31501 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY t
CITY OF CUPERTINO BUILDING ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJECT IDENTIFICATION
- BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTALDATE
733514 '
OWNER'S NAME: PHONJEJ CONTRA TOR'S NAME: '. LIC NO: rx -
Q NIC CONTROL M
ROHITECDENGINEER: LIC NO: ADDRESS. ❑
a: tk
owL CONTACT: PHONE: BUILDING PERMIT INFO
'i a a / '❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
CENSER CONTRACTOR'S DECLAITATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
00.'Z with Section of Division Sof the Business and Pro scions Gde.andm Hemmeis RESIDENTIAL:
00 wt - PERMIT ISSUANCE, '
in full force era effect ❑SPDWL [I KITCHEN REMODEL
�U License Cla _ cmru APPLIANCES—RESIDENTIAL"' 'TIADDITION El PLUMBING RE-PIPE
N Z Rete 7`S DEL «
Gay ARCHITECPS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.'
I understand my plans shall be used as public records MODIFICATION
p,T,_� UPT02WAMPS []INTERIOR [I CHIMNEY REPAIR
q0.' Licensed Professional. 201.1000AMPS IMPROVEMENT
f9OWNER-BUILDERDECLARATION OVER["AMPS "[I BATH REMODEUREPAIR El DEMOLITION '
W 1 hereby affirm that I am exempt from the Comrn ant's License Law for the
U following reason.(Section 7031.5,Business and Professions Code'.Any city or countySIGNS ELECTRICAL ❑OTHER
which requires a permit to consumer,alter,improve,demolish,or repair any structure - '-
�Fy�OyJ prior to its issuance.alsa requires the applicant for such permit to file a signed statement SPECIAL CIRCUFLMISC.
,{ y (commercial,
with
itpursuant tathtpfDivisioo ca a Business and
Prodetion,Capter9
P� p0 thammencixem it therefrom nd hDivisi for oftheeged exempt Professionslation r ,TEMP.METER OR POLE INST. COMMERCIAL:
0. c aG that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ws N Section 7031.5 by any applicant for a permit subjects the applicant m u civil Penalty of POWER DEVICES f1 Tar,CpNT ❑FOOD SERVICE
zz D, not more than five hundred dollars($500). IMPROVEMENT-
6 I,os owner of the pmpeny,or my employees with wages es their sole compensation, SWIMMING POOL ELECTRIC
G will do the work,and the smando,is not intendedoroffered farsele(See.]0FL Business []OTHER
m and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
r property who builds or improves thereon,and who does such work himself or through
his own employees,provided mat such improvements are not intended or offered,for NEW RESIDENTIAL ELECTR SQ FT �pp� {p
sale.If,however the building or improvement is sold within one year of comphoomme SQ.Pr FE'" MRI D 5/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pun- r" M, n
owswrsalu). - - - -
I, u owner of the n y encircling with TOTAL: �0V 211996 1 1996
props y,am exclusive) [main th licensed contractors to /8 M%
construct the project(See.o an owner
of and Professions Codei The Com emon.LL
cense Law does not apply ean ownerofproperlywho buildsorimproves Merton,and QTy. PLUMBING PERMIT FEE
who contracts for such prole"'with a canua"ot(s)licensed pursuant to the Contractor's ,
License Law, PERMIT ISSUANCE CI I Y UY V Vf Cil 1114
I am exempt under Sec. B&P C for this reason
.ALTER—DRAIN&VENT—WATER(EA) VALUATION
Owner Dem ..nn
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE Z� OVO e0
1 Y hereby affnm under penalty of pe jury one of the following ded...firms:
I have and will maintain.Certificate of Consent to self-insure for Worker's Camper- DRAINS—FLOOR.ROOF,AREA,COND. STORIES - TYPE CONSTRUCTION
satme,as provided far by Section 3700 of the Labor Code,for the performance of the -
workforwhichthispermitisissued. FIXTURES—PER TRAP - -I
Fl have and will maintain Worker's Compensation Insurance,as required by Section
37Wofthe Labor Co ,forthdpd.rman a of the work for which this permit is issued. GAS—EA.SYSTEM-I INCA OUTLETS OCC.GROUP APE
My War satlo Durance ca :rand Policy Inff Ia-9� GAS—EA.SYSI'EM-OVER4(EA)
- Cerise Policy Nn.: /M
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
Mods siolmateednot be,completed if the Permit is for one hundred dollars(5100) GREASETRAP
In leas) PLANCHECK FEU '
I certify that in theperformance of the work for which this permit is issued,Ishall SEWER—SANITARY—STORM EA.200 PT.
not employ any person in any manner ata'tn hecoure'rule"m the Windom,Compen- ENERGY FEB
z moon Laws of California.Dam WATER HEATER WNENTIELEClt
OO Applicant GRADING FEE'
V] NOTICE TO APPLICANT:If,hirer making this Certificate of Exemption,you should WATER SYSTEM(TREATING '
f~t�' become subject to the Worker's Compensation provisions of the Lobar Code,you mum SOILS FEE
Wforthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
aD Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLATE. SQ,FT, PAID
U O _ _ Date ReceiP[N -
1 hereby affirm that mere is construction lending agency Porth:performance of
I—i the work for which this permit is issued
uee (Sce.d(See.3097,Civ.CJ
Lenders Name TOTAL:
O wLenddea Address TOTAL: -
y I certify that 1 have read this application and state that the above information is BUILDING FEE
N correct.I agree to comply withal)city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE -
UZ. building conswetion.and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify,and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accree against said City ALTER OR ADD TO MECH,
in consequence of the gratnting of this Permit.
- PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HUMID(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazandous material HEATING UNIT(TO 100100)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(x)1 HEATING UNIT(OVER 100,000 BTU)
❑Yea ❑No VENTILATIONPANVEILATION FAN(SINGLE RFSID) Date Receiptil
•—J,4 Will the applicant or future building occupant use equipment or devices which BOILER—COMP(!HP OR 100,1100 BTU)
mit hezallous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
District)
❑Yes 7 N BOILER_COMP(OVER 100,000 BTU)
� •
I have rend me hazardous materdei materials requirements unChapin AIR CONDITIONER 6.95 of the Cali- ISSUANCE DATE '
Ramie Health&Safety Code,Sections 25505,25533 and 25534.1 understand mat if the NEW RESIDENTIAL MECH. SQ.FT
building does not currently have a tenant that it is my responsibility m notify the occupant
of the requirements which most bo met prior to issuance M a Certificate of Occupancy. is +
- Owner or authorized agent Date TOTAL ISSUED BY:
OFFICE