31487 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
FBUILIJING
Y OF CUPERTINO BUILDING-ELECTRICAL r - PERMITNO.
31487
ILDING UIVIti10N APPLICATIONIPERMIT PLUM1iBING-MF.CHANICAI.
BUILDING PROJECT IIIKNTIFI(JATION
SANITARY NO. APPIACA'I'ION SUIIMITTAL DA'ff
ADDRESS:RSNAME: _ PHONE: �j3— COT CTp¢'S NAMEI LIC NO: NYC CONTROL#
RCHI'TECf/IiNGINEBR: LIC NO: ADDRESS: ❑
\^
V
CONTACT: - PHOw?; BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB D SCRIPTION
I hereby amrm Net I.m licensed under provisions of Chapter 9(commencing
DOO with Section 7000)of Division 3 at the Bcainasmm Pro(c..ors Cde,andmy license is RESIDENTIAL,
PERMIT ISSUANCIi
in full force and e(f ❑SFOWL ❑KITCHEN REMODEL
aUzU Licen. Class _ _ Lic.p gPl'LIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-VIPF.
In6L Date Contractor
ARCHITECTS DECLA TION ❑MULTI-UNIT [I STRUCTURAL
p,prn PANELS. MODIFICATION
1 undemmnd my pions shell bo used as public records
OZrF�-�CC�$ .., UPT0200AMPS - [I INTERIOR El CHIMNEY REPAIR'
Fst3 tw Licensed Professional 201-1000AMPS IMPROVEMENT
Oy OWNER-exempt
DECLARATIONeCool..m OVER 100h AMPS El BATH RF.MOUIiI/RJ:PAIR [I DEMOLITION
RGj 0 I hereby affirm that I an,exempt frmn the Coximm,C's License Law Iia the []OTHER — /`'wy�W{a{-
Na. - following rw nn(Section]OJ LS.Business and Professions Cade:Any city or roomy SIGNS ELECTRICAL
uW13 n. which requires a permit m conswe6 aper,improve.denmlish,or repair any strvcwre
�� prion.its kamawe,also requires the applicant fnrsrich portnam fi le a signed statement SPECI AL CIRCUIT/MISC.
} That he is licensed pursuantto the provisions of the Contractor's license Law(Chapter 9 CDMMFR .IA
<0 (commencing wit Section 7")of Division 3 afthe Birinessmad Pmfcssions CWc)m TEMP.MUTER OR POLE INST.
that he is exempt Nerefmm and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION -
4• Smtion]OJ13 by any applicant for a permit fuhjects the applicant to a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
F iy^ not more Nan Eve hundred dollars($500). - IMPROVEMENT
p0 ❑I,as ownendthe propeny.or my employes with wages os their sole compensation, SWIMMIN 0 ELECTRIC' -
eiC will do the work,and Neswcwre is natimendeJ or offemd(orsale(Sec.]!144,Business ❑OTHER
a and Professions Code:The Contractor's License Law dues not apply w an owner of OUTLETS W FIXTURES
propeny who builds or improves therein,and who does such work himself or through
his nwa employees,provided tin such improvements are not intended or.Hared for NEW RESIDENTIAL Aekt, SQ FT.
sale,If.however,the building or improvement issold within one year ofcompletion,the SQ.PT.FLOOR AREA $SQ.IT.
owaa-bullder will have the b.fdehof proving that he did not build or improve for pia-
post,of
ar-poseof wee.). -eny, A w
L as owner of the propam exclusively contracting with licensed"conlranofs to TOTAL: 1
onsunet Bw Protect(Sea 7044.Business end Professions CWa:)The Contmctnr'a LI- O
cense law does not apply to an comer of property who builds or improves Ncreon.end QTY. PLUMBING N FEE
who contracts for such projects with a'coal outmost licensed pursuant Rho e Contranm's - �U�I\
{/
0 1 oro exempt code,Sec. E
License Law. PERMIT ISSUANCE Cloy&P C for this reams -
Owner WORKER'SCOMPENSATION DECLARATION BACK FLOW PROTEC'EDEVICC•tli(EA) VA.RIZRZN
11/40I lonchY afOrm trade,peadty of perjury one ofine fnllowi ng declarations: -
❑I have and will maintain a Certificate of Consent to self.insurefor Worker's Compen. DRAINS-FLOOR.ROLE AREA,COND, STORIES TYPE CONSTRUCIIOls
smioa,At provided for by Section 3700 of the lama Coke,for the performance of rhe
work for which this permit is issued. - FIXTURES-PER TRAP
1 have end will maintain Workers Compensmion Insurance,os required by
Senior
K3 of the labor Code,for Ne performance ofrhe work for which this permit is issold. GAS=EA.SYSTEM-I INC.4 OUTLETS DEC.GROUP APN
My Wnrk ItN➢Gn`u11tL 1nsn�B4-eprzi.and PolicyPol cy N.,M101b,, GAS-EA.SYSTEM-OVER 4(EA)
Cameo. 1 k 1 Fi f T 1J
CERTIFICATE OF EXEMPTION FROM WORKERS' GRliAS1YINDUSTRL WAST P.INTF.RCEPTOR.
COMPENSATION INSURANCE "BUILDINGDIVISION FEES
(Thisseerionmeed not hecomplered ifte permit is for one htrnladdollars($10(1) GREASETRAP r .
ser less.) PLANCHECK FEE
I rectify that in the performance of t he work for which this permit is issued, .shul l SEWER-SANITARY-STORM HEA.210FT.
not employ any person in any manner m as to became subject to the WorkersCompen- ENERGY FEE
Z sation Laws of Califomia.Dare .WATER HEATER WNENTMLECTR
Q . - GRADING FEE
Applicant -
NOTICE sTOAP,the Work If,after making this Certwman.of of Exemption.You should WATER SYSTENVfREATING SOILS FEE
(-' y become subject to it Workers Compensation provisions of the Inbar Coke,you must
Conhwith comply with such provisions nr thea pcnnh shall be deenmtl rewked. WAGER SERVICC
0
CONSTRUCTION LENDINGAGENCY
w, NEW RESIDENTIAL PLMe. SQ.Pf. PAID
Thereby otitem that there isamnmmceon lending agency!oohs performance of Dote kweiptp
rhe work for which this Permit is issued(Sec.31W],Civ.C)
Rs F'r Landers Name TOTAL:
W' Lender's Addo o, - TOTAL;
BUILDING FEE
fy 1 certify that I have read this application and stare that Nmale above inforon is
impact.l agree to comply with all caXand county ordinances and surto laws relining to QTY. MSCI IANICAL PERMIT FEE SEISMIC THE
G' huildi,smalruchon,anJ herehymomaue reprawntatives oflhlscirym amerapn the'
N7
above-mentioned propeny for inspection purposes. PERMIT ISSUANCE35
(We).gree to aave,indemnify and keep humdess the City of Cupertino against ELECTRIC lEE
liabilities,judgments,costs mad expenses which may many way ancon against said City ALTER OR ADD TO MECH, + Cy I
inconsequence of Ne granting of this Permit. PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ATR HANDLING UNIT(TO 10,000CFM) MECHANICAL.FEE
C CGULATIO S. ,.
r M AIR HANIl1.ING UNIT(OVER IO,IXq CFM) CONSTRUCTION TAX
Si ut sof ApplicanUCona.cmr Al Dute EXHAUST HOOD(WIDGET) - HOUSING MITIGATION FEE
HAZARDOUS MATERIA D SCLOSURE -
WiillNeapplicant orfumre building occupan smrenrhandIchazmdommarerial HEATING UNIT(In RaLono BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'! HCATING UNIT(OVER"I""BTU)
❑Yes ❑No VENTILA'T'ION PAN(SINOLERESID) PAID Umo -Receipt
Will the applicant or future building occupant use equipment or devices which BOILER-COMP OHP OR I W,(#Ml BTU)
emir hazardous air contaminants as defined by the Baan
,Area Air Quality ManagementTOTAL
Dtsrnot! BOILER-COMP(OVER 100.000 BTU)
[3 Yea
❑No
AIR CONDITIONIiR
I hread the bnrmm
dous a¢dalx ax rem ¢enunder Chapter 6.95 ofthe Cali-
ave ISSUANCE DATE
foods Health&Safety Code.Sections 25505.25533 and 255]4.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not starchily have a tenant,that it is my responsibility m ramify the occupant ..
of the requirements which most he met Prior to issuance of m Cer ificare of Occupancy.
Owner in,armorlaed agent Date TOTAL: ISSUED BY:
OFFICE