31111 APP,LICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY^
CITY OF CUPERTINO IBUILDING-ELECTRICAL. - PERMITNO.
BUILDING DIVISION APPLICATIONTERMIT PLUMBING.MECHANICAL. 31111
BUILDING PRO,IKCT IDENTIFICATION -
BUILDINGA 1]RRSS: . - SANITARY NO, APPLICATION SUBMITTAL DAO
tl .S" c � GG•• �
ph'
NER' ME: PHONH: CONTRACT'S NAMEx LIC NO:',� N/C CONTROL# �-
AkCHITECT/ENG EE LIC No: ADDRESS: ❑
7 .
CONTACT: , ' - PHONE: - BUILDING PERMIT INFO
❑.Consultant Fees Paid by Applknht(Initial) - D ELECT PLUMB MECH
✓err ��.L�z �c ❑ ❑
! LICENSFDCONTRACTORSDFCLARATION -+ QTY ELECTRIC PERMIT FEE
-I hereby affirm that I am licensed under provilioroofCh peer 9'(a,mme c ng JOB DESCRIPTION
aZ Ili Secl n9Wo)dD n3 fm Busi nJP fsslnn Cal d ayliecn: is RESIDENTIAL
00 in fault i iteffea/Q PERMIT ISSUANCE.
PW f". -'T ��` 1 ❑SFDWL ❑KITCHEN REMODEL
UU Lme .e Clays 'TT,.^—C�T—Lia# APPLIANCES kESIUENTIAL El El PLUMBING RE-PIPE
yG Date Com l .a' ,
AR HITFCr'S DECLARATION PANELS O MULTI-UNIT O STRUCTURAL
ZOr"Z InnderstanJ my plans shall be used as poblio reemds A' � -• MODIFICATION
CZ48
Lice dP f I - UPTO 200 AMPS - ❑INTERIOR El CHIMNEY REPAIR
201-IOOOAMPS IMPROVEMENT
4 OWNCRBUILDLR DECLARATION OVER1003AMPS ❑BATH REM D LIREPA LITTON
1 h by ffpm he,1 am exempt term to,Contractors License Law for the
iyyi O y U folk wing rwsnn (S,ettinn 9031 s Braine and Pn fe..n my GSIe Any city ar wunty SIGNS ELECTRICAL F1 OTHER
hichq pe 'II aaImpve,dmolishar. repair
proItLanal 'ehppl If hpemitlCIe.d6dmet SPECIAL CIRCUITISC.w
Hm-,
hathe is licensed ptt
the provisions oftleCumbactuds License Law(Ch pmr9
tvOG�O
(commencing with Sect )0W) fD' .lo J fth Bu.nes, blP fe.r n Code) TEMP.METER OR POLE TNST. COMMERCIAL: ,
dy�4 c e� that he is exempt mann a then.L'f r the alleged e e pl n A y lation of ❑NEW BLDG/ADDITION ElDEMOLITION
W^ Section 7031.5 by any applicant for a pennt subjects the tppbcam to a civil penalty of POWER DEVICES. -
ti ❑TENANT [I FOOD SERVICE"
ES6not more than ave hundred m,uara(&sora.
1,as owner of Be property, employees with wages their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
0 ❑ t pe Y Y P Y gds ns p
' y 'lldothework,and the structure manchisnot v License
ondferedfmotl Pfec.]I ad Won,of ❑OTHER
6 3$ and Professions Cwle:imp Co,,rime a License Law does not apply s if owner of WTLGTS-SWITLOTS-FIXTURES
his two who builds or improves thdreou,and who does such work
te himself oaredfurnishfor ,
his two employees,provided that such mere is old within are not intended or offered far NEW RESIDENTIAL ELECTR SQ FI'. -
owne buildevegllmhuildingurenpdrvemem isat hddon buildyear of
or improve fon,Ne SQ.FT.FLOORAREA $ISQ,PT.
a builder will have the harden of provin6 that he did not build or improve for par-
p ae Lale) -' .
O 1 f Ilio property,am exclus ely r t' g ith 1 J t cram to AR. l 8 RfC
consumerhep jct(Sc7N4,B dProfessions Cd )TheContractor's Id
cause Law I t applyt f pectserlywh builds Or p 'Neemand QTY PLUMBING PERMIT PEE .
who vnots for such pmize,with a cmnrau,r(s)Icen.ed pucaaat the Cmtracmrs - �EI --
License Law. PERMIT ISSUANCE �r MUrCRI Ilvu
O l am exempt under Sec. ,B&P C for this reason -
Owner nt
ALTER-DRAIN$VENT-WATER(EA) - VALUATION
- - - -
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hi affiron orderpicanaft,of adjury be of the fall 'ng dad mf
❑Ili d II mm Genft fC a lf'nsu o far Wink C pen- DRAINS-FLOOR,ROOF.AREA,GOND. STORIES TYPE CONSTRUCTION
smiah,as provided for by Secti m 3700 aide"ban Code,per the nt,f athancc of the -
work fnr which this fiction is issued. FIXTURES-PER TRAP .T'
O 1 have and will metra in Workefs Compensation Insurance,as required by Section
3]00 of the La C or eperfermance ofthe work for which this permit is issued GAS-RA.SYSTEM-1 INC.4 OUT'PIS
My Work 'n m In d Policy numhe OCC.GROUP APN
Cvrtien e they Not
GAS-EA.SYSTEM-OVER 4(EA)
CERGFICA EOF EXEM ION FROM ORKERX
COMPENSATION INSURANCE ' GREASFIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
section need not be complemd if the permit is for hundred doll ars p$100) GREASETRAP or less.) PLANT][ECK FEE
I certify that in the performance ofine work far which this perm,is Issued,l shall SEWER-SANITARY;S'T'ORM EA.200 FT.
,not employ any person In any manner so as m become subject m the Worker,'Compen- ENERGY PGC
Z cation Lawsof Camiu
dfo ,Date
'� 0 Applicant WATER HEATER WNENT/ELHCfR HEADING HE
f% NOTICE M APPLICANT:If,after making this Candie ld of Exemption,you should
WATER SYSTF.M/fREATING
a �^
become su comply
to it Worh pre Compensation provisions of the Labor Cade,you most SOILS FEB '
G forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE "
Q
CONSTRUCTION ENDlNGAGENCY I' NEW RESIDENTIAL PLMB: SQ.FT. PAID
U� ,Thereby affirm that isaconslmctinn lending agency forthe performanceof Dale .kcceipl#,
W Fthe work for which this pem,il ix issued(Sic.300].Civ.C.) -
Lender'sName
- TOTAL:
U Lenders Address - •TOTAL: n _
a1 century that I have read this application and state that Lha above information is BUILDING FEE /r
h comes.T agree an comply with all city and county ordinances and stale laws relating In QTY. MECHANICAL PERMIT FEC
U building consumption,and hereby authorize representatives ofthis city in enter upon the SEISMIC FEE.
above-mentian.I property for inspection pnfpases. PERMIT ISSUANCE s
(Wm agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE'
hadilines.jutgments,eostsand expcnscs which may in uny It,aocmeagainst said City ALTER OR ADD TO MECH. -
in consequence of the greating mind,Permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. AIR HANDLING UNIT(TO IO,Wo CPM) MECHANICAL.PCE
.,•
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signature of AnplicamaCounnaor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE -
' Will the applicantar future limiting oceupamsmre or handle baz.Nous mmerial HEATING UNIT(TO 100,000 BTU)
as defined by the Cuperlind Municipal Code,Chapin 9.12,and be Health and Safety -
Code,Section 255320)'I - HEATING UNIT(OVER 100,000 BTU) -
OYe: ON. PAID
- VENTILATION FAN(SINGLE RESIO) Date Receipt#
Will[heit cohn or future builJms by the B use ea Air Qui or de ices which BOILER-COMP QHP OR 100,000 BTU)
emit h b air nnmminants as defined by the Ray Area A Quality Management - ,
DistO,? TOTAL
OYesNo BOILER-COME(OVER 100,000 BTU)
I have re ad the h materials Mdui msu _er Chaptrd6.95 nfthe Cali- AIRCONDITIONER lSSUANCED
fomia Beat Safety Cede,S s 5533' 25 .I understand Ihm if the NE RGSIUENTIAL MECH. SQ.Er.
buildin actuarial estana�m" sibiit In 'lily lheoocupanasiniit m 'tify lhemcupso •,
,. is hs asll�•
ramhorizc g - Dam TOTAL: ISSUED BY:
OFFICE .. '