31019 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY
CITY
OF CUPERTINO BUILDING.ELECTRICAL. PERMIT NO. 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIF'ICA'TION
DINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATI
6'77 W -pP- 7
ER'S NAM PHONE: CTOR:S NAME: - LIC NO:
r' NUC CONTROL#
CHITECT/ENGINEER° LIC NO'. ) t ❑
4o in
CONTACT. PHONE'. S BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ElLICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter A arty lmers,is JOB DESCRIPTION
�0Z with Seaion9W0)of Division3ofthe Business and Professions Code,and mylicense is - RESIDENTIAL'
O in Poll force and effect. - PERMIT ISSUANCE
I Vy� License Lln.# ❑SFDWL ElKITCHEN REMODEL
rF�W Dare = mmener APPLIANCES-RESIDENTIAL ❑ ❑
CoADDITION PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZO Z�z I understand my plans nhull be used as public records
MODIFICATION
0 UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
F., W Licensed Professionab 201-IWOAMPS IMPROVEMENT
g cd 2 OWNER-BUILDER DECLARATION Contractors
ON OVER 1000AMPS ❑BATH RE EP 7OLITION
ad
G R C I hereby affirm that 1 am exempt from the Contructois License Law for the
Lbpi5�O y u following reason.(Section]031 5,Business and Professions Cale:Any city or county. SIGNS ELECTRICAL ❑OTHER
ar t'+ O y which requires u permit m construct,alter,improve,demolish,or repair any structure
y prior w its issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUIT/MISC.
,is that he is licensed pnrsmnuo the previsions of the Contractor's License Law(Chapter 9 _
(commencing with So,imr]000)of Division Sof Ne Rusineesand Pmfedoons Code)., TEMP.METER OR POLE INST. COMMERCIAL:
y n p( that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION
to Section 9031.5 by any applicant for a permit subjects the applicant toa civil penalty or POWER DEVICES
ern ❑TENANT ❑FOOD SERVICE
11FF...... not more than rive hundred dollars yempl.
�6 1,asownc.nfthe m or to ees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
❑ p pe y yemp y g p ❑OTHER
C will dothewons and the mo Cont is tors Liceed araffe does et army
y 1. a Business
and Professions Code:The Conimcmr'e License Law does not apply toll owner of OUTLETS-SWITCHES-FIXTURES
a' progeny who huilJs or improves menet,and who rtes such work himself or through
his own employees,building
that such i sealsarpro,conartswithin are not intended or offered for NEW RESIDENTIAL F,LF.CTR SQ FT.
sole.ILhoweventhevethnburdenfpricintitatheddone year in prpletinn,the SQ.IT.iF1pOI#ARREEA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or in for par- W 1 6J
J�se assale.),
of the property.,B sinus and contracting with.lecher contractors In TOTAL,:
MnsULa owner
project(Sea.904q owner
of and rt,whoioa i d,or i The Contractors ad - NAR
c srommetefintrapplytmaownerofpropers)nerwildsoriinpromeCo monm's QTY. PLUMBING PERMIT rrr: c fC0
wM10 ctntraa6 PorsucM1 projects wimocono-amr(s)Iicemed pursuannothe Ctnvacmr9 yli YY I� '
License Law. -"38170 PERMIT ISSUANCE' VP L�h'CHI p'
❑1 am exempt under Sec._3 B&P C for this reason jr yU
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
10-
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirn under penalty of perjury one of the following declarations:
❑,I have and will maintain a Certificate of Consent to self-insure for Worker's Couper- DRAINS-FLOOR,ROOF,AREA,CONDA15 STORIES TYPECONSTRUCTION
salon,as provided for by Section 37W of the Labor Code,for the performance of the /
work for which this permit is issued. FIXTURES-PER TRAP
❑ I have and will maintain Worker's Compenvtion Insurance,as required by Section
39W tftbe Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My WorkCoca p cdsmi__rELlnsurmce�cypptrfIm midfsmcyn�u�n�4r �_�.�s,��
Cartiee 1 Mq 17-1A Policy No.: xs""lt,151"`10 GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRLWASTE INTERCEPTOR
(This section need notbe completed ifthe permit is forone hundred dollars($I W) BUILDING DIVISION FEES
or less.) SET AP PLANCHECK FEE
I certify that in the performanceofthe work for which this permit is issued,I luill SEWER ANITARY-
nrt employ an n in an STORM EA.2W FT. /'�/'
p y y Person y manner so as to become subject m me Workers'Compen- v ENERGY PEE
,� sation Laws of California.Date
O ATER HGTER W/VENT/ELECTR
7 Applicant GRADING FEE
F7 TA NOTICE TOAPPLICANTthe Worker's
Cmnnnkition it Cenifcute of Labor Code.
should WATERSYSTEM?RLATING
become subjecttothe Worker's Compeneaennprovisions of theesured Code.yon must SOILS FEE
ronhwith comply with such prnvinitns onhis permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL FUND. SQ.PT. PAID
V 0 1 hereby affirm that there is a construction lending agency forthe performanceof Date Receipt#
w the work for which this permit is issued(See.3097,Civ.C.)
O Lander's Name TOTAL:
Leader's Address
1 certify ohm 1 have read this application sad seam that the above information is RUILDING FEE
y correct.l agree to comply with all city and county adinunees and state laws relating to QTY. MECHANICAL PERMIT FEE
U building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above mentioned progeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamdesnhe City of Cupertino against ELECTRIC FEE
Hithilams,judgmern.coeaend expenses which may inany way armuci,mostwid City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IBM)CFM) MECHANICAL FEE
SOURCE REGUL IONS.
^3-9:g-- AIR HANDLING UNIT(OVER lB,M CFM) CONSTRUCTION TAX
Signature rplicant1forposcour Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building overprint store or handle hurallous material HEATING UNIT(TO I WAW BTU)
as defined by the CupoNnt Munlclpal Cade,Chapter 9.12,and But Health and Safety
Cade,Section 25532(0)? HEATING ON IT(OVER 100.011)BTU)
❑Yes ❑No PAID
VENTILATION PAN(SINGER RESID) Date Roccipt#
Will the applicant or futon building ed occupant use ea Air Qu or devices which BOILER-COMP QHP OR 100,010 BTU)
° mit hazardous air contaminants as defined by the PnY Arca Air Quality Management TOTAL:
District? _
❑Yes . ❑No BOILER-COMP(OVER IW,"BTU)
AIR CONDITIONER
I awe reatal Safet haoardou coons Z55 5,2i 533 an under C 1 and ricand6.95 Fiat
ifth- ISSUANCE DATE
fomia Health&Safety Cade,Sections 25505,arry and 25534.1 understand Nat if the NEW RESIDENTIAL MECH. SQ.FT.
building does nmcurrently have a met prior
ismy responsibility to ratifythe occupant
- of the requirements which must be met prionoissnancc of Certificate of Occupancy. �• _�
Owner or andon red agent Dale TOTAL: ISSUED BY:
OFFICE