31287 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES•USE BALL POINT PEN ONLY. "
CITY OF CUPERTINO1, . - BUILDING-ELECTRICAL PERMITNO.
G
BUILDINDIVISION P` APPLICATION/PERMIT PLUMBING-.MECHANICAL 81287
BUILDING PRW F.C'T IDENTIFICATION
LDINC,ADDRESS: ' - SANITARY NO. APPLICATION SUBMI'FI'AL DATE
�'S$v
Asst LA^� .: b�L�Per-kho /o-fLN-�L�
,u O F$ A� 1 M;11 c+' ZP� 'I�/ti, CONfRAC'I'OR'S NAME' LIC NO: NIC CONTROLp
ARCHITECT/ENGINEER: -LIC NO:" ADDRESS: _ ❑
CONTACT: - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB. MECH I
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE -
I hereby affirm that I am licensed under provisions of Chapter 9,(commencing - JOB DESCRIPTION
MaZ with Section 9000pdDivision3oTlhc Business add Professions Cale,and my license is - RESIDENTIAL,
In - . PERMIT ISSUANCE,
aW Poll force and effect. _ ❑SFDWL ❑KITCHEN REMODEL
aUZU License Class Lic.M APPLIANCES-RES NENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
t Q 1 Date Contractor
�' ARCHTTECTS DECLARATION .. ❑MULTI-UNIT F1 STRUCTURAL
.L O H 4 1 understand my plans shall he used as public records � PANELS MODIFICATION
,0 zt3 t UPTO 200AMPS ❑INTERIOR ❑CHIMNEYREPAIR
,P45 Licensed Professional ^ f 201-IOMAMPS IMPROVEMENT
Eq OWNER-BUILDER DECLARATION OVER IOOO AMPS ❑BATH RE DE EP 1 ❑ EMOLITION
1 hereby affirm that I am exempt train the Contractor's License Law fur the '�M+D
O U (.Mowing reason:(Section 90315.Business and Professions Cada:Any oily or county SIGNS ELECTRICAL ❑OTHP.n �j1T�
a IL yF which reyuima a permit to eonswm,olmr,Improve,demolish,or repair any structure /// �
ptldrm as lemic.,also tortures the applicant for such permit to fi le a signed statement SPECIAL CIRCUITIMISU -
ra6r�l law he is licensed purenanim the provisions of the Counceaf's license Law(Chapter 9 -
W CO tcommencingwlthSeli.,,1000)ofDivision3bfthe Businessand Prafes,mus C.dc).r TEMP.METER OR POLE INST. COMMERCfA
d o K that he is exempt therefrom and the basis fur the alleged exemption.Any emmlon of _ El NEW BLDG/ADDITION ❑DEMOL
4•
Section 909I5ti any appbwnt fora perms. lrye , he applicantI c"I It f POWEROEVICES
�y ypeeyo ❑TBNANT ❑FOOD SERVICE
F. not more than five hundred d II ($500)
qy60'1 of the pr perry y ply d g slh ' lecompensation,tiSWIMMING POOL ELECTRIC IMPROVEMENT,.
I,Ci2L1 wdld 0 k and the structure moro
t ddedflored are(S ]044 tl mess ❑OTHER
m and P . .fieCod,:Th C tit a t License Law does t,apply t r of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that xwh impmveater s are not Intended or offered for NEW RESIDENTIAL.ELECTR ., SQ FT.
sale.If.however,the building or improvement issold within one year of completion.the .. . - SFT FLOOR AREA( $ISQ,FT.
b.
-builder will have the burden of proving that he did not build or improve for par- %p a .
con ' - +i.d
a f the property,an)exclusively contracting ilicensed contractors -TOTAL
construct the p
o.I tlhep je,(See 7044,Business4 dProfession,Code)nC tLi-
comQTY UM LNGPE2MI1 :
FEE
who vada for such projects with acoincidental Itensed paant to the Contractors
4 X996
License Law. PER TI, CE �II Ur L i
❑ I am exempt tinder Seo. ,B&P C 4tthis re son Uf tp��i
Owner Dam ALTER-D T- TER(EA) VALUATION
WORKER:SCOMPENSAHON DECLARATION BACK FLOW PROTICT—kyilICE
I hereby affirm under penalty of perjury one of the following declnnnions: IIJJ
❑I have and will maintain a Certificate ofConsent in sell-insure for Worker's Cmparr DRAINS-FLOOR, Oi REO, D. _ STORIES - TYPE.CONSTRUCTION
action,as provided for by Section 37N of the Letter Code,for the performance of the
work for which this permit is issued, FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required By Surfen
TIDO of the Labor Code,for the performance of the work for which this permh is issued 'GAS-EA:SYSTBM-I INC,00 ET OCC GROUP APN,
My Worker's Compensation Insurance carrier and Policy number are: - - t
Carrier: Polley No.: - GAS-EA.SYSTBMOVER4(0A) -
CERTIFICATEOFEXEMPTIONFROMWORKERS'
- COMPENSATION INSURANCE GREASEIINDUSTRI.WASTE INTERCId-ro
'(This section need not be'compleded ltthe permit is throw hundred dollars($HIM - , gU1LDING DIVISION PE&9
.Ansa.) n GREASETRAP A. NCHNCK,FEE
Icenify thein the performmce.f lhewmkfor wh'mh this permit is issued Lshull SEWER-SANITARY-STORM EA.2001T
not employ any person in any manner so as to becomesubject o the Workeri Coni - ENERGY FEE
,Z sation Laws of Cchfomia.Date WATER HEATER WNENT(ELECTR
O O Applicant - - - GRAVING FEE
y NOTICE TO APPLICANT:If,after making Ibis Cerrificate of Exemption,you should WATER SYSTEMRREATING
(•" become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
Fakl forthwith comply with stmh provisions or this permit shall be deemed revoked.' WATER SERVICE
CONSTRUCTION LENDING LENDING AGENCY NEW RESIDENTIAL FUND. SQ.Up PAID
U 0 l heachy aErmtharthem is o construction lending agency for lho performance of Data Be iptR
V. F the work for which this permit is issued(Sec.301 Civ,C)
O U lender's Name .TOTAL: -
'Lend r a Address s - TOTAL:
I y m that 1 have read this apptlie d x i that theabove information is 'BUILDING FEE
o-Hi N correct 1 agree maimpty with all city and c bury ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
L) building construction,and hereby vbthorize representatives ofth'n city ld now upim the SEISMIC PEE
above-mentioned progeny for inspection purposes. PERMIT ISSUANCE
(WI agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE. '
liabilities ,judgments,costs and expenses which may in any wayaccme against said City ALTER OR ADD TO MECH.
inconsequence of the'coming of this permit. PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINIAIR H ANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL PEE
s AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signature otApplicanVContractor Date EXHAUST HOOD(W/DUCT). HOUSING MITIGATION PEE
''IL ZARDOUS MATERIALS DISCLOSURE,'
Will the applicant.Jame buildingocenpaid shanwhandle hacadmomaterial HEATING UNIT(In 100,000 BT U) -as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety _
Cade,Section 25532FIC - HEATING UNIT(OVER 1011,000 BTU) _
0 Yes N - VENTILATION CAN(SINGLE RESID) PAID
Will the applicar futurecu
building ocpant use ertipmnnt devices which
- ' Dore ReceiptN
-
emitmaintains contaminants as defined by the Bay Area Air Quality Management - BOILER-COME CHIP OR 100,000 BTU)
TOTAL:
District?-
❑Yes ON. BOHER-COMP(OVER'I00d)0l BTU)
I have reedthe hazardous matr
eials requirements under Chapter 6.95 ofthe Cali- AIR CONDITIONER ,ISSUANCE DATE
fond.Health&Safely Cade,Sections 25505,25533 and 25534.1 uaderaland that if the NEW RESIDENTIAL MECH SQ.FT
building does not currently have a tenant,that it is my responsibility to notify the occupant , t
of the requirement,which most he at prion.items.of a Cenificad of 0ecupmcy. yP ' "
Owner nr uuthnrisal agent - Data TOTAL: JSSUEDBY:�Le—=ams
OFFICE