31293 (2) `PPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
/CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 31293
BUILDING PROJECT IDY:NTIFICA'1'ION
BUILDING ADDRESS: SANITARYNO. APPLICATION SUB. TTALDAT
quo -
OWNERS NAME: PHONE: CONTRACT'OR'S NAME: LIC NO:
NIC OM1 ROI-
Cf/ENGINEtJt IC NO: AD ESS if= ❑
/ <<oo xkd. ca
CONTACT: PHONE: BUILDING PERMIT INFO❑ Consultant Feu Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION of hap QTY ELECTRIC PERMIT FEE
I hereby affirm Nal I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Section] ,) ID ofthc Business n n fci turdmylicenseis RESIDENTIAL:
'al_
- O in fullforee and Rat PERMIT ISSUANCE
G U U License C Uc.x ❑SFDWL ❑KITCHEN REMODEL
QLLti' Dam Contactor APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE
A HITF.CTS D. TI ❑MULTI-UNIT ❑STRUCTURAf.
Z p ti Z 1 understand my plans shall W used as public records PANELS MODIFICATION
O Z UP TO NO AMPS
FBF-IWil Licensed Professional ❑INTERIOR CHIMNEY REPAIR
,j OWNER-BUILDER DECLARATION 201-I000AMPS IMPROVEMENT
C C 6 1 hereby affirm that 1 am exempt from the Comrunor's License Law bathe OVER IOW AMPS ❑BATH REMODEL/REPAIR �DEMOLITION
X 3 6 F following reason.(Section](131.5.Business Po
and desions Codore:Any city county SIGNS ELECTRIC ❑OTHER nlfl>(� \.J d i An
rn which requires a permit to construct,alcor,impress,demolish,or repair any structure
Q prior o its issuance,also requires the applicant rot such Permit o file a signed statement SPECIAL CLRCUI C.
CQ� Nat he is licensed pursuant it)the provisions arthe Contractor's License Law(Chapter9
I+I�pO (commencing wird Sectian]BIXB nTDivision3of Nc Business and PmfecM,ur,Cde)or TEMP MET OR POLE INST. COMMERCIAL
d%v 9 thathe is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 70315 by any applicant for alrarmil subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOODSERVICE
� < n more than five hundred dollune 55001.
❑Lasownerot the IMPROVEMENT ' .
pmpcny nnny employees with wage.a.their sole compensation, SWIMMING POOL ELECTRIC
F will do Newons aide:'?he Confr.nolinanded nr Law
ma
it)an,Business 0DTHER
C w and ed,who
ill—,The Conaoctan'v 1andn.e da Jars oat a I man owner of OUTLETS-SWITCHES apply S FIXTURES
properly who bulls,sir sided t a tbsuch improvements and law such wnte himself offered fah
his own employees,building oral,ver eatisuldare nut intended or offered toe NEW RESIDENTIAL ELECTR SQ IT,
sale.If,hnwevcpll have
buten of pemenl i,sold wlid noncyarofcompletion.the SQ.Fr FLOOR AREA A/SQ:FT.'
er-M1uilJer will have the burden of proving that he did not buil)or improve for bur- '
Mre of sale).
1,as owner of the progeny,mar exclusively atonement,wifh Iiarsd mtarectos o, TOTAL:
construct the project(Sec.](Hn,Business and Professions Core:)'I'he Conoaaor's Li.
cense Lowdeas not apply m art ownerofpropeny who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a nmmowlerl)licensed pursuant to the Contractors
License Law, PERMIT ISSUANCE
❑I not exempt under Sec. ,B&P C for Nre
is ason
«
ser are
ALTER-DRAIN&VENT-WATER(EA) Me —
DVALUATION 'rqa
1 WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE l hereby affirm under Penalty of perjury one ofthe following declarations: I (/as. Oa P7 yDL
❑I have and will maintain o Cenifiam of Conscm hovel!-insure for Workers compeer- DRAINS-FLOOR,ROOF.AREA,9WD,
Nation,as provided for by Section T/W of the Labor Cute,for the perfomance of be STORIES TYPL CONSTRUCTIOs
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
37W of Ne Lubar Cde.far parfonrttaace of the work far which Nis permit is issuad. GAS U'
IN•. T, OCC.0 OUP qPN
My Works' Co lio I sus cecameranJPudi,lyW—�h�eTp.am:
Carrier: Policy No.: rWC-'01 r, dad GAS-EA.SYSTEM-OV 44A)
CERTIFICATE PEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE /i/ZY GREASFIINDUSTRL W. 'TL INTERCEPTOR
(This section treed nut be completed ifidc permit Is!atone handed dollars(5100) BUILDING DIVISION FEES
or les.) GREASE TRAP PLANCHECK FEE
I certify that in the performance of the work for which thispcomit is issued,I shall SEWER- AMTARY-STORM EA.2W FT.
not employ any person in any manner sat subject as to Wcon,subjeco the Worken'Comber- ENERGY FEE
o Z rataw
tion s of Califrmia.Date
�
WATER HEATER WNENT/ELECI'R
Z Applicata h NOTICE TO APPLICANT:If,after making this Cert ificae of Exemption,you should GRADING FEE
a ; become subject the Workers Compensation provisions of Ne Labor Code, t WATER SYSTEWfREATING
forthwith victim, Ih such you most SOILS FEE
� Owi previsions onhis permit shall he seemed resided, WATER SERVICE
G
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMR. SQ.BE PAID
[_30 l herebywhich thi that fom,aisaed(Sea constructionlendingagency for performance at. Date Receiptk
Li•I F Newark for which this ponnit is issued(Sec.l00],Civ.C.)
Lender's Nome
TOTAL:
TOTAL Lcnset,Address TOq'A L:
F 0. 1 cerlity that 1 have read this application and stale that the above Information is BUILDING FEE
(Z) cancer.l agree to comply with till airy and County ordinances and slate laws rcmling to QTY. MECHANICAL PERMIT FEE
UZ building construction,and botchy awheruerepmactuafivexof this cityasemerurym the SEISMIC I+F:E
ahove.mcationed property for inspection ImMascs. \
or
(We)agree for noose,iadleau fy unit kucp hunt.,.the City tit Cupertinoagund PERMIT ISSUANCE, ❑LEC'TRIC PEE
liabilities,juJgmcnfe.cost.unit cxpcnn,ishahrety in any wayaa'mcagninslsuid City ALTER OR ADD TO MECH.
in asequence of the grunting of Iris penial. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IBM)CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signature of Applicanl/Contmmmr Data !EXHAUS!THOOD(W/DOD(W/D )HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building tccupanl store or handle haoudous mamnal LTO I W 0)B Uas defined by the Cupertino Municipal Cdc.Chapmr 9.12,and thn Health and SafetyCada,Section 255321a)I T(OVER W,(;p BTU)❑Yes ®Nn ���FAN(yNGLE RFSID) PAID
1rhWill the applicant m Ibmrt building occupan ua equipment or devices which emaaniou,air contaminants us defined by the Boy Area Air Quality ManagementP(3HPOR IW.000 BTU)Didn't? TOTAL:
❑Yes ®No P(OVER 100.010 BTU)
1 have read the haaaNnus materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER I U CE
maria Hat&Safety Cook.Sections 25505.M533 and 2553understand1.IunderstandNm if the NEW RESIDENTIAL MECH. SQ.FT.building docs not currently have a tenant.that it is my responsibility to notify the occupant
of the requiomanu which must Ice met poise m issuance of a Certificate of Oce patsy,
Owneroramhoead per Dae TOTAL:
ISSUED
OFFICE