31224 APPLICANT?0 FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. 3122 /1
BUILDING DIVISION APPI.ICATION/PERMIT PLUMBING-MECHANICAL. J GLgt}+
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRfSS: SANITARY NO. APPLICATION SUBMITTAL DAFT
d 8 T-p-9
,gdmhJO NF. 'S NAME: 1'HON': CO RACfOR'S NAME: LIC NO:
d Iffo'e— / —f3� 71L 5' N/C CONTROL as
ITECI'/ENGINE LIC NO: A DRB. ❑
" CONTACT: PHONE: BUILDING PERMI'I'INFO
❑ Consultant Feat Paid by Applicant(Initial) BLDG ELECT PLUMB MF.CH
❑ ❑ jR ❑
LICENSED CONTRACTOR'S under DECLARATION Q•ry ELECTRIC PERMIT FEE
1 heathy affirm that 1 am fmc En under provisions of Chapter 9(commencing JOB DESCRIPTION
{"{�00 with Section Division Sof the business and prnfesniarts Cnde.and my license is RESIDENTIAL:
F+�� full force urW cfluo. ItiNMI'I'ISSUANCP.
❑SFDWI. C:1 KITCHEN REMODEL
�U License Class Lica
Dore APPLIANCES—RESIDENTIAL ❑ADDrr10N 54LUMBING RE-PIPE
{�Ze - Contractor
=aj ARCHITECTS DECLARATION PANELS ❑MULTLUNIT ❑STRUCTURAL
1 undersmnd my plans shall be useds p
aublic seconds MODIFICATION
O, -� UPTO2MAMPS
rr� t�i Li ❑INFERIOR (I CHIMNEY REPAIR
Licensed Professional
201-IINIBAMPS IMPROVEMENTyg fL OWNF,&BUILDER DECLARATION pyliN IINNIAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
qy5d CC I hereby affirm that I um exempt from the Contractor's License Law for the
ulO Q.U following neuro.(Section 7031.5.nosiness and Professions Cale:Any city or county DOTTER
LLT 3 u.[�' which requires a permit to construct,alar.improve.demolish,m repair any suucmm SICNS ELECTRICAL
oiormidissuanle.also requires Ne applicant farwch permit to filen signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuanOo the provisions of the Conuacmrs License law(Chapter 9
(commencing with Scoid.7000)of Division Sof the Business.ad Professions Ctde)nr TEMP.METER OR POLB INST. COMMERCIAL:
Sgqd o Iv mm he is exempt ihcretiam and rite hais for the alleged exemption Any violation of ❑NEW BLDG ADDITION ❑DEMOLITION
W^m
Section 7031.5 by unyupplibunt for.permit subjects theupplieuntm acivil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
not more than En($
rive hundred dolle5001.
(]Las owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,mW Ne structure is not inended oroRcrcd frmeale(Sec.'l044,Business ❑OTHER
W and Professions Cade:The Commerce.,License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
H
r property who builds or improves thereon,and who docs such work himself ar through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL.ELECTR Q
sale.IL however,the building or improvement is sold within one year of completion,the I'. ORARFA $ISQ.ET.
owner-builder will have the burden of proving that he did not build or improve for pur-
macofsac.). Si n
El I.ax owner of the property,am exclusively contracting with licensed contracton to TOTA4 T yf [f��a.,
construct the project(Sec.7044,Business and Professions Coi The Contractors Li-
cense law does not apply to an owner of property who builds or improves daemon,and QTY, PLUMBING PERMIT F f7 J�:
who contracts tot such projects with.comocau(s)licensed pursuant to the Contmcnrr s
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,R&P C far this reason
Owner Date ALTER—DRAIN&VENT—WATER(FA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I herchy affirm under penalty of perjury one of the following declarations
•[]Ihuve and will muinmina CenificmeofConumto self-insure for Worker's Camper,- DRAINS—FLOOR,ROOF,AREA.COND.
radon,as provided for by Section 37(X1 of the Labor GWc,for the performance of the STORIES TYPE CONSTRUCTION
work far which this Permit is issued. FIXTURES—PER TRAP
El I have and will maihmin Workers Compensation hommnce,as required by Section
3700of Ne Lahur Cola,mrthe erfonttanceofthemd workfBu scbhhiicecrchhyjthis,smansissed. GAS—EA.SYSTEM-IINC.4OUTLETS OCC.GROUP APN
CynWor Comen,t Policy No.:7VyX Z3x� GAS—EA.SYS TEM OVER 4(EA)
ox
�C�N IFICA s Ir EXEMPTION FROM WORKERS' GREASFIINDUSTRLWASTEINI'ERCEITOR
COMPENSATION INSURANCE
(This rection need not be completes),the permit is faronu hundred dollars(S I INE BUILDING DIVISION?BPS
oGREASE TRAP
r less.)
PLANCHECK FEE
Loy anythnlnthe perfarroany
nme rof as he
ork Isecom subject
bjech tto permit irkesued,'Co Isbell SEWER—SANFfARY
not employ any person in any manner sen ox to buotoe suhjat m the Worked Compcn- STORM F.A.200 FT' ENERGY I7Eo
Oz union Laws of California.Date WATER HEATER WNENTB3LECTR
Q Applicata GRADINGFEE
NOTICE TO APPLICANT.IL eller making this Cenifrwr of Exemption,you should WATIiR SYSTEMORRATING
a become subject m the Worker's Compensation provisions of the Iabar Cale,you must SOILS FBP.
{gl forthwith comply with such provisions or this permit shall Is,deemed revoked. WATER SERVICE
4LF CONSTRUCTION LENDINGAGENCY nNEW RESIDENTIAL PLMO. SQ. PAID
V I that
em isaconstructionlending agency for theperformaceof
Due Receipt
rfor which this isissued
(Sec. 0],Cm C.)
QULenders Name
_ TOTAL:
�.r W Lenders Address 'TOTAL:
�+. I certify that 1 have rent this application and store that the above information is BUILDING FEC
ZI correct.l agree to comply withal]city and comayardinances and state laws relating to QTY, MECHANICAL PERMIT FEE
U z building construction,and hereby auNnrim representatives of this city to enter upon Ne SEISMIC FEE
above-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(We)agree m rm
save,indemnify and keep beardless the City of Cupertino Fund ELECTRIC PER
Iiubilities,plIlmcnts,cousund expenses which may in any w.yaccme against said City ALTER OR ADD TO MEGA.
in consequence of the grunting ofthisthis permit PLUMBING FEE
APPLICANT UNDERSTA 11f AN C 1PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0110 CFM)
Is
SOURCE ,ATI 4 MECHANICAL FEE
/ AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCFIONTA%
Sig ofAp c�m/Cum / Data EXHAUSTHOODOVIDUCT)
HAZARDOUS MATERIALS DISCLOSURE. HOUSING MITIGATION FEE
Will theupplicurn or future building occupant sorcorhandie harardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupemimo Municipal Code,Chapter 9.11 and the Hanhh and Sofmy
Code,Section 25532(u)'! HEATING UNIT(OVER IM.000 BTU)
❑Yes C]No VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices WBIWI Dam Receipt X
emit huzadma an,conmminams as defined bydw Be,Area Air Quality Management BOILER—COMPOHPOR IM."BTU)
District? TOTAL:
❑Yes No BOILER—COMP(OVER 100,000 BTU)
(have read the haruNous materials¢quirtrronto under Chapar 6.95 of lite Cali- AIRCONDITIONER ISSUANCE DATE
fomia Health&Safety Code.Sections 25505,M533 and 25534.I understand that if the NEW RESIDENTIAL ME CII. SQ.IT.
building does not cunemly have a rerun.Out it is my rase sasibiliry to notify the oecupant
of the"mremems which must he met pour to issuance of u Certificate of Occupancy.
Owner or authrnixd agent Date TOTAL: ISSUED BY:
OFFICE