31230 . APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT NO. 312 3 0
BUILDINGDIVISION .- APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
WN R'SNAME: / PHONE: CONTRACTOR'S NAME: LIC NO:
(f�L - N/C CONTROLp ,
iRCHITECTIENGINEER: - IC NO: ADDRESS: ❑
a
CONTACT:'- PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) - BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I amlicensedu under provisions of CM1aprei9 ormancium,museis JOB DESCRIPTION
pZ withllfro andefecUivigionJufthe Business and Rofeesiona Code.and my license is PERMIT ISSUANCE RF.CID NTIA
���. in full force and effect. D SFDWL D KITCHEN REMODEL
License Class Contractor
APPLIANCES-RESIDENTIAL.
ZWti Date Contmdor �.(]ADDITION i C1 PLUMBING RE-PIPE
Q> ARCHITECT'SDECLARATION PANELS DMULTI-UNIT. ]STRUCTURAL
Ox�G 1 understand my plans shall he used as public records - MODIFICATION
UPT0200 AMPS ❑INTERIOR UCHIMNEYREPAIR
GrG r(j Licensed Pmfessonal 201-HpOAMPS IMPROVEMENT
s+hE OWNER-BUILDER DECLARATION Com un OVERIM)AMPS D BATH REMODEL/REPAIR [IDEMOLITION
pyoo a I hereby effrm that I em exempt from the Comrectors License Law for he _
W 3 per,F following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL D OTHER
F Oya which requires a permit to construct,alter,improve,demolish,or repair any sweture I _
g�0J prior to'its issuance,also requires the applicant for such permit file a signed statement SPECIAL CIRCUIT/MISC.
F?qaC.� p, that he is licensed pursuant to the provisions of the Contracue's License Law(Chapter 9 _
fat 00 (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.MEIER OR POLE INST. COMMERCIAL,Sx
GL y sp eG that he is exempt therefrom and the basis for the alleged exemption.Any violation of D NEW BLDG/ADDITION r D DEMOLITION
i4C1 4• Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
not mare than fvc hundred dollars F$50q I - D TENANT D FOOD SERVICE
G Dns
I as ownernf the properly,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
W'If do the work,and the structure is not intended or offered for sale(So,7044,Business D OTHER
aand Professions Cade:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FI
properly,who builds or improves thereon,and who does such work himself or through -
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELF.0 SQ Fr.
sale.If.lummin9rhe building or improvement is sold within one year of completion,the SQ.FT FLOOR AREA $ISQ.ET.
owner-builder will have the burden of proving that he did not build or improve for pur-
po ofsale). -
owner of the property,nm exclusively contracting with licensed contractors to -T
„ asuuctthe project(See.7M4,Business and Professions Code:)The Contractor's Li- PAID
-
ense Law does not apply to an owner of property who builds m improves thereon,and QTY. PLUMBING P PEE
who contracts for such projects with aoentractor s)licensed pursuant to the Contractor's
License Law.l OK - -
a C)1 am anent t it Se. B&P C fur this mason PERMIT ISSUANCE a C.a.
MAy
wner Dale '— ALTER-GRAIN&VENT-WATER BEA) VALUATION
fWORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE , ``ITV Ur tau NtH 1.�NU ,
ereby affirm under penalty of perjury one of the following declarations.
aveandwill maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND.
satma,as provided for by Secfian 3700 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
D I have and will maintain Workers Compensation lnsnmnce,as required by Section
3700of the Latour Code,for the performance ofthe work for which this permit is iisued, GAS-EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP -APN-
My Worker's Compensation Insurance carrier and Policy number me:
Carrier. Policy No.: GAS-EA.SYSTENFOVER 4(EA) ,
CERTIFICATE OF EXEMPTION FROM WORKERS', GREASEgNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE
(This section need not be completed if Ne permit is picture hundred dollars($1007 BUILDING DIVISION FEES
or less.) ( r GREASETRAP
+ PUANCHECK FEE
Toy any that int he peaany.mahceofthe work for s1.beemna subjech ct to
permit ikera'C,lshall SEWER-SANITARY-STORM EA.200 FT.
not employ any parser in any manner su as,m become subject m the Workers'Compen- ENERGY FEE -
0 mlion Laws of Califomie.Dam
.
00 Applicant, WATER HEATER W/VENT/ELECTR
yGRADING FEE
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you shoal WATER SYSTEM/IREATING
f~ 5 became subject to the Workers Compensation provisions of the Labor Code,you must - SOILS FEE '
WL� forthwith eomply,with such provisions or this permit shall be deemed revoked WATER SERVICE -
Q
az CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB. - SQ.FT. PAID
V0 (hereby affirm that there iso convulsion lending agency far the perform..of Date
4. H the work for which this period is issued(Sea 3097,Civ.C.)
0 Leac Its Name - OTAL: .
W Landes Address TOTAL'
Ow I certify that I have read this application instance that the above information is � BUILDING FEE
h correct,I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT -
L)z building constmdion,and hereby authonre represenuuves nfthis city to enter upon the FEE SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
KIN
(We)agree to save,indemnify uad keep harmless the City of Cupertino against ELECTRIC FEE '
liabilities,judgments,costs and expenses which may in any way seems,against said City
in onsaquence of the granting of this permit. ALTER OR ADD TO MECH. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REG ATIONS.
� AIR HANDLING UNIT(OVER 10,000 CPM)
CONSTRUCTION TAX
nature of APPlicanVCommctor Dare EXHAUST HOOD(W/DUCf) HOUSING MITIGATION E -
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhandle hazardous marerlal HEATING UNIT ITO 100.000 BTU)
ea defined by the Cupertino Municipal Code,Chapter 9.12,and rbc Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
❑Yes UNo t -
"' VENTILATION FAN(SINGLE.RESID7 PAID
Will the applicant or tbmm building occupant use equipment or devices which Data -_RT`Pt K
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP QHP OR 100,000 BTU)
L�vm
TOTAL:
s _ BOILER-COMP(OVER 1040WBTU)e read the hazardous materials requiremets under Chapter 6.95 of the Call- AIR CONDITIONER ISSUANCE DATE
&Safety Code,Sections 25505,25533 and 25534.1 understand that if theNEW RESIDENTIAL MECH. SQ.FT.squarently haveatennnk that it is my msponsibilisy tonotify the occupantments which must be met prior m issuance ofa Certicate of Occupancy.hmindagem Date aonA
ISSUED BY:
OFFICE t