31365 Is
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY - .,
-CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 31365^ ^ k�
BUILDING DIVISION APPLICATIONifPERMIT PLUMBING-MECHANICAL J< 3165
BUILDING PROJECT IDENTIFICATION "
B ILDINGADDRES.S:a- SANITARY NO. APPLICATION SUBMITTALDATE
U L
OW 'S ME: - PHONti:. CONTRAC FOR'S NAME: LIC NO:
U tINU SIC CONTROL#
.•1RCHITECT GINEER: LIC NO: AUURESS. ❑ .
CONTACT: PHONE: BUILDING PERMIT INFO
r ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB , MECH
❑ ; D ❑
LICENSED CONTRACTOR'S DECLARATION'
Chapter
QTY. ELECTRIC PERMIT FEE
I hereby affirm that film licensed under provisions of Chapter 9 my firemmng TOB DESCRIPTION
QZ with Section 7(100)uf Division3 of tha Rosiness and Professions Code,and my licence is RESIDENTIAL'
F O In full fore and effect. PERMIT ISSUANCE
0UV License Class Lias ❑SFDWL ❑KITCHEN REMODEL
iZ; l Date kContractor APPLIANCES-RESIDENTIAL El ADDITION - El PLUMBING RE-PITH
run a' ARCHITECTS DECLARATION
O Z 7a I understand my plain shall be used as public records PANELS ❑MULTI-UNIT LD STRUCTURAL
MODIFICATION
UP102M AAfvs
p.n.nZECq'q LrenMRf I 1 ❑INTERIOR ❑CHIMNEY REPAIR
q`,E2� OWNER-BUILDER DECLARATION - 201-1000 AMPS IMPROVEMENT..77 CC M1 h 1 by afford that T am exempt from the Contracts License Law for the OVER 1000AMPS ❑BATH REMODEUREPAIR El DEMOLITION
O pi U following mason.(Sectio
3 WI- n 9031.5,Business and Professions Cade:Any city n_r county SIGNS ELECTRICAL ❑OTHER
t++ m¢ wMah requires pe it to construct, Iter.impmve,demolish, P Y structure
prom.na illuounil,insuniquin,,he pphreadi -: 'Pendin1 file a same'someoe' SPECIAL CIRCUIVMISC,
Ihat h 1 n. cip va tt theprovisions fth Contractors L L (Cherner9 _
p0 (coin Cng wall Section TWO) fD"nm 3(lithe Business ad Profoilione,Code)or TEMP.METER OR POLE INST. COMMERCIAL
4 y m C that he is exempt beneficial and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION El DEMOLITION
0
Second by any applicant for permit mbjec4 the applicant tau civil penalty of " POWER DEVICES ' ❑TENANT
yFp. not more than Eve hundred unite,,($50(). e - -[:1 PGGD$eRY1Ge
SQp ❑ I,as owner of the property,or my employm,,with wages as their so le compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
I. will do the work,and the structure is not intended or offered forsale(Sec.7044,Business ❑OTHER
and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
0•'3 Property who builds or improves thereon,end who doe,such work himself sr through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR
isle.If,however,theboilme,in improvement is sold wllhin one yearn[completion,the .FLOOR AREA $/SQ.FT.
" ner-builder colli have the burden of proving that he did not build m improve for per-
' peso of pale).
❑ L as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
comhad me project(Sec.9044,Business and Professions Code p,I'he Contractors Li
rise Law does not apply to on owner of property who builds or,improves thereon,and QTY, PLUMBING PERMIT FEE - -�
who contracts 0a such projects with a eontraeeps)licensed pursuant to the Contmener's -
License Lou. PERMIT ISSUANCE
❑ Iain V7Wncry, ,B&PCfo t ' son
- ALTER-DRAIN&VENT-WATER(EA)
Owner D: - VALUATION
f I WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
(� I hereby affirm under penalty of perjury one of the following declarations,
❑I have and will maintain a Certificate of Consent to self-insure fsrworkere Condom- DRAINS-FLOOR,ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
soden,le provided for by-Section 3700 of the Labor Code,for the perfonrwnce of he
week far which this peralow ixsued. - FIXTURES-PER TRAP.
❑'1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,forte pefnrtname ofthe work for which this peonit is issued, GAS-EA.SYSTEM-I INC. OUTLETS OCC.GROUP
My Worker's Compensation Insurance carrier and Policy number am,
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE,OF EXEMPTION FROM WORKERS'.'
COMPENSATION INSURANCE GREASEINIIUSTRL WASTE INTERCEPTOR - BI111.DING DIVISION FP.P.S
(Thio section need not becmnpleted ifthe scout,is Intone hundred dollars($1(111)
or less.) SE TR PLANCHF,OK FEE
fructifythat in theperformance ofthe work for which this -
p the Workers'
Comprll SEWLR- ITARY-STORM EA.200 ET.
not employ any person in any mannenn as m become subject m the Worked Cnmpen- ENERGY PEE
Q �.. ration Laws of Califomia.Dale ATER HEATER WNENT/ELECTR -.
'Applicant - GRADING FEE
h NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTFM/TREATING
abecome subject to the Worker's Compensation provisions of the Labor Code,you mum SOILS FEE
Wfonhwithcnmplywith,mliprovisisnsor this marts hall be deemed revoked WATER SERVICE -
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM Is SQ.Ff. PAID
V I hereby affirm thatthere is a conseraniun lending agency fee the perfmmlmce is Date Receipts
w the work for which this peri issued(Sec.3099,Civ.C.)
Q Landerr
s Name - - - - TOTAL:
LQ)� Lender's Address TOTAL:
1 certify mat I have read this application and state mot Itic above information ie BUILDING FEE y,
F.t 0 correct.I agree to comply with all city and county ordinances and state laws relating ,, QTY. MECHANICALPERMIT FEE
building constiuctice,and Ismehyamhorize repmsentmives ofthis city to enter upon the SEISMIC PEE,
abovomentuded property for inspection pumesea. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way aceme against said City ALTER OR ADD TO SUCH,
in consequence of Ne granting.1 this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) '
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
Signature dApplieant'CrintraCtm Date FAHAUST FOOD(W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNI'F(TO 100,000 BTU 1
as defined by the Cupertino Municipal Code,Chapter 9.12,and me Health and Safety - r�
Cade,Section 25532m I? HEATING UNIT OVER 100,000 B U
E]Yes F-1 No - �� -
VENTILATIONPAN(SINGLERESID PAID Data Receipts
Will the applicant or future building occupant use equipment or devices which
emit hazardous in,mnt5minants as defined by the Be,Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)" -
District' TOTAL:
❑Yes F1 No BUTLER-COMPO 0
I have read the hazardous materials requirements tinder Chapter 695 of the Cali AIR CONDITIONER- OEWD? f ARr7LAT ISSUANCE DATE _
barrel Health&Safety Code.Sections 25505,21533 and 25534.1 understand thing the NEW RESIDENTIAL MECH. Q. RTINO
building does not canemly have a tcount,that it is my rs ose,,bila,as notify the moots nt
of the requirements which must be card prior to Issuance of a Com,ficamof Occupancy. 1, '
` Owneroramhoozedogem Dote TOTAL: ISSUED BY:
OFFICE