31083 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-RLECTRICAL - PERMIT NO. 310831
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTAL DATE
JV�
O NER'S E: PHON�: CO ACTOR'S NAME: / LIC NO:
-.AYN 1L6^•✓• NIC CONTROL k
ARCHITECTIENGINEER. - LIC NO, 'ADDR _ ❑
;�Ox KS
CONTACT: -PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLrU�MB// MECH
III ❑ ❑, L7 ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OaZ with Section?000)of Division 3 onhe Business and Professions Code,and my license is RESIDENTIAL:
O O PERMIT ISSUANCE
in full force end eff•pl. ❑SFUWL [_1 KITCHEN REMODEL
�UZV License lass V LicW AppL1ANCE5-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F-G d Dote Cammdor
p.pm> ARCHITECT'S DECLARATION PANELS [I MULTI-UNIT El STRUCTURAL
z p�A I understand my plans shall be used as public records - MODIFICATION
OZ UP TO 200 AMPS El INTERIOR El CHIMNEY REPAIR
F ce I:_W Licensed professional 201.1"AMPS IMPROVEMENT.
OWNER-BUILDER DECLARATIONOVER 1000 AMPS El BATH RF.MODEVREPAIR [I DEMOLITION
I hereby affirm that I am exempt from the Contractor's License Law for the
O y U following reason.(Section 703 1.5,Business and Pfofesslmns Code:Any city oncountySIGNS ELECTRICAL C OTHER
'3 4 which requires a permit m construct,after,improve,demolish.or repair any structure
�qOq primo,its ismance.alsu requi sthevpplicunt bnnoch permit to file asignedstnmmem SPECIAL CIRCUITIMISC.
yi that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 1 -
OO (commencing with Section 7000)of Division 3of0e Business and Professions Code)or TEMP METER OR POLE iNST COMMERCIAL:
d o y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDOADDITION C DEMOLITION
k• Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
^y []TENANT [I FOOD SERVICE
z pts not marc than five hundred dollars 85010. IMPROVEMENT
6 has owner of theproperty,nr my employees with wages es their sole compensmion, SWIMMING POOL ELECTRIC
q will do the work,amd the structure is not intended croffered for sale(Ser,9044,Business DOTHER
m and Prmillions Code:The Connector',License Law does not apply to an owner ml OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,Provided that such improvements arc net attended or offered for NEW RESIDENTIAL ELECTS
sale.If,however,the building orimprovement is sold within one yearofcnmpletion.the My Ffp(W JRU $/SQ.Er
nerbuilder will have the burden of pmving that he did not build or improve for pun-
P oriole.). {�C'D
❑1,as ow er of the property,704 vis exclusively contracting with licensed contractors i- MAR 1 e
mme Law
a the project(Sec.o an Business and ray wh i but Cale:i The es thereon,
Li- Q
cense Lvwdoesnotapply man ownerofproperty whosedpnrimproves thereon,aril QTY. PLUMBING PERMIT E
I who contracts for such projects wiNacommemr(s)lieemed pursuant to the Contractor's
License Law. PERMIT ISSUANCE i C11 Vr Wr-n111VU
Iumexemminder Sec ,B&PCfmdd., eama
Owner Dote ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑Ih:rveendwlll mvinmin nCenificam of Conserv to sdf-insure fur Workers Cnmpen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
%mice,as provided for by Section 3900 of the Labor Code,for the peffomwmco militia
work for which this permit is issued. FIXTURES-PER TRAP.
❑I have and will maintain Weakens Compensation Insurance,as required by Section
3900 afthe Labor Code,form,performance ofthe work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC CROUP APN
My Worket/iiCmnpjna.d.ons ce ca ' rand Policy numbv.aq
Cartier d 'Ai•/Mf/t1 Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATEOPEXEMPTIONFROMWORKERS' •J
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not becompleted ifthe permit is for one hundreddmllors($100) GREASETRAP
carless.) PLANCHECK FEE
I cenifythm indm performance.fthe work forwhich Nispermit is issued,],hall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner se ex m Iacocca subject m the Worken'Compen- ENERGY FEE
O z sation Laws of California.Date WATER HEATER WNENTMI-ECTR
Z Applicant GRADING FEE
zn NOTICE TO APPLICANT:If alter making this Cenificam of Exemption,you should WATER SYSTF.M?REATING' SOILS FEE
become subject m the Worker's Compensation provisions of the Labor Code,you most
r! r✓y forthwith comply with such provisions or Nip permit shall be deered revoked. WATER SERVICE O
Wa' 6lz
z'
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR SQ.ET. PAID
Thereby uffirm Nauhereis aconswmion lending agency(onhe performance of
L) Data Receipt#the work for which this permit is issued(Sec.309],Civ.CJ
u" Lender's Num. TOTAL:
V Lender's Address TOTAL:
rti til BUILDING FEE
[.y 1 certify that 1 have rend this application and stem that the above infortnoting is
., rail building agree mcomply
and
y city riz countyordinancesof this
cite lawsrelntmgm QTY. MECHANICAL PERMIT FEE
U � building consumption,and herehy authorize representatives mf Nls shy to entsr upon Ne SEISMIC PHH
above-mentioned property for inspection ptupses. PERMIT ISSUANCE
(We)mace it)save,indemnify and keep harmless the City of Cupertino against ELECTRIC F28
ag
liabilities,judgments,costs and expenses which may in any way crime against said City ALTER OR ADDTO MECH. t PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTAN AND WILL COMPLY WITH ALL NON,POINT AIR HANDLING UNIT TO IO.OIXI CFM) MECHANICAL RE
SOURCE REGULATIONS
xEP AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sig/ot�ur/, . VCarmed., •b Data EXHAUST HOOD(WIDUCT)
• HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will The applicant or future building occupant store or handle hazardous material HEATING UNIT(TC,I W,M)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532m)? HEATING UNIT(OVER,100,000 BTU),
E]Ya, ❑No VENTILATION PAN(SINGLE RESID) PAID
Data Receipt#
chit
N.applicant furore building occupant use equipment of devices which BOILER-COMP IMF OR 100,000 BTU)
emit hazardous sir contaminants as defined by the Bay Area Air Quality Management TOTAL: D
xO ct?
❑Yes ❑No BOILER-COMP(OVER 100,0(10 BTU) ,
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
fomla Health&Safety Code,Sections 25505,25533 and 25534.1 understand @m if the NEW RESIDENTIAL MECH. SQ.FP.-
hi ilding does not currently have a r.nmm,that it is on,responsibildy m notify the oecupam
of The requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner or autburleed agent Data -1 1 TOTAL: ISSUED BY:
OFFICE