31543 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY -
CITY
OFCUPRRTINO BUILDING-ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICA'IIONIPERMIT PLUMBING-MECHANICAL 31543
BUILDING PROJRCT IDKNTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
79,;2 Ad-t
O R'S NAME: / P ONI,?:/ CONTRACTOR'S NAME: LIC NO:
RC '
�~ �` LIC NOADDRESS: N/C CONTROLN
\ IIITE (ENGINEER: : v , ❑
ONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Foes Pald'by Applicant(Initial) BLDG ELECT PPPQjjj ��_
MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑
1 hereby affirm last 1 am licensed under provisiom of Chapter 9(commencing JOB DESCRIPTION
aZ with Section 7000)of Division 3 ofthe Business and professions Code,and my license is RESIDENTIAL:
0 0 PERMIT ISSUANCE
L easeail lass effect. ❑SFDWL f1TCflE1PREM0UEL
License Class Lic.p -
N< Dmc - t Cnmmcsnr `` APPLIANCCS—RP.SIDENTIAL � ❑ADDITION• PLUMBING RE-PIPE
�O ARCHITECTS DECLARATION pgNL'IS ❑MULTbUNIT ❑STRUCTURAL
Vj I understand my plans shall be used as public records MODIFICATION
O Z�"-1 a UPTO 200 AMPS
p - [I INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 2oLItXM)AMPS - IMPROV
Oat I am except
focus
DECLARATION
yy I hereby affirm that 1 am exnnpt from the Contractor's License Low for she OVER I WOAMPg REMGDEDREPAIR ❑DEMOLITION
Ada WN following melon.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
YY]] O which requires a permit to causwet,eller,improve,demolish,or repair any structure
prior to its issuance,also requires she applicant for such Permit o file a signed statement " SPECIALCIRCUIT/MISC.
that he is licensed pursuant ro she provisions of the Contmnai s License Low(Chapter9
GC (rommencing with Section'I(Nlfp of Division 3nf she Business and PmfexsiunxCode)or TENIBMETERORPOLEINST. COMMERCIAL: '
d C that he is exempt therefrom and the basis for the alleged exemption.Any violutim of ❑NEW BLDG/ADDITION ❑DEMOLITION
o" Section 7031.5 by any applicant for a permit subjects the applicant DEVICESo a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
Y rot mare thea fif thundred e property.
or yenipl. IMPROVEMENT
❑Lenswna of Ne pmpmy,mmy employres with wages as their tons compenselon. SWIMMING('001.ELECTRIC
win do the work,etas the swamr,is not intended orofPeted for We(Sec.7044.Business ❑OTHER
and Prvftssions Code:The Contran cto's License law donot apply to an owner of OUTLETS—SWITCHES—FIXTURES
property who builds or improves thereon,and who does such work himself or through p
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL - CTR SQ Pr. Ir
rale.If.however,the building mimprovement is sold within one year of completion,the SQ.F..FLOOR AREA WSQ.ET.
tuner-builder will have the burden of proving that he did not build or improve for pur.
potentiate). DEC 96
❑I,as owner of the property,am exclusively contracting with licensed conductors to TOTAL: a
rnnnruwct the project(Sec.'7044.Bwinesa and Prolamines Code:)The Contrarian's
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING P FEE CI I y Llr IJV YCf s I IIVU
who conuacts for such projects with u conlrectorD)licensed pursuant to the Contractor's
Lic law. - PERMIT ISSUANCE
❑ amexemptunder .Sec. ,B&PClarthis.
r - Date ALTER—DRAIN&V W IEA) VALUATION
�
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT. F.V
1 hereby affirm under.penalty of perjury one of the following declomtions: .......// VVV
I have and will maintain o Certificate of Consent o self-insure for Worker's Campers- DRAINS—MOOR,ROOF,AREA, ON STORIES - TYPECONSTRUCf10N
ration,a provided for by Semina 3701 of the Later Code,for she performance of she
walk for which this permit is issued: FIXTURES—PER TRAP •sem /
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Lobar Cade,for the performance of the work for which this permit is issued. GAS—EA,SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Werkee.Compensation Insurance carrier and Policy number ate:
Carrier. - Policy No.: GAS—EA;SYSTEM-OVER4(EA) �^..
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF/INDUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE - BUILDING DIVISION FEES
(This section treed nest a completed if the Permit is throne hundred dallars(S 100) GREASETRAP
or len.) - PLANCHECK FEE
I certify that in the performance ofthe work for which this permit is issued,l shall ' SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner au as to become subject to she Workers'Counter- ENERGY FEE
a-tion Laws of California.Dose WATER HEATER WNENT/BLECPR
Applicant GRADING FEE'
Fl ffVV//��22 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTEMTREATING
a [^ become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
W forthwith comply with such provisions or Nis permit sall bmed
he deerevoked. WATER SERVICE
Q
� z CONSTRUCTION LENDING AGENCY NEW RGSIUEM'IALPLMB. SQ.FT, PAID
V 0 I hereby aNw that them is a construction lending agency for the perfomunceef Date ,Receipts
{In p Be work for which this permit is issued(.Sec.3097,Civ.C)
0 [13 Lender's Name TOTAL:
Lender's Address TOTAL:
as certify that I have read this application and stare that the above information is - BUILDING FEE
IA correct.I agree to comply with all city and county ordinances and state Iowa relating m QTY. MCCIIANICAL PERMIT PEE - �ea
(.J building construction,and he untharize representatives of this city to enter upon the SEISMIC FEE '
above-mentioned property for inspection purposes. - PERMIT ISSUANCE
(We)same to save.indemnify and keep hardest the City of Cupertino against ELECTRIC FEE
IiabiliticsJudgmenta,costs and expenses which may in any way accrue against said City ALTER OR ADDTO MECH.
in mamma erre of the granting of this pewit. PLUMBING FEE
a
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO 10,000 CFM)
SO' REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CF CONSTRUCTION TAX
nammufApplicam/Cmurecmr Date EXHAUST HOOD(w,0uUI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupuntstore urinous hamrdous material - HEATING UNIT G70 Itail o ) .
M defined by she Cupertino Municipal Code,Chapter 112,1111 the Health and Safety,
Code,Section 25532(a)7 BEATING UNIT(OVER ,000 BTU) 0.0
❑Yes C]No ,
VENTILATION FANANGLE RFSID) PAID
Wilt the applicant or future building occupant use equipmehra or devices which Dale Receipts
emit harardova su contaminants as defined by the Bay Arra Air Quality Menagetiteiit BOILER—CO (311P OR 100,000 BTU)
District - TOTAL:
❑Yea ❑Na BOILER—/MP(OVER 100,000 BTU)
1 have read the hematites materials redomes us under Cha ter 6.95 of the Cell- AIR/5DITIONER
q p ISSUANCE.DATE.
funis Health&Safety,Costs,Sections 25505,25533 and 25534,1 understand that if the W RESIDENTIAL MECH. SQ.FI'.
building does not cmrently have a tenant,that it is my responsibility m ratify the orcupsm
of the requirements which must nc mel prim to ismance of a Certificate of Occupancy.
Owner or authorise)ager Dam TOTAL: ISSUED BY:
OFFICE