31374 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE'RTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 31314
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
lfl `7 !S f� ro0 LA—)'r— L I dr Ir7-
OWN ME CONTRACTOR NAME: LIC NO:,
71.411
J NCS �CSS OYI V_ Sal C;;,3 NIC CONTROL»
RCHITECT/ENGINEER: IC NO. A pOSS� ❑
oe It
coNTACf: " PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT -PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
G 0 Z e herebygh.17 that I am licensed under provisions of Chapter 9(commencing 'JOB DESCRIPTION_
�O with Section AN10)of Division 3ofthe Business and Professions Code,and toy license is RRIDE '
In full force and effect PERMIT ISSUANCE NTIA
UU� License I Lic,# 0�S _ DSFDWI_ -❑KITCHEN REMODEL
V.1 Date Contractor L e-50 APPLIANCES-RESIDENTIAL
FF ❑ADDITION, DPLUMBING RE-PIPE
ARCHITECT'S DECLARATION pgNELS 11 MULTI-UNIT ❑STRUCTURAL
Cz.'/C 1 understand my plans shall be used as public records MODIFICATION
� UPT02WA PPS �" INTERIOR HIMNEY REPAIR
pmE"I�al Lsenecd Prnfesstonal 201-IOMAMPS IMPROVEMENT
CC "I
OWNER-BUILDER I am eUILDE urn the RATION OVER I WO AMPS D BATH REMODEUREPAIR ❑DEMOLITION
yy a'W 1 hereby s[Flrm that!am exempt from the Contracmr's License Law for the
hC 3 L F+ following reason,(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
t1[[l7 O which requires a permit m rm,mm,:alter,improve,demolish,or repair any structure
�w prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.-
y that he is licensed pursuant the provisions of the Contractors License Law(Chapter 9
(eommeneing with Section 900(l Division 3 ofine Boniness and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL
0.y y t•G Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of D NEW BLDG/ADDITION D DEMOLITION
IWC h Section T031.5 by any applicant for a Permit subjects the applicant m a civil penalty of POWER DEVICES
Sp, not more than Five hundred dollars($500). ❑TENANT ❑FOOD SERVICE
q ❑I,as owner oRhe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRICIMPROVEMENT
c`. will do the work,and the stmctme isnot irmadedoroffend forsale(Sec.]04q Business ❑OTHER
d3 and Professions Code The Conuadm's License Law does not apply to on owner of OUTLETS-SWITCHES-FIXTURES
properly who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ En
sale.If,however the building or improvement is sold within one year ofcompletiou.the 90�C4REA .$/SQ.IT.
owner-builder will have the borders of proving that he did not build or improve for pury Y
pose oxide.). Jq
❑I,as owner of the property,am exclusively contracting with licensed contiaaors to TOTAL: �Apw
centra does
apply too owns of ess and
Professions Ps ori The Contractor's Li- n tl ��
sone Law does not apply to an owner of propel who builds or improves thereon,and QTY PLUMBING PERMIT FEE
wicensemasfor such Mojems with oconwemr(s)IieensW treuom to the Contractor's f 'I C[� •'
License Law.
[I & PERMIT ISSUANCE
Ism exempt under Sec. ;BPCfor this reason own
er Date ALTER-DRAIN&VENT-WATER(EA) LLL VALUATION
WORKER'SCOMPENSATION DE CLARAwing BACK FLOW PROTECT.DEVICE / nS
(hereby afWORKER peCOMPfNSAryoN Of EFIefoliowing declarations: (( / l/ V
I haveand will mintain a Certificate ofConsent m self-insure furWorkees Compen-. DRAINS-FLOOR,ROOF,AREA,CON❑.ion,as provided fur by Section 37M of the Labor CWe,for the performance of the STORIES TYPE CONSTRUCTION
lk for which this permit is Issued. FIXTURES-PER TRAP
1 hove and will muimeio Workcr'e Compensation Insurance,as rcgoi ed by Section of the Labor Code,fMY foWorq the prreqrr��formance ovf tqhe work for which this permit is iossued. GAS-EA.SYSTEM.I INC.4 OUTLETS - OCC.GROUP APN
e came
polic
rier. •tNIGLT10VigyXoy No.rl-o �-`�G09ay GAS-EYSYSTEM-OVER 4(M)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRT;ASMNDUSTRL WASTE INTERCEPTOR
(This semina need not be completed lOM1e permit is fomnehundred dollars($I W) BUILDING DIVISION FEES -
mlessJ GREASETRAP - -
Icenifythatintheperforname,of Ne-work for which this PLANCHECK FEE ,
pee Worlcri'C, anted, SEWER-SANITARY-STORM EA.200 ET.
not employ any person is any manner so as m become subject ro the Workers'Compen- - ENERGY FEE
0 Z nation Laws of California.Date t
Z Q Applicant WATER HEATER WNENT/ELECfR
o-^i GRADING FEE
(-w y NOTICE TO AP.the Weak.If,Compensation
ti this provisions
of of Labor io de.y uM1mulst WATER SYSTWO'REATING
�i becameh cont t y the Worker's Compeor this ermi sof the Labor Cade,you most SOILS FEE
forthwith comply with such pmvisians onhis permit shall he deemed revoked. WATER SERVICE
C
Z) zONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL FLATS. SQ.En PAID
I hereby affirm that there is a consuturion lending agency for the performance of Date Receipt#
the work for which this permit is issued(Sec.3097,Civ.C.)
Q U Lender's Name _ TOTAL:
W Lenders Address TOTAL:
,I certify that I have read this application and state that the above information is BUILDING FEE
y cortex.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE•
V Z building courametion.and hereby authorize representatives ofthis 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 accrue against said City ALTER OR ADO TO MECH. '
In consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT IO,WCFM)O
SOURCE RF�LAT� 1`� -
I MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,00)CFM) CONSTRUCTION TAX
Stgnawrea plwanVContractor I Date T EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hmardous material HEATING UNIT(1'0100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
Code,Section 25532(a)7 HEATING UNIT(OVER FXLWO BTU)
DYcs [I No
VENTILATION FAN(SINGLE RESID) ' PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt#
it hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR 100,0110 BTU) -
nsulctP TOTAL:
`tet ❑Yes. . 1-1 No BOILER-COME(OVER 1DEOWBTU)
I have read the hmallous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
Famia Health&Safety Care,Sections 25505,25533 and 25534:1 understand that if the ISSUANCE ATE
building does not cu ly satenant,mar it is my responsibility ton city the pant NEW RESIDENTIAL MECH. SQ.PT. _
oftha requirements hl t��tr�ptplior to issuance of a Ccadri f u a -
OwnerorauNonze gent 'Dam
TOTAL: ISSUED BY:
__ OFFICE