31317 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO.
BUILDINGDIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �KJ s
BUILDING PROJECT IDENTIFICATION
17
ILDINGADDRESSI ,SANITARY NO. APPLICATION SUBMITUL DATI
lo9y�' zg $)rp 3GG-6 Sy to
N NAME: 91- PHONE: CONTRAC9'OR' LIC NO:
N/C CONTROL#
ARCHITE :NGINF.ER: LIC NO: ADDRESS: ❑
G ONTACI: 'PHONE: BUILDING PER MFO
M'� �� �I�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG LLE T PLUMB MOH
LICENSED CONTRACTOR'S DECLARATION • QTY ELECTRIC PERMIT FEE
I hereby affirm that l am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
HOOC wiNSection7000)of Division 3.f he Husinessand Professions Code,and my he as.is PERMIT ISSUANCE RESIDENTIAL
DENTIAL
I— in full foreevnd affect. ❑SFDWL ❑KITCHEN REMODEL
FUtj License Class Ilc.I APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
rn 66Dam Cement.,
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z p r,=2 4 I undersand my Atoms shall he mind republic records PANELS MODIFICATION
oZ"p
UP TO 200 AMPS
11 INTERIOR [-)CHIMNEY REPAIR
j� Licensed Professional 201-10EMAMPg IMPROVEMENT
X
OWNER-BUILDER DECLARATION Cant ON OVER I"AMPS ❑BATH REMODELREPMR (]DEMOLITION
R a I wago affirm the I 1 exempt from the Cssions eros License Law for the
ii�S C LU which followingwagon.(Seaton ounde 1, It,ss unit ase,Professions orrany city mommy SIGNS ELECTRICALess
❑OTHER
I-El W 1••' which requires v pemut re cores the short improve,demolish,or repair arty ned statement
I-El prior to its issuance,nma,aths, minoring offlue
fueor suchmealuoicensfile ae Law
(CIpmmem SPECIAL CIRCUITIMISC. _
} that heeNcccnsnd Sectio 7")ofDrosionf the a Buveror'sndPofiioks Chapmr9
G�O ]bat he is
(commencing withtherefrom
and the basis for ofthe Business andon.Any
violaNe)of TEMP.METER OR POLO INS
CL that he is exempt therefrom end the basis for @a alleged exemption.Any violation of ❑NEW BLDG/ADDI'T'ION C1 DEMOLITION,
Section 7031.5 by unyapplicvatfor a Permit subjects the applicant to m civil penalty of POWER DEVICES
/
^yEf4pNT - ❑FOODSERVICE
Z y rte more Nun five hundred dolours e1.
� a0 ❑I,ns owownerof the pmperty,emy emm ployees with wugvs as theiranle compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
ttRTYRTRI� will dothewons ands: structureis not intended ornw does
apply to4n'tornrof []OTHER
and Professions Care:The Contractors License LawJaes not apply m on owntt of OUTLETS-SWITCHLS-FIXTURES
4' ^ pmpeny who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements arc not intended or offered for NEW RES IDF.NTIAL ELECTR
sale.If.however,the building in improvement is sold within one year of completion,the (� SQ,J'r fl-OORAREA SISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for our. yr. All)
,
Page of ole.).
❑1,as owner of the propeny,am exclusively contracting with licensed cantmemrs to AL'
road.,the Exalter(Sec.7044,Business and Professions Caren The Corrtracmr's Li-
cense Law docs not apply to an owner of property who builds or improves thereon.and QTY, PLUMBING PERMIT FEE C V M
whormaracts forsuch Pxajunwnh acummemoid liceirsedpmosanuo the Ccomictor's ` h
Luxes,taw' PERMIT ISSUANCE LU(-
❑I am ex pt under Sec. .B&P C far this reason C�•/(/
Owner Dam ALTER-DRAIN&VENT-WATER(EA) VALUATION
ff"
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE 1_ �b O
hereby eby air,.under penalty ofperjuty one of the following declumtions: �D
I haveand will mninmin a CertificiarmConsent to self.insure for Wake?,Contain- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPO CONSTRUCTIOb
.V! Nation,as provided far by Section 37(X1 of the Lahr Cade,for Ne piammusim a of the
work for which this permit is issued. FIXTURES-PER TRAP
I have end will maintain Workers Compensation Insumnce,as required by Section
3700 of the Labor Code,for the perfomtartce of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC,GROUP APN
My Workers Compensation Insurance carrier and Policy number arc:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASHIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION MES
(This section need not he completed ifthepeumit is forone hundred dollars($100) 0
or less] - GREASE TRAP PLANCHECK FEE ct it-L Ir
I certify that in the perfmmanceafthe work for which this permit is issued,Ishll SEWER-SANITARY-STORM EA.200 FI'.
nut employ any person in any manner so as to be ecomsubject to the Workers'Compero ENERGY FEE
O z sudden Laws of Cmimrm..Data WATER HEATER WNEM'IELECTR GRADING FEE
O Applicant
to NOTICE TO APPLICANT:If,after making this Cmificme of Exemption,you ehauld WATER SYSTEMRREATING SOILS FEE
I" become subject to the Workers Compensation provisions of the labof Care,you most
Lail forthwith comply with such provisions or this permit adult be deemed revoked. WATER SERVICE
0. A
.�. z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
Data Receipt# "
V l for
ria the there issued(Sec.30 len ding agency forthepMnrmattce of
Tn
'he work far which this permit is issued(Sec.3f97,Civ.CJ
u" !^ Lender's Name TOTAL:
0. Lenders Address TOTAL: BUILDING FEF: .
le+^" is-
1 certify tht 1 have read This application and information that the above infomtion is �
W coned.l agree to comply with all city and county eminences and Asia laws relating to QTY MECHANICAL PERMIT FEE
U building construction,and hereby authouiu representatives of this city to enter upon the SEISMIC FEE
a awarnantimed propeny for inspection imrp rgal. PERMIT ISSUANCE -
(We)agree m Nnve,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgrnenrs,costaund expenses which meyinany way vecmeagiimt said City ALTER OR ADD TO MECH.
in consolation of he oon,of this permit. PLUMPING FEE
#m
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOURCEREGULATIONS.
AIR HANDLING UNIT(OVER 10,0011 CFM) CONSTRIATION TAX
Signature of Applitim/Con«uctar Data EXHAUST HOOD(WOUGT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle htwNous material HME ING UNIT(TO I OBOEI0 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Satlnn 2553200? HEATING UNIT(OVER IUo."Eig U)
❑Yen ❑No VENTILATION CAN(SINGLE RESIDE PAID Data Receipt#
Will the applicant or future building occupant use equipment or devices which pOILER-COMP OHP OR 100,fg0 BTU)emit hard
zaous elm cor aminan s as defined by the Bay Arca Air Quality Management TOTAL:
ismict?
C]Yes ❑Nc BOILER-COMP(OVER 100,000 BTU) -
-I have read the haaardous mutemals noon ttenla under Chinese 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
made Health&Safety Cafe,Smions M%5,M533 it 25534.1 understand that if in, NEW RESIDENTIAL MECH. SQ.FT. t
building does not currently hove a tenant Nat it is my responsibility,to notify the Occupsot _
of the requirements which must be met prior to issuance of a Cer ificmc of Occupancy.
Owner or authorized agent - Date TOTAL: ISSUEDBY:
( . OFFICE