31358 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY C
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. a] C•�`
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J 3
BUILDING PROJEM IDENTIFICATION
HUILDINGADDRESS: SANITARYN3 APPLICATION SUBMITTAL DATE
0 I'dr ?04 pt� r ' 0 =LKAb
OWN' 'SNAME PHONE: CONTRA OR:S NAME: LIC
— Uri11 NIC JJJ/\ CON'1'ROLp
:RCfiiTF.CTIENGEER; DR
INLIC NO: ADESS: 0 4 ❑
r %• N r l
CONTACT: PHONE: BUILDING PERMIT INFO
��� I - / �^
1:1 Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PI.U❑MB ECH
jt�LA
LICENSED CDN FRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I herehy affirm map 1 mm licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Section7")of Division 3 ofthe Business and Professions Code,and mylicenseis RESIDENTIAL:
WOO ` PERMIT ISSUANCE
FU.. in full force and effect ❑SFDWI. [I KITCHEN REMODEL
<UU License Class Lica - APPLIANCES-RESIDENTIAL []ADDITION ED PLUMBING RE-PIPIT
h a a Date Carmetor
ARCHITECTS DECLARATION a ❑MULTI-UNIT El STRUCTURAL
Z p o1 Z I undersand my plans shall he used us public reemds PANELS MODIFICATION
OZ4Q UP'10200 AMPS ❑INTERIOFP w D El CHIMNEY REPAIR
1-�E"LLl Licensed Ptofcnsional
201-1000AMPS IMPROVEb1EIsTfl
OWNER-BUILDER DECLARATION
pCY � OVER 1000 AMPS ❑BATHRFMODELREPAIR ❑DEMOLITION
C Q 1 hereby Oman that I am exempt from the Conlmcim's License Law fnr the ..'�rQQ���'tt
5a5�.paU following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL 0O en/�
LLl'3 LL F" which requires a permit m construct,alter,improve,demolish,or repair any structure QC(,•
��•�
prior o its issuance.also requires the applicant for such Permian file a signed,,mcment SPECIAL CIRCUIT/MISC. �S
thin he is licensed punm tto Ne provisions ofthe Contractors License Law(Chapter 9 it Gka
ad C, (commencing with Section 7000)of Division ofthe Business and Professions Coslc)or TIiMP METER OR POLL(NST. rL11"Nfng
a a ey Nat he is exempt therefrom end the basis for the alleged exemption Any violation of ❑NEW BLDG/ADDITION LJ DEMOLITION
W_ Section Section70J1.5 by any applicmt for a permit subjects me applicant m a civil penalty of POWER DEVICES ENANT [3 FOOD SERVICE
not more than Five hundred dollars($500).
•F.Z� SWIMMING I'O ITL "RIC OTHER F.MENT
fZ ❑ Lor me work,
dumnac-or my mendedwain wages r their 0,14.0 lines,
LL will do mewons and Ne Omnuma torintendede Law doforot apply o an weer oz OTHER
3 and property
who
Cale:The Contractor's License Law does not apply m if owner of RfRETS-SW -FIXTURES
properly who bulldx or inspmves thereon,and who docs such work himself or niraugh
his own employees,provided rant such improvements are not intended or offered for NEW RESIDENTIAL ,CI'R SQ 14.
sale.IL however.the building or improvement is sold within one yearofcompletioqthe SQ.FE FLOOR AREA SIgQ.F1'.
owner-builder will have the burden of proving that he did not build or improve for par-
pow of sale.). y
TOTAL:
0 1,as owner of me prnpeny,am exdosively contracting with licensed contmmms m pA
instruct the paged(See.9144.Boom,and PmE,,inns Cale:)The Commcnn's Li- P M
cense Law does not apply to an owner of properry who builds or improves thereon,and NDRAINS
PLUMB GNI: FEE
who contracts fm such projects with a commare(s)licensed pursuant m the Comracmr's
License Law. RMIT ISSUANCE, OCT 2 2199
0 Iran exempt under Sec. .B K P C for mix maxm
LTER-DRAINK VENT-WATER(EA) VALUAT'p VU
•Owner nine Gr�Y1`'k `�
WORKIfR'S COMPENSATION DECLARATION ACK FLOW PROTECT DEVICE
I hereby affirm under penalty of perjury one of the following deductions:
I Etwirid will maimma aCenifcamof Consem mwlf-intone fur ,Worker's Compen- -FLOOR,ROOF,AREA.GOND. STORIES TYPE CONSTRUCTION
cation,us provided for by Section 3700 of the Labor Code,for the per omemoc of the
work for which this permit is issued. FIXTURES-PER TRAP
19 1 have and will maintain Worker.Compensation Insurance,as required by Scetion
17(X)of the Labor Code,for performance of the work for whichad,permit is issued. GAS-EA.SYSTEM-I INC.40 .ITS OCC.CROUP APN
My Workers Compensation Insurance carrier and Volic)sup b�cr y
Cartier: 6? m8a1� 'Tie Policy No.:O/J.II4e�sJ /�T M GAS-LA.SYSTEM-OVER 4 )
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPJINDUSTRI.WASTE lR EERCE BUILDING D ISION FEES
(This section need not lc completed TOM permit is form=hundred dollars(SIM) GREASETRAp
or It.,,.)(This
FEE
I certify that is the pedisrounccofthe work l in which Nis permit is issuid.[,hall SEWER-SANITARY-S'IORME FT.
not employ any person in any manner m as to become%object to me Workers Compen- ENERGY ITE
Z cation Laws of California.Date WATER HEATER WNEICEELECIR
ZApplicant GRADING�1
Z NOTICE TO APPLICANT.If,after making this Ccnificmc of Exemption.you should WATER SYSTEM/1UEsMING
a ? become subject m me Worker's Compensation provisions of the Labor Code,you must SOILS P
{SI F-t (onhwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
a0
.7- Z CONSTRUCTION LENDING AGENCY NEW RFSIDENTIAI.PLMB. SQ.FT. PAID Dm Rcceiptp
U0 Ifar,h,hthithat
penoi i,aed(See ion 30lending agency for performance of
U the work for which this permit is ixxved(Svc.]097,Civ.C.)
�s Lender's Name
TOTAL'.
W Lender's Add., TOTAL:
1 verify that 1 have read this application and spam quids,above infoonntlmn i, BUILDING
F•'y coned.l agree to comply with all city and county mdinances and sate laws plating to QTY. MECHANICAL PERMIT FEE
UZ building construction,and hereby minimize representatives of this city to enter upon the SEISMICFFs L
oMrve-oteminned propery for inspection purposes, PLIRM['1'ISSUANCE
(We)agree m save.indemnify and kap hmmlcssthe City of Cuperino again,, /1s 1?LIiCTRIC EE
liabiom,,jid ts,costs and expenses which may in any way accrue against mid City ALTER OR ADD TO MECH. � '� PLUMBINpME
or nsequn e t O'hixpernpit.
APPLICA ERSTAN)S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('IY)IOdXO CFM)
SOUR ONS. MIiCHANI' FEE
_9/ AIR HANDLING UNIT(OVER 10,MOCFM) CONSTRUCTION
Signature of Applican unuaztm Date F� EXHAUST HOOD(W/DUCT) HOUSING MITIGATION L
A7ARWU5 RIA . DISCLOSURE
Will the applicant or future bu ing occupant store or handle hazardous material HEATING UNIT PTO 100,000 BTU)
as def nal by the Cupertino Municipal Code.Chapter 9.12,and me Health aril Safety
Cale,Section 25532m)'t HEATING UNIT(OVER 100.000 BTU)
Yes No
0 VLNTILA'1'ION PAN(SINGLE RLSI[p PAID Uatc Recupl
Will the applicant or fumm building occupant use equipment or devices which
emit bmanloos air comominars as duGncd by[lie Bay Arca Air Quality Management BOILER-COMP(3HP OR 100,M)B'TU) TO L:
Ld��nm
BOILER-COMP(OVER iM."BTU)
EINo
read me hwmtka,materials requirements under Chapter 6.95 of the Cali- AIR CONDOIONER ISSUANCE DATE
&Safety Cele,Sections 25505.M533 and 25514.1 understand Nat if Ne NEW RESIDENTIAL MECH. SQ.FT.
nm crummly have a tenant.that it is my msp,msihillty to notify me o,cupamtmnts which must hemet prior m sssuumn da CrniOcu¢of Occupancy.horized agent Dae T 7_ ISSUED BY:
OFFICE