31159 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL 31159
BUILDING PROJECT IDEN-1'IFICAI'ION
BUILDINGADDRESS: I I SANITARY NO. APPLICATION SUBMITTAL DATE
U 72G� y-�d•.
"NNE N ME: PHOLJE: CONTRACTORS NAME: LIC NO:
N NIC CONTROL is
t IIECOENGIbMR: LIC NO: ADDRESS:, - ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ ConSultant Feet Paid by Applicant(Initial) BLDG ELECT P U MECH
LICENSED CONTRACIOR'S DFCLARAI']ON QTY. ELECTRIC PERMIT FEE
I hereby affnm that I am licensed under pmvisions of Chapter 9(commencing JOB DESCRIPTION
ED D
X00 with Sectim.7000 .Mivisian3.fthe Bucinessnnd Prufessi.ns C.daturdmylicw.e is
�f Op PERMIT ISSUANCE RESIDENTIAL:
O-Fr Licene full force Class
effect. ❑SFDWh ❑KITCHEN REMODEL
�UV License Claw Lich APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
GDote Contractor
ARCHITECT'S shlluseDs pLARAI licrecON - ❑MULTIUNIT. ❑MODIFI RAL
MODIFICATION F.prn - PANIi1.S
Z O�2 1 undersand my plum shall he used as public records MODIFICATION
OZ— UPT02WAMPS ❑INTERIOR ❑CHIMNEY REPAIR
[-.N-,E' Licensed Prafessiowl 201-1000AMPS IMPROVEMENT
ay�X OWNER-BUILDERexempDECLARATION OVER IWIIAMPS ❑BATH REMODEUREPAIk [I DEMOLITION
at I hereby.(firm obs 1 am exempt from the Connotations Co License Low cot the
3O ac O (ollowin6 reason.(Section]031.5.Business von Professions Crnle:Any city or army SIGNS ELIiCTRICAI. []OTHER
1y Hme which requires a permit to construct,alter,improve,demolish,or repair tiny structure
t�yJ prior ns its issuance,also requirestM1e opplicam for such petmiuo Ele a.igned smmment SPECIAL CIRCUIT/MISC. CLQ
y that he is licensed pursuant o me provisions of the Contractor's License Law(Chapter 9
00 bonnummag wi III SecAanT000)of Division 3 of the Business mal Professions Code)or THMP METER OR POLE INST. COMMERCIAL:
a a n�' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
❑TENANT ❑FOOD SERVICE
not more @m liveaprophundred y,many
y employees
Las ownerofthe / n,onn to as with wages ox Reaction compensation, SWIMMING POOL I3L[CTRIC 1 ROVEMENT
❑ pct Pe ct Yot in Y 6 P
� 0 dWill dothesnies wer Code:
The mreisnoes Licenstended or Law
dosmd not apply to tan Business TIER
W and Professions Code:Tho over th mrs License Law does not apply s if owner of OUTLETS-SWITCHES-19%TURES f
63^'
property who Fuelsi or improves arch i and who noes such work himself off rough
his own employees,provided thm such improvements ore nm intended or affean for NI?W RESIDENTIAL ELECTR SQ FT. sit
aide.If,however,the building or improvement is sold within nuc year of completion,the SQ.FT.FLOOR AREA E/SQ.PT.
wnerhuilderwill have the burden of proving that he and not build or improve Iia put-
pose of sale.).
❑ 1,as owner of pmpI am exclusively connecting with licensed contractors to TOTAL:
construct the ruicel(See.9044;Business and Professions Co.,., a Commnor's Li- -
cense Law does not apply to an owner of property who builds or improves thereon.end QTY PLUMBING PERMIT PEE
who cam sforsucunh pmj ns ah ntmchaPi)licensed pursuanun the Contractors
ice
m exempt der ,B&PC nr this rcas.n PERMIT ISSUANCE ,
a
weer _ ALTER-GRAIN&VENT—WATER(EA) VALUA'HON
Dae
WORKER'S COMPENSATION DI!CLARA'1'ION BACK FLOW PROTECT.DEVICE
I hereby affimt under penalty of perjury one of the following declarations:
I Instead w it l maintain.Certilica .02masenu.self-insure for Workers Camper DRAINS-FLOOR,ROOF,AREA,COED.
snBan,as provided for by Section 3900of the Labor Code,for the pefoman
rrce of the STORMS TYPE CONSTRUCTION
work far which this Permit is issued. FIXTURES-PER TRAP
El have and will maintain Worker's Compensation Iexamine,ac required by Section
3]00 of the"be,Code,for the ped'nrtnance oft he work on which has venni[is issued. GAS-EA.SYSTEM-I INCA OUTLETS OCC.GROUP AI'N
My Workers Compensate.ho m ee«nit,and Policy number am:
Currier. Policy No: I GAS-EA.SYSTEM OVER 4(EO
CERTIFICATE Olt 13XEM P'I'TON FROM WORKERS'
COMPENSATION INSURANCE ORIS SE/INDOSTRL WASTH INTERCEPTOR
(This se am.need out be completed if the permit is for one hundred dol[.IS I00) BUILDING DIVISION FEES
less.) GREASE TRAP PLANCHECK FEE
I eenify that in the performance ml work for whichthl..Permit is is.cued.l shut[rsY-STORM F.A.200 FT.
_ SEWER-SANITAR
not employ any peon in any manner so as m become subjm to the Workers Compcn- ENERGY I-ME
OZ colon L.ws.I California.Dau: WATER BEATER WNENI7ELECTR
Z 2 APP[icnnt GRADING FEE
Cry NOTICE TO APPLICANT,It.after making this Certificate of Exemption,you should WATER SYSTEMOR RATING
F ; hecome subject m the Worker's Compacted provisions of he Labor Coca,you most SOILS FEE
{a11 F.t forthwith comply with such provision..or lxsrmit>hall battered revokedWATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PIT. PAID
U. 0 k far Whichirm thus there issued a,.30lennln.agency far the performance of Date «iplY
U. P+ the wok(or which this petmb Is issued(Sec.309].Civ.C) - -
L) Lenders Name I TOTAL:
s
Lender's rifys
I«WTOTAL:
y ily the 1 have readhis tapplicationnohatth
ion and m te above information iBUILDING FEE
V) eameal.I agme to comply with all city and county ordinances and state laws relating to QTY. MECHANICAI.PERMIT FEE
U7 humbug commumlao,and a nchynuthorim¢presemutivea ofthiscity It,contrarian the SEISMIC FEE
above mentioned property for inspection purposes. PERMIT ISSUANCE(We).9.m save,indemnify and keep harmless the City of Cupertino against ELECTRIC ITE
Iiabilltiesjudgmcnts,costs and"Tenses which may in any wiry accrue against said City At:[ER OR ADD TO MECH.
in me
comegn«efthe mating of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WIT H ALL NON-POINT AIR HANDLING UNIT I TO 10,000 CFM) MECHANICAL FEF. Q
SOURCE REGULATIONS.
' AIR HANDLING UNIT(OVER IO,)(XI CFM) CONSTRUC'UON'TAX
Sign.mrc ofApplicnnVGmtereem Date EXHAUSTHOOD(W/DUCO HOUSING MITIGATION FF.F.,
HAZARDOUS MATERIALS DISCLOSURI?
Will ore app[ic.nt or future building ocespam store or handle hazardous materia[ - HEATING UNIT(TO 100,00I)BTU)
as cleared by the Cupertino h4 j'ipal Code.Chapter 9.11,and the Health and Safety
Code,Section 25532(.)? to HHXrING UNIT(OVER 100,0190 BTU)
❑Yea r�V,//1 PAID
VENTILATION FAN(SINGLE RESIU) Dam ' Receipt M
Will the apple. nr I t hulI argue
use equipmcnl o,devices which
tit hormoRms air com!IZients r defined by the Hoy Arca Air Quality Management BOILER-COMP IMP OR 1(111,1X)0 BTU)
' istrict? TOTAL:
❑ye9 BOILER-COMP(OVER 100,010 BIL)
1 have mad the hvadous materials AIR CONDITIONER
,5,2553 an under Chapter Cali- ISSUANCE DATE
fnmiu Health&Safety tly h.Sections 25hai i 25533:sn 25534.I understand that if the NEW RESIDENTIAI.MECH, SQ.Fp.
builJi ac arm ntnc cosyhuvenntetpoorto ismnce of
ibtlityto omits Ne cecupontt
of ac arm Neh must be ran pd�no issuance of a Ciandfic inj
7 TOTAL:
6 ISSUED BY:
OFFICE