31457 APPLICANT TO FILL'IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY "
CITY OF CUPERTINO BUILDING-ELECTRICAL - - "PERMIT NO.
BUILDING DIVISION APPLICATIONTERMIIT PLUMBING-MECHANICAL. - „ .31457
BUILDING PROJECTIDENTIFICAT/ON
B ILDINC ADDRT;SS: SANITARY NO. - APPLICATION SUBMITTAL DATE
-, ✓eN/ A CONTRACTORS NA- '
MSNAME:, - Mfr.
NIC CONTROL#
ARCH! ECT/ENGINEER: + LIC NO RESS:. L
�j '' ',�( a e , ❑
D it /�• / ..
CONTACT: - - PHONE, • - BUILDING PERMIT INFO
At' ❑ Consultant Fees Paid by Applicant(InfBal) BLDG ELECT PLUMB' MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT PEP,
I hereby.from Nat I am deemed nder pr i n. f Chapter 9(comma I' g JOB DESCRIPTION
000 wiN9ect on 9Ofln)ofD sion3�f NeBus a adPmfessw :Cnde and my llc n. in - RESIDENTIAL:
�� full force and effect ,• PERMIT ISSUANCE''
�yyy���U1 1° CSFDWL . C KITCHEN REMODEL'
¢�U License Claes Lia# APPLIANCES RESIDENTIAL - [I ADDITION ❑PLUMBING RE-PIPE
y� 'Date - Contractor _
[r ay ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT „ " El STRUCTURAL .
ZO Z I understand my plans shall be used as'public records � - - MODIFICATION '
g UP TO 2AMPS
�'Z00 p - - ❑INTERIOR ❑CHIMNEYREPAIR
-
LicenuJ Professional - 201-IOWAMPS _ _ $IMPROVEMENT
OOGG Oat I am exempt
from
DECLARATION Com ION OVER IOBBAMPS ., ,O BATH REMODF,L/REPAIR El DEMOLITION
yy 1 hereby affirm that I am exempt from rhe Commas is License Law for the
iW5 t U following reason.(Section 7031.5.Business and Professions Coda Any city.u'ru,unty SIGNS ELECTRICAL ❑OTHER _
w+a W y which equirre s e permit I combeel, II p dernal sh,m repairany structure _
Ep.�0 priort t ' I req Ili ppl tf 1'permtt fl a tgned statement SPECIAL CIRCUIT/MISC.
thar
h laersed,co . dap s ftbeC ntmt r Lice1 w(Chapier9
(commencing with Section nxl(p f D v s n 3.(the B .one,a d Pref a Cede)or TEMP.METER OR POLE INST. - COMMERCIAL:, +
Y c eG that he is exempt therefrom and the basis for the II g d exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
tc Sect un 7031.5 by any applicant for a permit subjects the applicant to a ofvll penalty of POWER DEVICES
not mute than five hundred dollars($5 W). - - ❑TENANT El FOOD SERVICE
QI as owner ofthe property,or my employees with wages as th' lv compensation, SWIMMING POOL ELECTRIC "' IMPROVEMENT
willdcthcw,, and thaswemrets tint tat dd Hcredfrale(Sec 9044 Buamess - COTHER
4�i 3 and Professions Carer The Carmelites License Law dues not apply to an owner of OUTLETS-SWITCHES-FIXTURES
a' progeny who builds or improves thereon,and who does such work himself or through -
his own employees,provided that such improvenunts are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT
sale.If,however,the building or improvement is sold within ane year of completion,the SQ.FT.FL R Z S/SQ.FT..
owner-builder wiII have the burden of pottving that lie did not b Od or improve for pur, s t
pose f T ). - -
I as ownerf the property,am exelust lycontracting with Ilecn ed c nt acro s t, - ) OO
consumer theproject(Sec 70144 Business d Pmfe. on:Code)Th Contractors
-L QPLUMBING
r C%y V 199 t
errs La does na dpplY man nwnerofp pry h 6 Id p th on end Jy, PLUMBING'PER�MIT' E / v76"
who contracts for such projects with a contractor(s)licensed Emotional tthe Contractors
j UUf- e
License Law. ( PERMIT ISSUANCE
m Cr!IUYV
❑I aexempt under Sec.- ,B&P C for this reason
ALTER-DRAIN&,VENT-WATER FA),r' VALUATION
Owner _ Date
" WORKER'S COMPENSATION DECLARATION
affirm ' RACK FLOW PROTECT.DEVICE
I hereby under penalty of perjury one of the Alluvia,declanti...
❑ I have and will maintain a Certificateof Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF AREA,CONED.
station,as provided for by Section 3900 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permn is issued: \ FIXTURES-PERTRAP' YJ 7�6
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section - " -
3900 of the Labor Code.for the performance of the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCT.GROUP ,APN
My Worker's Compensation Insurance carrier and Policy number are: _
Carrier: Policy No.: GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' '
+ COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR y c >
(This section need not be npleted'fth permits forone hundreddollats($100) S, li VI- B-IIEDING DL VISI 0. FEES
�- or less) a GREASETRAP PLANCHECK FEES '
Icerofy lhannn pert ceeokf h htpermute ssuedlsh - SEWER-SANITARY-STORM EA.200 FT.
of employ any person m any manner sees
ass t to become subject to
m Ne Workers Comper - ENERGY FEE
Oz eAtion Lawso omjp.Dale WATER HEATER,W/VENT/ELECTIR
F
y Applicant ��e q,(�y _ GRADING PER
i NOTICE TO APPLICANT:11;after making this GniBcare of Exemption,you should
WATER SYSTGMITREATING
a became subject Coply the Workers Compt or this
nprmit provisionsofthe Laborvodayou must SOILS FEE "
Lkl forthwith comply with such provisions or this permit shall be deemed rcvnked, WATER SERVICE, 10
.
`s .. ,
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ Ff. PAID 4
I hereby affirm thenhere is.wnawnlon lending agency fonhe perform.nee of :Date .Receipt
0I. me work for which Nis,permit is issued(See.3099,Civ,C) °
ULender's Nunte ' TOTAL:
Lender's Address TOTAL:s .
y 1 can fy thrift have read this application and state that the above informations - ,S I,. BUILDING
ra 07 comet I agree m comply all city and county ordinances and laws testingto -Q'PY, ME QHANICALPERMCF," FEEX - u Y P
U w7 building eonstrvwan and hereby authorme representatives M thiscity to enter upon the �..4n, SEISMI th
above-mentioned property for inspection purposes PERMIT ISSUANCE ELECT IC FTE
(We)agree to save,indemnify.ad keep hvrmlese the City of Collection against
liahilities.judgments:costs and expenses which may in any way accrue against said City ALTER OR ADDTO MECH.
inconsequene of the granting of this permit. PLUMBINGFEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH'ALI,NON-POINT AIR HANDLING UNIT(TO IO,OW CFM), p' MECHANICA FEE
' SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) _ CONSTRUCTION
Ignd mofAPPllcim teal own .Daur 1. EXHAUST HOOD(W)DUCT) .HOUSING MITIOATIO EB '
HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant or furore building accupanl store or handle M1ccandous material HEATINGUNITLD IW,IIOOBTU) -
is defined by the Cupertino Municip.l Cade,Chapter 9.12,vad the Health and Safety I,
Cache,Section 25532(x)4 HEATING UNIT(OVER 100,000 BTU)
❑Yes F1No - - PAID
VENTILATION PAN(SINGLE REBID) Dote - Receipt# -
Willtheapplicant ft building ooccupant use egap t device,which pO1LER-COMP(3HP OR 100,000 BTU)
emit h.� ir co 'nam. a defined by the Bay Am Art Quality Management _ h TOTAL'
District? ' •BOILER-COMP tOVER'l 00,000 BT'I])r'
- ❑Yes .. ONo . . - ,.
I have read the haxardous materials r AIR CONDITIONER. 'ISSUANCE DATE
equimments ands Chapter IS95 of the Cali-
'+ forma Health&Safety Code,Sections 25505;25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.PT.
b.ildingdmsnnmurzently have amnanl that it is my responsibility mnntify the occupant - "
of the
-requirements which t be met prior to vane of a Cen T ate f 0 vpancy. "
Owner or uuN mud.Bent a Date," L
\ - ISSUED BT
OFFICE