31035 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION - APPIACATION/PERMIT PLUMBING•MECHANICAL 31035
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY ND. APPLICATION SUBMITTAL DATE
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CDNI'ALT. PHONE BUILDING PERMIT INFO
Consultant Fees Paid By Applicant(Initial) BLDG EK PLUMB M:C
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE ❑ ❑
I hereby affirm that Tom licensed under provisions of Chapter 9(cmmuctrom, JOB DESCRIPTION
o50 with Section WllNoof Oivisinn3of the Business end 'rz fessioms C le,and m licensees PERMITISSUANCC
O O_ y RESIDENTIAL:
in Cull force aW eff
aEMODEL
U tW Liccnac Clas Lira z ❑A DWL E3 KITCHEN RE-PIPE F�LLI Dom Commnor APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
IN,Oran ARCHITECTS II[CLARA'fl N PANELS ❑MULT4UNIT ❑STRUCTURAL
z O r12 z 1 understand my plans shall bo used as public records MODIFICATION
Ozu, UP TO 200 AMPS El INTERIOR 11 CHIMNEY REPAIR
l-lW Licensed Professional 201-Ing%TAMPS IMPROVEMENT
C6 ay OWNEmexempt frmdue Concision's
OVER[(Hill AMPS ATH REMODEUREPAIR 0DEMOLITION
I heresy affirm rhes 1 nm exempt from the C,oms,C'e License Law far the
X3aF whichfollow
nquires a (Section 7031.5,Business alte.sand Professions Code:Any city ar county SIGNS ELECTRICAL OTHER
F. 0 which requires o permit m emsuuct,altar,nt for su demolish,or repair any stmcrme
gF,�.,O prior,.its issuance,also rcyuircsthe applicant for such pertain.filcusigned suucmem SPECIAL CIRCUIT/MISC.
C;!{Ny that be is licensed pursuant to the provisions of the Contractor's License Law(Chapter9 ''J
..00 (commencing with Section T%kB of Division 3of the Business and Proms,nns Code)or TEMP.METER OR POLE INST COMMERCIAL: Wh�—
d a n that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NE•W BLDG/ADDITION ❑DEMOLITION
Seclon70315 by any applicant for apenmit subjriudeapplimmum.civil mmaky.f POWER DEVICES
w []TENANT ❑FOODSERVICE
not more than five hundred dollars($500).
,F.zL�' IMPROVEMENT
� a0 ❑ Lasowncrofthe propcny, my.t mmadeswuffinees for side
sole compensation, SWIMMING POOL ELECTRIC
wdl dosework,Core: structure,eCmars t.e.I.,veme Law
du,vol apply .tr o Business ❑OTHER
L ono mly who I Csde:The Cnnroaors License Law dress nal apply m f owner of OUTLETS-SWITCHES-FIXTURES
.. his o ny who irds in improves themhn,and who docs e n work himself itthrough
his own employees,building
Net such meat is said
within art not intended m.leered for NEW RESIDENTIAL ELECfR SQ FT.
sale.ILhowever wll hauilthe buren ofpementithat hedoneymor imprveforthe SQ.FT.FLOOR AREA LSQ.FT. -
cr-oric.) will have the burden of proving that he did not build or improveforpur-
poscof as owne —
❑ I,uctthetof the ojem(Smpengu exclusively contacting CoM1......Co.....censed ... t. TOTAL:
mnnmnt the pmj¢t(Sec.7M4,Business and Pro&ssions Code:)The Contrunnls U.
cense Low does not apply,.anowmer.f property who builds in improves fiction.and QTY, PLUMBING PERMIT FEE
whoc.mmucts fortach projects with a contractor(s)licensed pursuan o the Comrwtnr's
License Law. PERMIT ISSUANCE
❑ IamexemptundrSec. ,B&PCfor Nisteasan
ALTER-DRAIN&VENT-WATER EA)
Data VALUATION
l owner
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ,f-6 OQ
1 hereby affirm under penalty of perjury one of the following declinations: -7 ` /
qiwj I have and will maintain a Cenificate of Consent o salf-insure for Worker's Compcn- DRAINS-FLOOR,ROOF AREA,GOND.
jSTORI as provided far by Section 3700of the Labor Code,for the pcommo.ce of the
IES 'IYPC CONSTRUCTION
w kdbrwhichthis permit is issued FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Lahr Code,for do erf...ce.ftheivoldifirowlimh1h ranifitihomed. GAS-CA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Wit
C pens - Suan cartrer.ma Pricy r
Carrier: Policy Na GAS-HA.SYSTEMAVER 4(EA)
CHRTIFICATE pn J`EMPIONMOM WORKERS'
COMPENSATION INSURANCE GRWEIINDUS'I'RL WASTE INTERCEPTOR
(This section need not bo completed if the permit is foronehundmddollars 0)1510Bl11LDIN0 DIVISION PCHS
or less.) GREASE TRAP PLANCHECK FEE
I certify that in performancenf the work forwhich this permit is issued,I shat] SEWER-SANITARY-STURM EA.200 FT.
not employ any person in any manner an as to become subject to the Worker'Compen- ENERGY FEE
O z salon I.aws of California.Dam WATER HEATER WNENT/ELECTR
O Applicant - GRADINGFEE
h NOTICE TO APPLICANT.IL after meningitis Certificate of Exemption,you should WATER SYSTEMITBEATING
a ; become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS PEE 13
{2a forthwith comply with such provisions or this permit shall he dccmcd revoked. WATER SERVICE
Q /�I
CONSTRUCTION LENDING AGENCY NEW RI351UENTIAI.PCMB. SQ.FT, PAID it V
V Q I herfar by which
that is sued(Sac.construction lending agency(nose Performance of Dat
� L•+ the work for which this pcnnit is issued(Sec.l09],Civ.CJ
Q V Lender'a Name Err T
Lendcr'x Address - TOTAL:
CL I cenify that 1 have mad this application and state that the above information is BUILDING FEE
In menet.)agree to comply%ith all city and county ordinances and nam laws miming to QTY. MECHANICAL PERMIT FEE
U 7.. building constriction,and hereby authurize representatives of this city to enter upon the SEISMECFEE
above-mentioned property for inspection proposes. PERMIT ISSUANCE50
We)agree to save,indemnify and keep harmless the City of Cupertino against 1 ELECTRIC FEE
Iiabilities,judgments.castaand expenses which may inmy way accmeagvest said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICA TUND13RSTANDS ANU WILL COMPLY WITH AL NON-POINT , AIR HANDLING UNIT(TO I0.000 CFM)
SOU . EGULATIONS. MECHANICAL FEC
�O AER HANDLING UNIT(OVER 10,1100 CFM) CONSTRUCTIONTAX
Sig mmnf Applicuw/Comramnr 'Doc' EXHAUST'1[001)(WIDIICT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hamrdous material THEATING UNIT Q0100.000 BTU)
m defined by the Cupertino Municipal Code,Chapter 9.12, it the Health and Safety
Code,Section 25532(n)] sa,r II HEATING UNIT(OVER BOOM BTU)
❑Yes YNn VENTILATION FAN(SINGLE RFS ID) PAID
Date Receipt a
Will the applicant or future building occupant B use equipment or ravines Management
ilhazardous air eonmminan5 as define)by the Bay Arra Air Quality Mawgcmcm BOILER-COMP(3HP OR IIpp(%1BTU)
TOTAL:
>inricYl
❑Yes No BOILER-COMP(OVER 100,0(i)BTU)
E have read the bromous materials uimunts under Chapter 6.95 of the Cali- AIRCONDITIONliR
r1, p I ISSUANCE:DATE
fom'a Health&Salbty Code,sections 2551)5,25533 and 25534.1 understand Nm If the NEW RBSIfICNTIAI.MECH. SQ.FT.
huildin do of currently havm¢nanL that it is my respnnsibiliymnn'fy the occupant
of enm
nts which most be etprionaiamnceof des pony.
rI
nrizeA ugimtate TOTAL: ISSUED BY: I O i
OFFICE