31218 AFFLICANI TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I - BUILDING-ELECTRICAL. PERMITNO,'31218
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDLNG PROJECT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATI
B AP—PA
OWNER'S NAME 4 PHONE: -
CONTRACTOR SNAME; LIC NO: T a�
N/C' �CONTROLM
RCHITTMRIGINBER: r, LIC NO: A KESS: ❑
e
CONTACT. PHONE: -
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECx
LICENSED CONTRACTOR'SDECLARATION T ID 0 El
I hereby affrm that I am licensed under provisions of Chapter 9(commencing QTYELECTRIC PERMIT FEE -
Iyyy�y1111QZ with Section]OW)of Division 3ofthe Businesx and Professions Code.rndmy license is JOB DESCRIPTION
,r infullfnrcea -e(ea PERMIT ISSUANCE RESIDENTIAL
UzU License Clac Lis.k OSPDWL [I KITCHEN REMODEL
wo , Date Contractor APPLIANCES-RESIDENTIAL IGADDITION El PLUMBING RE-PIPE
RCHITECTS DECLARATION
ZO g r I understand my plans shall be used as public records PANELS' 0 MULTI-UNIT 0 STRUCTURAL
OZ Q UP TO 200 AMPS ATI IS
�.',y.,E'{y _sensed lou-smnal El INTERIOR IMNEY REPAIR
p¢,' a-J OWNER-BUILDER DECLARATION 201,-I WBAMPS IMPROVEMENT
^� - OVER 1000 AMPS
O `
U I hereby affirm that 1 am exempt front the Contractor's License Law for the 0 BATH REMODELG EPAIR DEMOLITION
a d F following reason.(Section]0715.Business and Professions Code:Any city or county
4 y which requires-permit to roe trod,.Iter,im rove,demolish,or re SIGNS ELECTRICAL ❑OTHER
O P pair ed swmure
Pather toisscense pursuant
rlso suarequires theapplicantofthe ContratoitmfleaeLaw nCammem SPECIAL CIRCUIT/MISC.
thathee t.,wiit purstion 7to 0theprovisions 3.1`11m
the Contractor's License Law(Chapter9
q0 (cat he
xempt thaileon]Od0)oe twoulon7 of thevised BusinessandProfessions Code)or TEMP.METER OR EI T ,COMMERCIAL
d p,m OE thin he is exempt therefrom and the beans for the alleged exemption.Any violation of
SNEW BLDG/ADDITION
it> wtiov]41LS by any opplloant foropermh suhjeab the opplicem toaoivil penalty of POWER DEVICES [IDEMOLITION
a iN+ not more than five hundred dollars($500). 0 TENANT 0 FOOD SERVICE
9 G
[],,[,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOLE ECfRIC IMPROVEMENT
{r wo the work,and theswdureis not intentleJ oroffereJ fo...le(Sec.]IH0.Busfires 'GOTHER
6C and Professions Code;The Contraries License Law dues not apply to to owner of OUTLETS-SWITCHE F URES
..
property who builds or improves thereon,and who does such work himself or through
his own employees;provided that such improvements are not intended or offered for NEW RESIDENTIAL FILE SQ -
.aid.If,however;the buildingor improvement is sold within one year ofcompletion,the $p,FT.FLOOR AREA $/SQ.PT.
er-builder will have the burden of proving that he did not build or improve for pur- r. li/pJ,n rr�
p se of so - - gtll IS_
❑1,as owner id the So.property,04 ,B exclusively contracting with licensed contractors i- AL. C�
'
construct the project(Sec.]M4,Business and Prokselens Coda)The Contractors Li- TyO -
cense Law does not apply to an owner of property who builds or improves thereor,and Q• V. PLUMBING PERMIT FEE Vh LVP
who contractsUs. for auch projects with a connndon s)licensed pursuant to the Contractor's ���Iry
License Lu -
❑1 am exempt ruder Sec. ,B&P C for Nis reason PERMIT ISSUANCE
Owner Dare ALTER-DR AIN&VENT-WATER(EAJ VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
'%hereby affirm under penalty of perjury one of the following declarations: - 1 '`OC'_
(have and will maintain a Cenifiette of Cmwdtnself-hoom for Worker's Compen- DRAINS-FLOOR,ROOFAREA,COND. LL
lilhun,as provided for by Section 37W of the Labor Code,for the Performance of the .STORIES TYPE CONSTRUCTION
work for which this Permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compedsatiun Insurance,as required by Section
3 Wuf the Libor Code,
For Performance of the work for which this permbui issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
My Wmke mpensatoe firamsececurrier and Policy numb,[ OCC.GROUP
carrier Policy No. 1 GAS-EA.SYEM-OVER4(EA)
C RFI ATOFEXMP ION qPN
FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section need nothe completed if the permit is for,,.hundrrd dollars($I W) BUILDING DIVISION FEES
or lass.) t GREASETRAP .
I certify that in the Performance ofthe work for which this permit is issued,l shall PLANCHECK FEE
not employ any person in any manner so as to become subject to the Workers'Compen- SEWER-SANITARY-STORM EA.2W FT
0 z '-tion Laws of California.Date ENERGY FEE
7 O� Applicant/ WATER HEATER WNENT/ELECTR
f7 NOTICE TO APPLICANT If,after makidg ffid;Cenifcate of Exemption,you shouldGRADING FEE
WATER SYSTEM/1'REATING
F+ become subject to the Worker's Compensation provisions of ther Code,you must
Q forthwith comply with such provisions or this permit shall be deemed
revoked WATER SERVICE SOILS FEE r
z CONSTRUCTION LENDING AGENCY NEWRESIDEN %ALP MB. SQ. T. PAID
L) O 1 humbyaflion than there is a construction lending agency for the perfmma o idt' DateN
W N the work for which this permit is issued(Sec.3N7.Civ.C.)
O U Lend,ea Name
Lender's Address
y I certify that I have read this application and state that the above information is - TOTAL. - BUILDING FE hconed.I agree to comply with all city amt county ordinances and state Inws relining to QTY. MECHANICAL PERMITFEE
building concoction,and hcreley authorize representatives ofthis city to enter uponam SEISMICFabove-mevtioned property forinspection purposes.(We)agree tv save,indemnify and keep harmless the City ofCupertino against PERMIT ISSUANCE ELECTRI FEEliabilities,judgments,costs and expenses which may in any way transit against said City ALTER OR ADD TO MECH.nn consequence of Ne granting of this Permit PLUMBINGAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)SOURCE EGULATIONS. MECHANICAL FEE/gAIR HANDLING UNIT(OVER%40(10 CFM) CONSTRUCTION TAStgnatureO ApPhcart Mntowtmr DaaEXHAUST HOOD(WMUCT)HAZARDOUS M %ALS DISCLOSURE HOUSING MITIGATI
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(x)?.` HEATING UNIT(OVER 100,000 BTU)
r7 Y. No
W
FAN(SINGLE RESID) PAID
Adlk� Will Ne upplin. or future building occupant use equipment or devices which 'Date Receipt it '
emit haaallous air contaminants as defined by the Boy Are Air Quality ManagementP(3HP OR 100.000 BTU)
District,
❑Yes ❑Noy P(OVER 100,000 BTU) TOTALI have mail the hazmdons materials requirements under Chapter 6.95 of the Cali- NER -
fomia Health&Safety CMe,Sections 25505,25573 and 25534.I understand that if theISSUANCE DATEbuilding does not currently have a tenant,Nat it is my responsibility m notify the occupantTIAL MECH. SQ,BF.of the requiaments which must he met Prior to issuance ofa Cenifcate ofof euonacom-gem Date ' TOTAL: t
ISSUED BY:
OFFICE