n(the Rosiness and ProfessionsCode)or TEMP.MUTER OR POLE INST. COMMERCIAL:
thin he is exempt therefrom and the basis for the alleged cxxmpfmi.Any i.lfimn of .D NEW BLDG/ADDITION ❑DEMOLITION
YiCI LL
Section 7031.1byany applicant fora parotin subjects the applicant too civil penalty of POWER DEVICESGTgNpNT FOOD SERVICE
H Z Y not mare than five hundred dollars 8500). IMPROVEMENT
QDla owner of the property.or my employess with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended or offered for sale(Sec.70,14,Business []OTHER
end Prufesskins Code:The Caricatures License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves themon,and who does such work himself or through
It,own employees,provided Wat such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
ala If,however,the building or improvement is sold within one year of completion,the
SQ.FT.FLOOR AREA LSQ.FT.
owner-huilder will have the human of proving that he did not build or improve for pur-
pnse of sola.) -
D 1,is owner of the property,am exclusively contracting with licensed,maracmrsm OPAL:
construct the project(Sec.7044,Business aM Professions Code:)The Comacmh Li-
cense Luw does not apply to an owner of progeny who builds nr improves thereon,and QTY. PLUMBING PE FEE p7 p
A
W
contracts for such projects with a contracmrfs)licensed pursuant to the ContractorPs
ID
License Law. PERMIT ISSUANCE
D l am exempt under Sec. .B&P C for
Owner IT 1 I1 ALTER-BRAIN&VENT-WATF:RLEA)air RMR 10 ION
WORKER" I'y.ENSATION IIHCLARATIl1rJ k BACK FLOW PROTECT DEVICE
Ibercby effimr undo �yof perjurynneohhc foil.wingdcclaations: II
I have and will maintain a Cenlficem of Coment to wif-insure for Worker's Compen- DRAINS-FLOOR,ROOF.AREA,COND. STORIPS TYPECONSTRUCTIOC
cation,as provided for by Section 37M of the Labor Cade,for the performance of the
work for which this permit is iaued. FIXTURES-PER TRAP
D 1 have and will maintain Wsirkds Compensation Insurance,as required by Section
3700 n1'the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP AP+1.
My Worker's Compensation Insurance carrier and Policy number arc: -ss
Cartier: Policy N., GAS-Eq,SYSI"EM-0VER 4 ELO
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not he completedtithe permit is income hundred dollars s W) GRE,sSETRAP
or less.) PLANCHECK FEE
I certify nom in the performance of the work for which this permit is issued,I shall SUWER-SANITARY-STORM PA.200 ET.
not employ any person in any manner sec as m become subject to the Workers Compen- ENERGY FEE
0 a.mm Ln...I California.Date WATER HEATER W/VENT/ELECB
Z GRADING FEE
Applicant
r NOTICE TO APPLICANT.If,after making this Certificate of Exemption,yam should WATER SYSTEM TREATING SOILS FEE
F became subject t.the Workers Compensation provisions of the Labor Cade,you must
{a11 foMwith comply with such provisions or this permit shall be decimal revoked. WATER SERVICE
Q
CONSONLENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U C) - Ihemby offimt that there'.isisaconstruction lending agency for the performance of Dam Receipt
W
P: the work for which this permit is issued(Sec.31197,Civ.CJ
TOTAL:
U Lenders Name
W TOTAL:
Lender's Address
Qs 1 Certify that 1 have read this application and state that the above information is BUILDING FEE
lA correct.I agree to comply with all city and county internees and sem laws rehiring to QTY, MECHANICAL PER MIT FEE SEISMIC FEE
U building construction,and hereby authorim repreanatives of this city to enter upon the
aboveonentionul property for inspection proposes. - PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Capron.against ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way same againstaid City gLTERORADDTOMECH. PLUMBING FEE
in consequence of the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FE
SOURCE REGULATIONS. -
AIR HANDLING UNIT(OVER 10,WOCFM) CONSTRUCTI TAX
Signature of Applicant/Comractor Dam EXHAUST HOOD(WMUCID HOUSING MIT IGA FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store unbundle incautious material HEATING UNIT M 100.000 BTU)
as defired by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532m)'1 HEATING UNIT(OVER 100.000 BTU):
EI yes DNo VENTILATION FAN(SINGLE RESID) PAID
Date Re iptN
Will the applicant or future building reception use equipment or devices which BOILER-COMP(JHPOR 100000 BTU)
emit haardous au contaminants ss defined by the Bay Arta Air Quality Managem ,
ent TOTAL:
District? BOILER-COMP(OVER 100,M)BTU)
E]Y's DNo
I have mad the Mama®materials requirements soder Chapter 6.95 of No Cnli- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Senium 25505.25533 mad 25534.I undcnand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does.cartandy have a temnt.Wat it is my responsibility to..at,the..,at
of the requirements which most be met prior in issuance of a Cerificam of Occupancy.
Owner or authorized.,cut Data TD ISSUED BY:
OFFICE