31539APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING -ELECTRICAL -
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL
BUILDING PROJECT IIIENTIFICAI [ON
PERMIT NO.
31539
BUILDINGADDRESS:
SANITARY NO.
APPLICATION SUBMI'ITAL DATE
OWR'S NAME: PI N)::��
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CO ACTOR'S NAME: LIC NO:
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ADDRESS:
oNTACE PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLI3G ELECT PLUMB MECH
COZ
y
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LL7
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm Nat 1 em licensed under provisions of Chapter 9 (roomomming
with Section]f0U)uf Division3 of Ne Business enJ ProfessinnsCase. and my license is
in full force and effect.
License Class LiaX
Oute Contractor
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RFSIDNTIA L
-�-
CSFDWL El KITCHEN REMODEL
CpDDIT10N El PLUMBING RE -PIPE
[I MULTI -UNIT []STRUCTURAL
MODIFICATION
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
p >
r__r ❑
ARCHITECTS DECLARATION IDN
(understand my plans shall be used ss Public rccuNs
PANELS
Z �
UPTO 200 AMPS
[I INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODELIREPAIR 0 DEMOLITION
(]OTHERY3.
bdf3
OyU
F
Licensed Profss -
eional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or countySIGNS
which requirens
s a Pemtit to construct, niter, improve,ctme
demolish, or repair any sw
prior,. its issuance,alwrequires the applicant for such Permit o fileasigned swtement
201401SAMPS
OVER IMAMPS
ELECTRICAL
SPECIAL CIRCUITIMISC.
ae0p
that he is licensed pursuant to no Provisions of Ne Conuamors License Law Chapter
(commencing with Second 7000)of Division 3nf,he B.,imessand Pndesniams Cade7or
TEMP. SISTER OR POLE MST.
COMMERCIAL'
I„ Ny
6
G
Nat he in exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicantfore permit subjects the applicant toacivil pcC.hy of
nu, more than five hundred doll.. ($500).
Cl, as owner ofthe pmpeny, or my employees with wages as their sole compensation,
will do the work,vnd the sbuctua is not intended oroffered fnsale(Sec. 7014, Business
C NEW BLDG/ADDITIONOLITION
❑TENANT FOODSERVICE
IMPROVEMENT
COMER
POWER DEVICES
SWIMMING POOL ELECTRIC
W
6'3
and Professions Cafe: The Contractor's License Law docs not apply to an owner of
prepery who builds or improves thereon, and who does such work himself or through
his awn employees, provided that such improvements are not intended or offered for
sale. IL however, the buildingor improvement issald withinone yamafmmpletion.the
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL BLECTR SQ PT.
SO FPL94R#RD
SISQ. FT.
cr-builder will have the burden of pmving that he did not build or improve for pun
e of side.).
❑Las owner of Ne pmpery, em exclusively contrening with licensed convucmrs,o
DEC ..
@
g
construct the project (See 7044, Business and Professions Code:) The Contractors Li-
_
1996
,ansa Law does not apply man owner.( property who builds or improves thereon, and
whoamtracm forsuchproectswitha c.nuact.ds)licensedpurs itelto the Comacmrs
QTY, PLUMBING PERMIT FEE
•T3,
CITY Uf- LVr,
PERMIT ISSUANCE
License Lew.
❑lame Jm . R & P C for this mown
t„ I AID
s/ f D --it
WORKIIIIIS COMPENSATION DECLARATION
ALTER - DRAIN & VENT -WATER (EA)
w `VALUATION
BACK FLOW PROTECT. DEVICE
I hereby affirm under penalty of Perjury one of the following declarations:
4s
DRAINS- FLOOR, ROOF. AREA, COND.
❑ I have and will maintain a Cerificato of Consent to self-insua for Worker's Conarn-
anion, to Provided for by Stenion 37W of the Labor Cale, fee the perf ornmea of the
STORIES
TYPECONSTRUCGON
work for which this Permit is issued.
FIXTURES - PER TRAP
C I have and will maintain Worker's Compensation Insurance, m required by Section
3710 of the labor Cede, for the performance of the work for which this Permit is issued.
GAS- EA. SYSTEM. I INC 4 OUTLETS
OCC. GROUP
APN
My Worker's Compensation Insurance cortin and Policy number aa:
Comer: Policy Nn:
GAS - EA. SYSTEM-OVER4EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEI"S
(This section need not be completed if the Permit is for one hundred dollars pt IN)
m less.)
GREASETRAP
PLANCHECK F13E
Z
Z
'Z1-+ y
I cenifythm lathe Pcrommumeofthc work for whichda, permit is issued, l shall
no, employ any Person in any manner sec as to became subject o the Warkers' Compen-
sedan Laws of California. Date
Applicant -
SEWER - SANITARY - STORM EA. HO PT.
ENERGY FEE
WATER HEATER WIVENTIELELTR
GRADING FHE
NOTICE TO APPLICANT: If. after rang this nkiCenificate of Exam,lum, you should
became subject to the Workers Compensation provisions of the Litho, Code, you most
WRIER SYSTEMOREATING
SOILS FEE
{ala
Q
�z
LJ
fL
LUL(
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I bar whaffirm Nut Nem is s ed Sce.. 30 (arming agency for the perfonnanct of
the work fm which this Permit is issued (Sm. 3097. Co. C.)
Lender. Name
1<ndcrAddress
WATER SERVICE "
PAID
NEW RESIDENTIAL PLMB, SQ. Ff.
Dare Rtceip[a
TOTAL:
_ TOTAL
PEE
Tod
U %.
I certifyBUILDING
that I hwe read this applicminn and state that eMwe information is
correct.I agree wcomply with .11 city aced county ordinances and sate laws relining to
is city[. en[p.n to
hae repoewmativesof Naru
building conmruainn, and hereby vmm
QTY. MECHANICAL. PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
abovamemioned Property for inspection purposes.
(We) agae to save, indemnify awl keep harmless the City of Cupertino egains,
AI.TCRORADDTOMECH.
PLUMBING FEE
babilities,judgments.costs and expenses which may in any way acme against said City
in consequence of the granting of this permit.
AIR HANDLING UNL'r(TO I0,000CFM)
MECHANICAL FEB
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCHONTAX
Signature of ApplicanuCoeractor - Dam
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCO
HOUSING MITIGATION FEE
HGTING UNIT 00100.00 BTU)
Will the applicants ser future building recupmd store or handle hazardous material
as defined by the Cupertino Municipal Case, Chapter 9.12, and the ".]In and Safety
Cale. Section 25532(x1?
1(EATING UNIT (OVER 1110.010 BTL)
E] Yes ❑No
Will the applicant m future building occupant use equipment Or devices which
emit haratcous air contaminants as defined by the Bay Area Air Quality Management
PAID
VENTIIXHON FAN (SINGLE RESID)
Dam Receipt X
BOILER -COMP (3HPOR IW.0BTU)
,
'IOTA(.:
BOILER-COMP(OVER 1f0,f00BU)T
Dinrict?
C Yes CN.
AIR CONDITIONER
(have rtad [he hazallous maariuls requirements under Chapter 6.93 of the Cnli-
ISSUANCE DATE
NEW RESIDENTIAL. MECH. SQ. PT.
Coria Health & Safety Cale. Sections 25505. 25533 and 25534.1 understand the[ if use
building docs not currently have a [count, tont i, is my responsibility unitedly the occupant
of be "am... which must Na me, prior to issuance of o Can aleae of fkcuPancy.
ISSUED BY:_�4/s�•�s
TOTAL I
Owner or authorized agent Data
OFFICE