31194 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO BUILDING•ELECTRICAL PERMIT NO. 3119[�/I
BUILDING DIVISION APPLICATION/PERMIT PLUMBING•MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BQJy�IN�DDRESS: � SANITARY NO. APPLICATION SUBMITTAL DATI
O N R'SN M':OkPHONIC C R' LIC
NIC CONTROL M
III ARCHITECT/ENGINEER: LIC NO: AIUVREW ��� J.
❑
CONTACT.- - PHONE: S BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG LECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑
1 hereby affirm that I am lirernsed under previsions of Chapter 9(commencing JOB DESCRIPTION
DaZ with Section 7")ol'Divi.sinr 3 ofthe Brainessund Professions Cade,and Iscnse is
+100 PERMIT ISSUANCE RESIDENTIAL:
It force=d eD _ GSFDWL El KITCHEN REMODEL
to ❑ License s Lit. APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
�j�j ul Date Contractoifft 04!e r
`R' ARCHITELTg DECLARATION 1 El MULTI-UNIT - []STRUCTURAL
PANELS
I Z p Z I undersand my plans shall be used as public records MODIFICATION
OZO UP TO 200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
r t�. Licensed Professional 201-1010AMPS IMPROVEMENT
ySbd , OWNER-BUILDER DECLARATION OVER IM)AMPS [I BATH REMOD FP GD 10LI77 N
C Cd' Q 1 hereby affirm that I am exempt from the Contrucmr s License Law for theII�
p1 O IS U following reason.(Section 7031.5,Business and Professions Cede:Any city or county SIGNS ELECTRICAL []OTHER
F�C{� which rtyuircs.permit to co creel,alter,improve,demolish,or repair any structure
.aJ prior m its issuance.also requires the applicant for such pemtil m file usiguW statement
thSPECIAL CIRCUIT/MISC.
at he is licensed pursuant a are previsions of the Contractors License Law(Chapter 9
COp (commencing with Section,000)of Division 3 of the Business and Professions CrAa)nr TEMP.METER OR POLE INST. COMMERCIAL:
a c K that he is exempt therefrom mM the bssis for Ne allegwl exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
+ may Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
FxZi not more Nan five hundred dollars(S500). ❑TENANT FOOD SERVICE
iQGI,as owner oflhc piopcoy,or my employees with wages as their sole companndon, SWIMMING POOL.ELECTRIC IMPROVEMENT
will do the work,and the auction,is not intended nr offered fafsule Sec.704,1.Business ❑OTHER
and Profession Code:The Contractor'a License Low docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES t
�' .. pruperty who builds or improves thereon,and who does such work himself or through .
his awn employees,provided that such improvements ore nor intended or olfcod for NEW RESIDENTIAL ELEC'M SQ ff.L howver
ole.If. the building or improvement is sold within one yearofeompletion,the SQ.FT.FLOOR AREA _ $ISQ.PT.
owner-builder will have the burden of proving that he did not build or improve for pun ! PAID
Dpose of We.). i�
G I,re owner of Nve
e property.am exclusively contracting with licensed contractors to TOTAL:
retard the project(Sec.7044,Business and Professions Cole:)The Comramar's Li.
cense law does not apply to an owner of Property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE r1AY 6 Qtpfp�
who comment for such projects with a contentions)licensed pursuant to the Commcmrs bled u
License law. PERMIT ISSUANCE
G lamexemptunderSec. .B&PCfordnareason r �vr Vyr
CH
Owner I Data (E
ALTER-DRAIN&VENT-WATER A) AI TION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby uffinm under penalty of perjury one of the following declarations:
I have and will maintain a CmiGcate,ofComentto self-insure for Workers Camper. DRAINS-FLOOR,ROOR AREA.COND. STORIES TYPE CONSTRUCTION
i cation,as provided for by Section 37M of the Labor Cede,for the performance of the
work for which this permit is i...ed. FIXTURES-PER TRAP -
C]1 have and will maintain Workers Compensation Insurance,as required by Section
37M of the Labor Cale,for the performance of the work for which this permit is iissuueed, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUPMy
APN
Cartier.Workcr,.5 m ensation spurs ce carni P Idy No,yrylQp yr8 �1�r GAS-EA.gYSTEMOVLR4IRA)
CERT IgCATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE GRI:ASE/INDUS'1'RL WASTE INTERCEPTOR
BUILDING DIVISION FL'ES
('This union need not he completed if th<permil is for one hundred dollars($1001
or less.) OR TRAP PLANCHECK FEE
I certify that in the pefforaceeaf the work for which this permit is issued,Ishall SEWER-SANITARY-STORM FA.300 FT. -
nat emmploy any person in any manner so as to become subject to the Worker'Compact.. ENERGY HE
Z ..lion laws of Colombo.Data WATER HEATER WNENLELECTR
y/� O Applicant GRADING HE
F4 T~/f NOTICE TO APPLICANT:IL after making this Ce"bilme of Faemption,you should WATERSYSTEMI'TREATING
['! become subject to the Workers Compensation provisiona of the labor Cole.you mum SOILS FEE
fLiLl forhwiN comply with such provisions or this permit shall he deemed revoked WATER SERVICE
a
Uz CONSTRUCTION LENDING AGENCY NEW RBSIDENTIALPLMB. SQ.PR PAID Date ReceiptN
U(21 hereby affirm that there is construction lending agency for the performance of
the work for which this pcnrdt is issued
ueded(Sec.3097,Civ.C.)
u.F' Lenders Name TOTAL:
Landers Address - TOTAL:
I certify that 1 have read this application and sate this the above information is BUILDING FEE
In correct.l agmen comply with all city and county ordinances and stars laws nothing hs QTy MECHANICAL PERMIT FEE
V z building convection,and hereby anionic representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamiless the City of Cupertino against ELECTRIC FEE ,
liabilities,pragmatist,corns
insists and expa which may in any way same against a a id City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of rhe granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICALFP.E
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER I10,000CFM) CONSTRUCf10NT
Signature of Appiontro/Conuacmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wrllthe applicant or fmurc brilding acuDem score or handle hmsrdow materiel HEATING UNIT(TO Iflu."BTU)
as ckdm J by the Cupenina Municipal Code,Chapter 9.13,end the Health and Safety
Code,Section 25532(.)4 HEATING UNIT(OVER 100,000 BTU)
❑Yes @N.— VENTILATION FAN(SINGLE RESID) PAID
Data Receipt M
Will the applicant or ntfms a building byoccupant Buseequipmentor Management
BOILER-COMP OHP OR 100,(100 BTU)
emit hazardous air conaminama as defined by the Bay Arca Air Quality ManagenK'nt TOTAL: '
District? I
BOILER-COMP(OVER 100,0X1 BTU)
GYes C3m�
I have rand 0e hatardnusmaterial,rtyuiremeim under Chapter R95o1'the Cid AIR CONDITIONER ISSUANCE DATE
forms Health&Safety Code,Seetions 25505,25533 and 25534.1 undersand than if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant,that it is my responsibility to notify tha occupant
' of Na^rtquuemrnst which mus t nor 'seance of a Cerilfica``tppf c r
I l�� Pz4 - ✓ TOTAL:
O n�utfinor, agent Date -I ISSUED BY.
OFFICE