31454 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL iPER NO. ^K1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL ,J1 /1 C-/I
4 J
BUILDING PROJECT IDENTIFICATION J �}
BUILDING ADDRESS: - - SANITARY NO. APPLICATION SUBMITTAL DATE
TER-91KANTE PHONE: CONTRACTOR'S NAME: LIC NO:
!J , �Jr 7� IQ R- +�( L �'� N/C CONTROL#
ARCHITECT/ENGINEER:- ,LICNO: ADDRESS:
/a Y MPF �e f .9s�i
CONTACT: F PHONE: BUILDING PERMIT INFO
❑ Consultant Finds;Paid by Appll(Initial) BLDG LECT PLUMB MECH
L70-777C, ❑ F-1 ElLICENSED CONTRACTOR'S DECLARATION
oo QTY. ELECTRIC PERMIT PEE
O 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing OB DESCRIPTION
Wpwith SecOon]000)of Division 3 ofthe Business and Professions Coda;and my license is CID NTIA :
Fy full force and effect. � ,�1 z PERMIT ISSUANCE �� '
yee��W�] 3 � ❑SFDWL - [I KITCHEN REMODEL
F•'UZW Datense lass C_ 1 Conuactnr i46aAruM,4)aN APPLIANCES-RESIDENTIAL"
yD51 - Z []ADDITION: ❑PLUMBLURAL PIPE
Z r„p ri>¢} ARCHITECTS DECLARATION PANELS 0 MULTI-UNIT ❑STRUCTURAL
O Z q I underslond my plans shall be used as public records - MODIFICATION
p UPT0200 AMPS
l�A+M I�y"ty Licensed Professional OO RIVE ❑CHIMNEY REPAIR
""�^LL pCe '6y OWNER-BUILDER DECLARATION 201-IWOAMPS IMPROVEMENT
I hereby affirm that I nm exempt from the Comuecmre License Law for the OVER 1000 AMPS ❑BAT -ELIREPAIR DEMOLITION
0;1.U fallowing reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ER
E' winch requires a permit to conswa,alter,improve,demolish,or repair any structure
0 pnonoire issuance,also requires the applicant far such permit to Fla esigned smlemenl SPECIAL CIRCUIT/MISC. -y
y. that he is licensed pursuant to the provisions ofine Contmerm's License Law(Chapar9
Q� (commencing with Scatter 7")of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL,
q o y that he is exempt therefrom and the basis for the alleged exemption.Any violation of I NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant a civil Penalty of POWER DEVICES
not more than five hundred dollars($50(d), _ []TENANT [IFOOD SERVICE
C]1,as owner of the property.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the strucwrc is not intended or offered for safe(Sec.]044,Business ❑OTHER A
end Professions Code:The Catharines License Law dues mol apply to an owner of OUTLETS-SWITCHES-FIXTURES"
property who builds or improves Hereon,and who does such work himself or through, _ -
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however,the building or imponemen,is sold within one yearof completion,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of praving that he did not build ar improve far put - A B
poseofsal,). - A
❑1,as owner of the properly,am exclusively contracting with licensed contractors to TOTAL: '
construct the project(Sec.71144,Business and Profusions Code:)The Ciouncowa Li- - ��
se Law does not apply to an owner of property who builds or improves
contractor(i) reon,and Qeve 5. �'
Who contracts for such projects with a contractor(i)licensed pursuant m the Cohtmcmes TY PLUMBING PERMIT FEE
License Law. PERMIT ISSUANCE. - t
❑l am exempt under Site. ,B&P C for this reason i;
CITY 4,�•-LUt•� ��N� ,,:
Owner ALTER'-DRAIN&VENT-WATER(EA) ,
Dem " VALUATION
WORKER'S COMPENSATION DECLARATION, BACK FLOW PROTECT.DEVICE
I hereby offrm under penally of permit,one of the following eclaustions:
❑I have and will maintain a CenificateofComent to self-insure for Workers Carmen- DRAINS-FLOOR,ROOF,AREA.GOND.
sation,ms prav' for by Section 3]00 of Hie Lubor Cade,far rhe performance of We _ STORIES TYPE CONSTRUCTION
work fave each this permit is issued. FIXTURES-PER TRAP -
d will maintain Workers Compensation Insurance,as required by Section
300 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Wo Com matitio`Innumn�ecart1ptand PalicypWmbe are:
Cartier 8 - =a-. Policy Nn:ry MC GAS-EA.SYSTEM-OVER4(EA)' I -
CERTIFICATE OF EXEMPTION FROM WORKERSI -
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(This section need not be completed if the Permit is farone hundred dollars($100) - - BUILDING DIVISION FRES
or less) nce GREASETRAP - PLANCHECK FEE
(certify thatinthe anymperformaterofs to me beefnambor jhthis tPermit 1mWisissuCmall SEWER-SANITARY STORM EA. FT.
'
not employ any person in any manner so as to#come subject w Ne Workers'Compen- ENERGY FEE
Z asoma Laws of California,Dare
z O ApplicantWA1ER HEATER W/VENT/E R
after GRADING FEE t ,
aIj .NOTICE TO APPLICANT:If, making this Certificate of Exemption,you should WATER SYSTEM/TRE NG ben
ecome subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
W �'y forthwith comply with such provisions or this Permit shall be deemed revoked. WgTER SERV(
�z CONSTRUCTION LENDING AGENCY, NEW ENTAL PLMB. SQ.FT. PAID
L) 0 I hereby affirm that there is a construction lending agency for the performance of D Rxeipt#
", are work for which this permit is issued(Sec 309],Civ.C.)
O Lender's Name TOTAL
LU Lenders Address TOTAL:
a, 1 certify Hier 1 have read this application and state that the above information is BUILDING FEE' t
Vl correct.I agree to comply with all city and county ordinances and slow laws relating to QTY, MECHANICAL PERMIT FEE
Ll building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE '
above-mentioned Property for inspection purposes.
PERMITISSUANCEp
(We)agree to save,indemnify and keep harmless the City of against s against ` ELECTRIC FEE !D
liabilities,judgments,costs ex this permit,
may in any way accrue against said City ALTER OR ADD TO MECH. "
in consequence of the greriting of this permit PLUMBING FEE '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS. - -
AIR'HANDLING UNIT(OVER 10,000 ) CONSTRUCTION TAX
Signature of ApplicanVComrecmr Dam EXHAUST HOOD(W/DUCT) ' - HOUSING MITIOATT E
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100 BTU) '
us defined by the Cupertino Municipal Code;Chapter 9.12,and the Health and Safety
Code,Seciiom 255320)? HEATING UNIT( R 108000 BTU) /
❑Yew
[]No
' - - VENTfLAD FAN(SINGLE RESID) PAID Date Receipt#
Will the applicant or future building occupant use equipment or devices which -
emit hazardm is it conmminanis as deflred by line Bay Area Air Quality Management BOfL -COMP(3HP OR 100,000 BTU)
District? - TOTAL:
7Yea ❑No , BOILER-COMP(OVER 100,000 BTU)
I have read to by us as at,re uirements under Chapter 6 95 of are Cali- AIR CONDITIONER
9 P ISSUA CEDATE
forma Safe ode actions 25505.25533 and 25534.1 understand Nat if the - .4
buil ' gdaes biroany
n v carom,thorn ism " NEW RESIDENTIAL MECH. SQ.PT.
n y y reeponsi 34 I understand
Ne occupant
requ' men .them, nor to issuance ofa Cen1dcaw oof cc acy
. e
raum z r Date TOTAL: ISSUED BY:
OFFICE 11