31409 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL .PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 31409
BUILDING PROJECT IDENTIFICATION
t BUILDINGADDRESS: ,SANITARY NO. APPLICATION SO MITTALDATE
0 'S sI , e
�.
OAMCN - PHONE: —tn� C ! 1r CS,/ Ur
NIC CONTROLN9p743
ECTNLC O:AREER:
:ADDRF�` i��� `+ O
CONTACT. PHONE: 5 J\, BUILDING PERMIT INFO
❑.,Consultant FM9 Paid by Applicant(Initial) BLDG/�FCT PLUMB MUCH r
r� ❑ ❑ ❑
'LICENSED CONTRACTOR'S DECLARATION
I hereby to of i that 1 am licensed under provisions of Chapter 9(cam QTY. ELECTRIC PERMIT FEE
p (commencing OB DESCRIPTION
�CZO with Section]000)of Dlvision3of the Business dPr deasions de,and my license es PERMIT ISSUANCE n
�UZV Lice1. oseoCe sadcR �2 Lic.# SMWL •' ❑KITCHEN REMODEL
y62 Date _ Contmdo APPLIANCES-RESIDENTIAL - ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECT'S DECLARATION El MULTI-UNIT - []STRUCTURAL�y Ov
�'b 1 understand my Plans mostshall be most public.,ad,rds S � l; • MODIFICATION I
OZ 1Q - UPT02WAMPS ❑INMRIORy [I CHIMNEY REPAIR
F4h W Licensed P t signal .. 201-1000AMPS • IMPROVEMENT.
g � OWNER-BUILDER DECLARATION OVER 1000 AMPS ,p ❑BATH REMQF IIREPAIR DEMOLITION
0.0.'' I hereby aff rte that I am exempt from the Contractors License Law for the '( ( 0
yx 3 F following ream (Section N31 5 Business and Professions C rode p city coot _ []OTHER Qg r
O%a
which requires Permit t c w t It ,improve,demolish p y y wcmre SIGNS ELECTRICAL t I
WJ prior W its smance,,alsonorms the applicant for such permit to file a signed statement SPECIAL CiRCUIT/MISC.
P• mat he is licensed pruant to the Provisions,of me Contractors License' La (Chapter9
00 (aero ten ing went Section]000) fDivision iufdoe Bus nessand Profes: id
ens Code)or TEMP.METER OR POLE INST. COMMERC
mat he is exempt therefrom and the basis for the alleged exempt Any violation of [I NEW BLDG/ADDITION El DEMOLITION
^ar Section 7031.5 by any applicant for a permit subjects the applicant mo civil penalty of POWER DEVICES '•
y not more than five hundred dollars($.500).. []TENANT' [I FOOD SERVICE r
C ❑I,as owner fine
propeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC _ IMPROVEMENT 1
will do the work,and the stmcmre is not intended oroRered for sale(Seo](414;Business - ❑OTHER
and Professions Code:The Contmenn's License Law does not apply to an owner of v OUTLETS-SWITCHES-FIXTURES '
memory who builds or improves thereon,and who does such work himself or through
his awn employees,provided but suchimprovements are not intended or altered for NEW RESIDENTIAL ELECTR SQ
sale.If,however,the building or improvement is sold within one yearndeempletion,the SQ.FT.PLOO$,IREA' - $/SQ.ET.
ner-builder will have the burden of proving that he did not build or improve for par-
pose ofsxleJ. . •
❑I,as owner of the property.am exclusively contracting with licensed contractors to
t+ IAL:
construct the project(Sec.7044,Business and Professions Code:)The Contractor,Li-
cense Law does not apply to an owner of peperty,who builds or improves thereon,and QTY, PLUMBING PERMIT O� 19
who contracts for such projects With aconnactor(s)licensed pursuant to the Contractor's
License Law. r PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C far this reason
ALTER-,DRAIN is VENT-WATER(EA) VALUADON
OwnerDate
WOR KER'SCOMPENSATIONDECLARATION BACK FLOW PROTEGE DEVICE
I hereby affirm under penalty of perjury one ofine following declications: '-
❑Ihaveand will mainmin6Certificare ofCoreentro self-insure for Worker'sCompen- DRAINS-FLOOR,ROOF,AREA.COND. SORIES TYPE CONSTRUCTION
action,as provided for by Section 3700 of the Labor Code,for the performance of the .f
work for which this permit is issued. FIXTURES-PERTRAP
I have and Will maintain Workers Compensation Insurance,as required by Section
3700ofthe aor odq fnnhe pertmucance ofthe work for which thispermitis issued. GAS-PA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN,
My War �^°�f y�IlnJcu�r• cruearferand Policy
Carrier: Policy No.; 4N�� Iv GAS-HA.SYSTEM-OVER 4(EA) �
' CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR-
. BUILDING DIVISION FP.F.S
TTie sectio
( nneeJ nm hernmplered dee permit is forone hundred dollars($100) GREASE TRAP
or less.) PLANCHECK FEE
toy any that in the my mnner o to to
for whichthis permitisissued,lshall
SEWER-SANITARY-STORM FA.20h)IT i
not employ any person in any mannerco as to hecome subject m the Workers'Camper- ENERGY FEE
,� cation Laws of California.Dam
WATER HEATER WNENT/ELECTR
OOApplicant � GRADING FEE'
NOTICE TO APPLICANT.If,after makin this Certificate of Exemption,you should
u g p
WATERYST N
S LMRREAT G SOILS FEE ,
a "
forthwith
subject to the Worker's Compensation permit
sof the Lake Code,you most
forthwith cam 1 with such provisions comply c prove i ns m this permitsshall be deemed invoked.'
CT) WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U Q I herebyaffirrn thin here iso construction lending agency for the performance of Dam Receipt#
{>•t f4 the work for which this permh Is Issued(Sea.3097,Civ.C.)
O U Lender's Name TOTAL:
W Lender's Address TOTAL:
certify that I have read this application and mute that the above information is BUILDING FEE
VV]t -correct.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
U building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE' t
alai e-mentioned property for inspection purposes PERMIT ISSUANCE
(We)ogee to save,indemnify ad keep harmless the City of Cupertino against ELECTRIC FEE
imbilitimitingm ts,costs and expenses which may in any way uceme egaiinl said City ALTER OR ADD TO MECH:
in conseyuene f the granting of this permit. PLUMBING FEE
APPLICA NDERSTA DS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM)
SOURCE :GULATIO MECHANICAL FEET
AIR HANDLING UNIT(OVER 100D)CFM) CONSTRUCTION TAX
ignature of Applin V&ntacter - or
EXHAUST HOOD(W/DUC17 `
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingoccupeor store or handle hazardous material' HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Monicipn Chapter 9.12,und'me Health and Safety
Code,Senior 255321a)I '� „ t t HEATING UNIT(OVER IINI,INID BTU) v
❑Yes ( jN VENTILATION FAN(SINGLE RESID) PAID -
Date Receipt#
Will the applicant or future bmldin We
Pont use equipment or devices which BOILER-COMP(3HP OR IIIB,(NIO BT U) � li.
emit hazardous air contaminants as d ed by the Bay Area Air Quality Management TOTAL:
District?
❑Yes BOILER-COMP(OVER 100,001 BTU)
' r.
1 has read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE 4
fomiq Heal &Safety Code,Sections 2;5505.25533 and 25534.I understand mat if the NEW RESIDENTIAL MECH. SQ.FT. '
bmldibgd noixurr Iy vea tenant,that it is my responsibility to notify the occupant
of the tremenG ce met noissuanceo Occupancy.. _
in or enthori daa, - Date TOTAL: ISSUED BY:
OFFICE 1