31196 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO " I BUILDING-ELECTRICAL PERMIT NO. 31196^/N
6
BUILDING DIVISION APPLICATION/PERMIT PLUMBING,MECHANICAL J{ JV
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - - SANITARY NO. APPLICATION SUBMITTAL DATI
o CN�Dwrcl� 22P4nCe ,. R/��Tp. 1. ♦�/ 2 �[7 1 , ; S]
16
OWNER-Slgr4g� �E✓ ATI4 4 F, W G .)LO T •A
(� N/C CONTROLM
ARCHITECT/ENGINEER: _ LIC NO; �.p ESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
s ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Q•TY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION'
O"Z with Section7000)ofDivision Sof the Bminewicallrofewhor,Code,and my license is - .. RESIDENTIAL,
k 00 PERMIT ISSUANCE
W I~ in full force and effect/', O O1{ ��,f ❑SFDWL ❑KITCHEN REMODEL
�Uz License Class 8.. Lina APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING R&PIPE
tib Date Utor
F5m ARC TECT'S DEDECLARATIO PANELS ❑MULThTT
UN ' ❑STRUCTURAL
SIIZ O 1 underamnd my plans shall be used as public records 4 MODIFICATION
OZO UP T0200 AMPS, [I INTERIOR - ❑CHIMNEY REPAIR '
Licensed Professional 201-IIXIDAMPS IMPROVEMENT
�bdy•�] -
OWNER-BUILDER DECLARATION OVER 1000 AMPS - El BATH RE IR Eh L N
yy PP44 WW I hereby affrm that I am exempt from the Comracmra License Law fur the
Dd O 6 U following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL' - O OTHER
which requires a permit to construct, h p d moll h,or rapid,my structure
�1yQ pnarbita issuance alae q ' rh ppl' tf hp It fl 'g d t mmenr SPECIAL CIRCUIT/MISC. n i
Y.....111 that he is licensed pursuant tthe previsions ofificContractor's License L (Chapter9
d� (commenamg with Sect 70(10)ofDivigion 3 offlue Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL,
O pOa that he is exempt theraftion,and he basis for the i II gel exemplum.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ySection 7031.5 by any applicant for a permit subjects the applicant to a crvd penalty of POWER DEVICES' 0 TENANT ❑FOOD SERVICE
zz not more Nan five hundred dollars($500) - IMPROVEMENT
Q (] has owner of the property,or my employees with wages as their role compensation, SWIMMING POOL ELECTRIC' • '
E ll da the work;and the sfmcmre is not intended or offered for sale(Sm.70",Business ❑OTHER
and Professions Cade:The Contractor's License Law does nut apply to nn owner of OUTLETS—SWITCHES—FIXTURES
r property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not immded of offered for NEW RESIDENTIAL ELECfR SQ
side.If,however,the building or improvement is sold within ane year ofcompletion,the SQ.ET. 14AREA 81SQ:FT.
owner-builder will have the burden of proving that he did not build or improve for pant- ^1I ��rr
for'..fsele.).
❑ umTO
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.70,UU Business and Professions Code)no Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT
who contracts for such pmjects with a corrosions)licensed pursuant o the Connacmr's
License Law. PERMIT ISSUANCE Q/y
I am exempt under Sec. .B &P C for this reason41—
_ ��
Owner - Date - ALTER—DRAIN&VENT—WATER(EA) VAL ATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declamtiom
• 71have and will maintain a Certificate of Censentm self-insure for Worker's Compen- DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTIOD
sation,as provided for by Section 37M of the Lebo,Code.for the performance of the
work for which this permit is issued. FIXTURES—PER TRAP "
EI I have and will maintain Worker's Compensation Insurance.as required by Section
37M of the Labor Code.for the performance of the work for which this permit is issued GAS—EA.SYSTEM.I INC.4 OU METS OCC.GROUP APN
My Work ' pe lion lnsumnce calricr and Policy tuber
Cartier , yNic: in. F GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EM ON FRO O K
COMPENSATIO INSURANCE GREASP/INOUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(Thisseetiooneed notlt completed ifthe permit is fmmne hundred dollars(SI00) GREASETRAP
or less.) PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued,I shall SEWER—SANITARY—STORM EA.2110 FT. • -
not employ any person in any manner so as to become subject to the Workers'Compea- ENERGY FEE
smion Laws of California,Date WATER HEATER WNENT/ELECTR
O .Applicant GRADING FEE
ti NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTEMTREATING
SOILS FEE
beeome subject subjeco the Worker's Compensation provisions of the LOsr Code,you in
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
z I hereby affirm dtanhere is a construction lending agency for the performance of Date ReceiplM
Uthe weak far which this permit is issued(Sec.3097,Cis,C) - TOTAL: I
O004
•, Lenders Name -Landers Addiess -TOTAL: r
pyI I certify that 1 have read this application and state that The above information is BUILDING FEE
r.x y emoad.I agree to comply with all city and county ordinances and state laws minting to QTY. MECHANICAL PERMIT FEE
(,) 4 building consvection,and hereby wtho,ize represermtives ofthis city to enter upon the SEISMIC FEE
abovementioned property for inspection purposes. - PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Coconino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in my way same against said City ALTER OR ADD TO MECH. r
in consequence of the graining of this permit, • PLUMBING FEE
APPLICANT UNDERSTANDS AND WILIi COMPLY WITH ALI.,NON-POINT AIR HANDLING UNIT DO 10,000 CFM) - MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signature of ApplicenVComracmr Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the medicinal or future building occupant store or handle hazardous materialHEATING UNIT(TO 100,000 BTU) „
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
Cods,Section 25532(ep ��.r(( HEATING UNIT(OVER 100,IX)0 BTU)
]Ye° "�,. ReceiplN
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
Date
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
District?
❑Yes BOILER—COMP(OVER 100,000 BTU)
� pI1S „
I have read the hazardous materials requirements under Chapter 6,95 of the Cali- AIR CONDITIONER - ISSUANCE DATE
fomes Health as Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a mnam,that it is my responsibility to notify the occupant _
of the req' menu whichm be et prior ro'ssuanas ofa Certifiwm of He ancy., -
TOTAL:
Owner or amhoriud agent Dam ISSUED BY:
OFFICE