31534APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO I I BUILDING - ELECTRICAL
F,RMIT 'PLUMBING -MECHANICAL.
BUILDING DIVISION APPIACATI?N/P31534
I BUILDING PROJECT IDEN IFTCATION
PERMD'NO.
BUILDING ADDRESS; -- .,, •-
��k v rtes A✓�
SANITARY NO.
APPLICAUON SUBMITTAL OAT
2 Z�{�6
OWNIiN'S NAME: PHONE: �r o
.• X " a 5' R / S/
Cp(YT_RACTOR'S NAME: n/� LIC NO
0 C� I IIID S(DI; I•- S v vb.
NIC
" ❑
CONTROLp
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ARCHOUCOENGINEER: LIC NO: ,-
ADDRESS:- -
CONTACT, 'PHONE:
'.
BUILDING PERMIT INFO
/
5ed4 t �_I �' (, % Gd — 7y �' 1.: -
]- `r`I'1 VV
I
❑ Consultant Fces Paid by Applicant (Initial)
BLDG ELECfr, PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
I hereby. amu ha I am licensed antler provident of Chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
- JOB DESCRIPTION
PERMIT ISSUANCE -
with Section 7000) of Division 3 orate Businessand Professiom Cade, and mylicense is
in full force and effect. s., '\
ll
'RESIDENTIAL:
❑SFDWh ❑KITCHEN RE,MODF.1.
pPl'LIANCES-RGSIDENTIAL
License Clav Lic.M
s.
❑ADDITIONa [I PLUMBING RE -PIPE
❑MULTI -UNIT 0STRUCTURAII
MODIFICATION
C1 INTERIOR - IMNEY REPAIR
IMPROVEMENT •.
Dam '
ARATION
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
PANELS
UP TO 200 AMPS
Licensed Professional -
201-1(XX)AMPS -
• OWNER-BUILDERDECLARALION
s I hereby amu shat 1 am exempt form he Contractor's License Law for me
following mason. fSection]031.5. Businessand Pmfessiom Code Anyciay mccunty
❑BATH RIiMODEVREPAIR DEMOLITION
❑OTHER
OVER IINXIAMPS
SIGNS ELECTRICAL
which requires a permit to constrict, alter, improve, demolish, or repair any structure
SPECIAL CIRCUIT/MISC.
prior to its issuance, also requires the applicant for such Permian rile a signed statement
that he is licensed pursuant,, the pmvi otooflhe Cnnlracmr's License Law Chapter 9
(commencing with Satinn](IW)of Uivisi„nJof the Business and Pmfexsion,. Code)or
TEMP MEI ER OR POLE INST
COMMERCIAL:'
that he is exempt dominion and me basis for he alleged exemption. Any violation of
❑ NEW BLDGIADDITION ❑ DEMOLITION
-
Section 7031.5by,any applicant for a permit subjects the arrPicantto a civil Penalty of
POWER DEVICES
TENANT ❑ FOOD SERVICE
net tame than five hundred dollars (S500), ''
❑,L as ownerofahe popery, or my entpinyces with wugcs as theirtalc contpenmmn,
will do Code:9mcmreators
IMPROVEMENT
..
�QTHER
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHIS-FI%TURES
i
License Law does
end Professions Code: The Contractors License Law Joca not apply m an owner of
Professionsapply in an owner
-
NEW RESIDENTIAL ELECfR Fi
properly who builds or improves hereon, and who Jaen such work himself or though
his own employees, provided that such improvements aro not intended or offered for
sale. If, however, the building or improvement is sold within one ycarof completion. the
I SQ. FBOt F AAt!A
S, SQ, FT
nenbullde, will have the burden of pricing thin he Aid urn build or improve for Aur-
IF ^
pose of sale^).
F1 h mow er of the pmpeny, am eaclmivcly commuting with licensed contractors to
consumer the p,njecl (Sec. TOW. Business and Professions Code:) The —olossou I Li
1996
DEC sis%{♦f
.
T
cense Law does am apply,, as owner of progeny who builds or improves hcren,and
QTY, PLUMBING PERMIT E
wbncommea forsuch projects with acontmcmg.)rcensed Lorimar tome contractors
License Law.
❑ 1 nm exempt under Sec. . B & P C fur this mama
(s yy (�j �NEHI•INO
yll I Uri ”" .
PERMIT ISSUANCE -
Owner Date
ALTER - DRAIN & VENT- WATER (EA)
VALUATION
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
I hereby affirm under Penalty of perjury one of the kolowing Jeclamtions:.
El[haveand will maintain a Certificate of Consent o self -unsure for Worker's Compen-
,,noon, os provided far by Section 370) m the Labor Code, for me performance of the
DRAINS- FLOOR, ROORAREA. GOND.
•ti STORIES
TYPE CONSTRUCTION
weak for which mos penia is issued.
FIXTURES-PERTRAP
-
I have and will maintain Workers Compensation Insurance, as required by Section
3000 of the Labor CW, for the performance of the work for which this penitis issued.
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
Out GROUP
APN
My Workr,!�o pen oris n,10 senior said Policy�,,yt;7�Itl{
Policy 6
carder: S�ti e� ^nEXE
-
GAS - EA. SYSTEM -OVER 4 LEA)
GREASEINDUSTRL WASTE INTERCEPTOR
ROM�ORKER
CERTIITCCOMPENATION1INN FROM WORKERS'
• - COMPENSATION INSURANCE 0
BUILDING DIVISION FEES
(Thissection recd not Lee completed if M1e penia is forme hundred dollars (S lip)
nrlcesJ
GREASE TRAP -
I'LANCHECK FF.Ii
SEWER - SANITARY -S"TORM EA, 20014.E
ENERGY FEE- -
I ccrtifydeminhc �crfnnance of thework forwliishthispermie la issued,Isbell
now employ any person in any manner m os to become subject m me Workers' Compen-
WATER HEATER WNENT/ELECTR
GRADING FEE
sation Incas of California. Dote -
Applicant
NOTICE TO APPLICANT: If, after making his Cenificatc of F.nempiion, you should ecome
's Compation provisions of the Lmsor Code, you man
bsubject to the W ..kcrens
WATER SYSTEM/TREATING
SOILS FEE
forthwith cotnply wihsuch provisionsonhis permit shall M1c Jecmed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
that there is a construction lending agency for e Performance of
I hereby affirm, hh
NEW RESIDENTIAL PI.MB. SQ. FT.
PAID'
Daae Re opted
TOTAL:
the work for which his permit is issued (Site. 309]: Civ. C.)
Lender's Name
-
TOTAL:
L'ndcr's Address -
is
BUILDING FL
1 cattily deal I have read his application and sem that me above information
neca. l agree to comply with all city and county ordinances out state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
QTY MECHANICAL PERMIT FEE
SEISMIC F
PERMITISSUANCE
IA.ECfRIC
ti . -
ahovatnenlioned properly for inspection purposes.
- (We) agree to ms'. indemnif y and keep hamdas the Cit of Cupertlno atimum
ALTER OR ADD TO MECH.
PLUMBING FEE
Iiabilities,judgrems, costs and expenses which may in any way accrue againstsaid City
conseyvancearth ��➢��➢ granting of his peniL
AIR HANDLING UNIT (TO 10,(I00 CFM7
MECHANICALE
APP6ICAN'5 �� ND W COMPLY.
$OURCF. R .GV ATIO
,
s AIR HANDLING UNI'T(OVF,R 10,000CFM)
CONSTRUCTI NTAX
�ALNON-POINT
Si to of Applicant onfmcmr Data
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST FOOD OVDUC)
HOUSING: IGATION FEE - _
HEATING UNIT ITO 100,000 BTU)
Will Ne applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and he Health and Safely
Code, Section 2553200
-
HEATING UNIT (OVER 100,000 BTU)
❑Yes - ❑No -
VIIILATION FAN (SINGLE RESID)
PAID Data ReccipaM
BOILER -COMP (3HP OR 100,00) BI U) -
Will the applicant or future building occupant use equipment or devices which
emit htimdous air contaminants as defined by he Bay Area Air Quality Management
)TAL:
BOILER-COMOVER I00,IXID BTU) • s - s
P,(
Dishicf7 "''
❑Yes, - ON,,
,. .
_
AIR CONDITIONER
I have mal the harard,,us maedals ragohemems male, Chapter 6.95 of he Cali-
ISSUA11CF, DATE
NEW RESIDENTIAL SHIED. SQ. FT.
fomia Health & Safety Cede. Sections 25505. M533 and 25534. 1 understand that if am
building docs nm currently have a mount, hal it is my msponsihihty In notify the owcupam
_
of the requirements which muse be fuel prior o issuance of it Certificate of Occupancy.
n
ISSUED BY:
TOTAL:
Owneraroudeotimdagem - Date
OFFICE