31541 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL :
BUILDING PROJECT IDENTIFICATION 31541
31ELDINGADDRMS: - SANITARY NO. APPLICATION SUBMITTAL DATE
vS PHONE
— CONTRACTOR'S NAME: LIC NO:GLZr
NIC CONTROL
NEC,IETECT/ENGINEER: j " LIC NO: ADDRESS:. ❑
CONTACT, - PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT LUMB MECH
LICENSED CONTRACH)R'S DECLARATION QTY ELF.CI'RIC PERMIT FEE
1 hereby AM.that 1 3 licenses under provisions of Cesht 9(cnmmemm i, JOB DESCRIPTION.
I� with Section Aldo of Division3ofthe llusiness end Professions Code.and my license is RESIDENTIAL:
O � PERMTI'ISSUANCI?
H UW�. m full force antl eRecs.
�Uk� License Class Lic.p - CSFDWI. [I KITCHEN REMODEL
A--)74 Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
IZ�=ol n ARCHITECCS DECLARAGON i' PANELS e a El MULTI-UNIT ❑STRUCTURAL
vv�J IumidertunJ my plans shullMused as public records MODIFICATION
0z SUP TO 200 AMPS CINTIiRIOR._ ❑CHIMNEY REPAIR
Licensed Pro(easi...I 201-11)(YAMPS IMPROVEMENT
OWNER-BUILDERDECLARATION OVER!"AMPS El BATH REMODEUItF:PAIR ❑DEMOLITION
Q 1 hereby affirm that 1 am exempt from the C.nwaors License Law for the
igpU following mason.(Smtion 703 t,5,Business and Professions Code:Any city m county SIGNS ELECTRICAL ❑OTHER
ser 3 LL F• which respires a permit to consumer,ahen improve,demolish,or repair any structure� 0� prionman
.its isce,.N.requires plim
theapnt forsuch percent I.Elea signed statement SPECIAL CIRCUITIMISb.
}
that he is licensed u
premano she pmvisinnsnfthe Contractors License Law(Chapter9
��� (commencing with Section 7")of Division 3 of Ne Business and Professions Cock)or TEMP.METER OR POLE INST. COMMERCIAL: '
P, that that he is exempt rherefmm and the basis for the alleged exemption.Any violation Of - C NEW BLDG/ADDITION C DEMOLITION
x Section 703 t,5 by anyupplicantfor.penut1
lt subjects the Applicant a civil pm.hy of POWER DEVICES
Wy - ❑TENANT C1 FOOD SERVICE
yyyyyy}
not room than Eve hundred
mrsn,llos($Se"I - - IMPROVEMENT
Q'❑ hu the work,and
thearny,m nyentphy r with g `al ,compensation, - SWIMMING POOL F,1..
40,
will Jothewons ander he Cormsnotintended B df I (Sec.to an B s ass ❑OTHER
and property
who
Code The C improvers
mcmis L' La tl not k hit of OUTLETS-SWITCf{L' FIXT
pmpedy who.adds orProvided
t thcrchn and who tlms such work deed A,Of thrush'
his own however
the provided that such mentis old w art not intended m ofkreJ for NEW RESIDENTIAL F.I.F. pyA ail
sale.If,hnweveq the building or improvement is sold within one sett.(completion,the � - SQ. .FL R Y $/$Q.FT.
owner builder will bav<she burden of pmving that he did not build m improve for par- Ar
pom of sale.).
1,as owner of the properly,aexclusively contracting with licenred c.mmcmrs m - �/
m 4
cnnswn the project(Sec.7044,Business anJ Pndeasinns Code:)The Comrvctorx Li
canna Law does not apply to an owner of property who builds or impmvcs thereon.and Qj PLUh1BING PERMIT PEE• c�Iy ser 1996
who contracts for such pmjeels with a contrucoms)licensed pussmal to the Contractor's `
Liceasn l.uw. - - 1 PERMIT ISSUANCE' - flftNV 9.
1 c nnnd Sec. ry ;B&PCfnnhix rcu.'sr ,
V0. mALTER+DRAIN&VENT-WATER(EA)_, VALUATION
Ow Dale
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTE(TE DEVICE
1 hereby affirm udder penalty of perjury one of the following declarations: - -
1haveandwillmeinWnaCenificateof Conunuoxlf.insum fm Workers Compon. DRAINS-FLOOR,ROOT:AREA,COND. ' .STORIES TYPE CONSTRUCTION
sation,m presided for by Section 37M of the Labor Code,for the performance of the
work for which IN,pectis is issued. FIXTURES-PER TRAP
C 1 have and will maintain Workers Compensation Insurance;As required by Seetion
37M of the labor Code,for the performance of the work for which this permit isissued. GAS-HA.SYSTEM-]INC.d OUTLETS / OCCGROUP, - APN
My Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.: GAS-EA.SYSTEM OVER 4 EE G
CERTIFICATE OF EXEMI'1'ION PROM WORKERS' '
. COMPENSA'I'IONINSURANCE '
GREASR NDus OIL WAS'TB INTP.RCF.PTOR
(Thio section need notbe vompldal i0he permit is foronebundreddnllaraSINE - IIUILDING DIV ISION I•E[S
or he's.) = 'i GRP.ASE TRAP" I. PLANCHECK FEE
I codify that in rhe Performanceof the work for which this permit is issued,i Shull SEWER-SANITARY-STORM EA.2100 FT.
not employ any person in any manner so as to besubject come subjeco the Worker'Cmnpen- ENERGY,FEE ,
zZ An ..Iaws.f Celiforia.Date WATER HEATER WNENT/ELCCIR
2 Applicant GRADING FEE
h NOTICE TO APPLICANT.If,after making this Cmifcaueof Exemption,you should WATER SYSTT.MffREATING
a ; bacon¢suhjecu.the Workers Cannot...in.I m emons of the Inbar CM,.you mmO SOILS FEE
s LiJ forthwith comply with such provisions to this permit shall he deemed revoked. WATER SERVICE
L) CONSTRUCTION
iclion LENDING AGENCY NEW RESIDP.NTIAI.PLMB. SQ,FT. PAID'-
L)
AID
U I for
rut permit
i imurd.L.:34Nending agency for the perfnrmnanttn( ,Dote Receipt
the Lendnrk for which this permit ix isxucd(See.31ri7,Civ.CJ .,
O U Lendoe,Nome ,. TOTAL:
Lenders Address
.6Wi 1 certify that I have read this application and state Nat the above inf.muction is $ BUILDING FEE
lA correct,l agree to comply with all city and county ordinances and auto laws reading to QTY, MECHANICAL PERMIT FEE'
U Z building construction,and herebyauth.iize representativesofthis city toenteruponrhe SEISMIC HE
above-mentioned pmpeety for inspection purrynes. PERMIT ISSUANCE(We)agree to save,indemnify and keep harmless the City of Cupertin.against ELECTRICFEE
Iiubili0es:judgmends,casts and expenses which may in any way seem against mid City ALTER ORADD'TO MECIL '
in consequence of the granting of this permit, PLUMBING FEE Lit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT,(rO IT"CFM)
SOURCE RIMULATIONS. ' MECHANICAL PER
AIR HANDLING UNIT LOVER Ig00o CFM) CONSTRUCTIONTAX
Signatureof Applicunl/Contmcmr Unna BXHAUSTHOOD OWIDUCI') HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future huildingiccupam store or handle huuNous material HEATING UNIT(TO 100.000 LOU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety '
Cede,Section 25532m)?' HEATING UNIT(OVER 100,(1(11 BTU)
❑Yes " CN. VENTILATION FAN(SINGLE RFSID) s PAID
Date Receipt K
Wel the a it oinnlor futureanisA building by upant um he
A.
ent or uality vices which BOILER-COMP(3HP OR 100,"BTU)
emit hazardous air conuminants as def ned by the Bay Area Air Quality Manogemcnt TOTAL:
DdmeB
ID Yea
CNo - BOILER-COMP(OVER 100,00)BTU)
I have read the hazardous materials AIR CONDITIONER
reyuirctdents under Chopler 6.95 of Ne Cah- " ISSUANCE DATE.
fnmin Heulth&Safety Cale,Sections 25505,25533 And 25534.1 understand that if the NEW RFSIDENTIN.MI?CH. SQ.IT.
d building does not currently have a tanam,that it is my responsibility to notify Nc..,ot � ,
.f the requirements which must be met prior to issuance of a Certificate of Occupancy..
Owner or uuthonzed agent Date r TOTAL: ISSUED BY:
OFFICE'