31492 --- ... . . ....... ... ......... iu."Fufs,,cw lIFCS Ubt ksA1.l MUIN 1 FCN UNL'f
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL 31492
BUILDING PROJECT IDENTIFICATION
BUIL ADDRESS: I SANITARY NO. APPLICATION SUBMITTAL DATE
bq ��n� N� - _ 2
,R' NAME: PH(lN8 C MAC' R'S NA E: LIC NO'.
1 _ _ 1 N/C CONTROL x
RCHITECT/13NOINTILTIL LIC NO, ADDRESS: ' ` ❑
1 _
CONTACT. PHONIi: RIJILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ME
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�aZ with Section]Of10)ofDivision Sof the Businemand Professions Code,and my license is PERMIT ISSUANCERFSkOENTIAL
in full force and eB WL ❑KITCHEN REMODEL
FU Lice a In
Lie APPLIANCES-RESIDENTIAL. ADDITION [I PLUMBING RE-PIPE
to,<Z Date Cnmmnar
ARCHITECTS DECI ON PANELS ❑MULTI-UNIT ❑STRUCTURAL
y 1 understand my plans shall h d ss rec
usepublic records MODIFICATION
OZunderstand0 UPT0200AMPS ❑EXTERIOR ❑CHIMNEY REPAIR
9Qog4 :til LiC..d Professional 201-I000AMPS IMPROVEMENT
a bdg� OWNER-BUILDER DECLARATION OVER I"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
Sy CC'' 1 heresy.(firm nt 1 am exempt from he Cssions o License Law for
9d36U which following wapeore(Section]036mr.alter, and Professions Code:Any city at county SIGNS ELECTRICAL ❑OTHER
{ui17 to pool rEx aims a pewter re c ares he,tiler,improve,demolish,or repair any structure
[:�y pdd he
pursuant
tote previsionofthcant e Contrasuch ctor',
LicenIle ase
Law
SPECIAL GIRGDlTB.11$G. -
y Nm he is licensed pumuam to the provisions of the a Business
nd Prof law(Chopmr9 .
GD (commencing with Section)E(h)of Division3 of the Business end ProfessinnsCode)orCnurv1aprlA L.
TEMP.METER OR POLE INST.
d n on that he is exempt merefmm iandal the hoses for the subjects
the
exemption.Any violation of ❑NEW BLDG/ADDITION ❑FOODDEMOLITION
SERVICE 4LL• Sot more 03 than
five
any it itdamrs($50rmir suhjcEts me upplicam mecivil penNty of POWER DEVICES
m - ❑TENANT ❑FOODSERVICE
Z not marethnn RfteprrN dollars($500). IMPROVEMENT
C� ❑Lo due work.the trepans%or myemployeeswith wages their sole compensation, SWIMMING POOL ELECT
IG` will Pr lesions Codec he c;ureCont is roti License La doeseal forot e IS apply to an Business ❑OTHER
and Professions Code:The ser theretr License Law dies not apply s if owner of OIITLCTS-SWITCHES-FlXTURES
hpropertyis own who builds or improves thereon,end who does such work himself or through
his own however.
weverces,proldingded r m such mentis old within thin not iyeer efc nr olfeml for NEW RESIDENTIAL ELECTR Q
onstraLuthda,wthe buil dingnden of preen itat reddon build or improve for
SQ.FT.FLOOR AREA g/SQ.ET.
owneof valdcr will have the burden of proving that he did not buil)or improve for Pur-
pose o(sowne
I,as r of the property,oro exclusively contracting with licensed cnmmemm to T
construct tha project(gee.]1144,Business and Profession Code:)The Commcmr's Li
-
caramawdoes not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT EE
who contracts for such projects with s contmcloroo licensed pursuant o the Cortracties
License Law' PERMIT ISSUANCE
El 1 am exempt under Sec. ,B&P C fur this mason
ALTER-GRAIN&VENT-WATER(FA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE
I hereby air.under Penalty of perjury one of the following declarations:
I have end will maintain a CeriEcate ofConsam to salf-insure for Workces Comper- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 370)of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maimed.Workers Compensation Insurance,to required by Section
3700ofthe Labor Code.for duferfnnomceofThe work for whichthis permit is issued. GAS-FA.SYSTEM-]INC.40UTLETS OCCGROUP APN
My Workers C_mmpen Insyr�W_ m r and PaiicµuyrpbT�pre'
Carier.Z "\sti\11 1J\C Policy NoGAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION TEES
(This sationnxJ not becompleudifthepewit is far onehundrtddo11ers(51110) GREASR TRAP
or has.) PLANCHECK PEE
I certify that in the performance afore work ferwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FE
not employ any person in any maoner so m m m
becoe subject to the Workers'Co.,.-- ENERGY FEE
,Z sation Laws of Calif.",!,,Date
z C) Applicant WATER HEATER WNENT/ELECTR GRADING FEE
pr L4) NOTICE TO APPLICANT:If,after making this aCen^^cam of Exemption,you should WATER SYSTEMITREATING i hecome subject m the Workers Cnmpcnvlinn po v '' sof the[..be,Cucic,you must SOILS FEC
forthwith comply with such provisions or this permit doll be deemed revoked. WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL PCMB. SQ.FT. PAID
U work
which
thin p[sere is a c d((repot lending agency(or the per(ormawc of Data Receipt p
D. f'^ the work for which this Permit is issued(Sec.3(19],Civ.C.)
O U
Leaders Name TOTAL:
Lcmfels Address TOTAL:
Gc I certify that I have read this application unit smut that the above information is
correct. BUILDING FEE \
V) l same ms comply with all city and county ondinaress and state laws relating m QTy. MECHANICALPERMIT FEE
U z building conswction.and hercbymarodze repmsemativa of this city 10 enter upon the SEISMIC FEE
above-mentioned posar,for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hwmless the City of Cupenino.,eine ELECTRIC FEE
Iiebilitics,judgments,costs and expenses which may in any way accrue against said City ALTERORADDTOMECH.
in consequence of the granting of this permit. PLUMBING FEB
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOU GULATIONS. MECHANICAL FF.E'
(#.•1, fry AIR HANDLING UNIT(OVER IO.INIU CFM) CONSTRUCTION TAX
ew sof AppliranVContactor )ale -I EXHAUST HOOD(WMUCI')
HAZARDOUS MATERUI DISCLOSURs HOUSING MITIGATION IEE
Will thenppliemit or for..building occupal,momhandetazmdous match.) HEATING UNIT(TO 10a"BTU) 11,00
At defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(u)] HEATING UNIT(OVER.100,000 BTU) -
0Yer ON.
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipnontr or devices which Dem Receipt Y
emit hazardous it comaminants.defined by the Bay A.Air Quality Management BOILER-COMP(3HP OR[00,000 BTU) Do
Oestrin] TOTAL:
Oyes ❑No BOILER-COMP(OVER 100,M)BTU)
I hove read the hazoNotn mmerials requirements ander Chapter R.95 of the Celi- AIR CONDITIONER ISSUANCE DATE
fore a Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Fr..
building does nut currently have a board.that it is my responsibility to notify the occupant
of the requirements which must be met prior to issuance of u Certificate of Occupancy. /t..
Owner or reeorcul agent Date TOTAL: Lk3a ISSUED BY:
OFFICE