31430APPLICANTTO FILL IN INFORMATION WITHIN RED LINES. USE RAI I PCHNIT.OEM riEli V
CITYOF CUPERTINO '•'
BUILDING. ELECTRICAL
'-I PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT
PLUMBING -MECHANICAL
'•
31430„
BUILDING PROJECT IDENTIFICATION-
BUILDING ADDRESS. - -' -
,
SANITARY NO.
APPLICATION GATE
�ke � L.i
QSU�BMITTAL
• �y
O\R'�S_ NAME: PHONE:
7= AME:
Vim/ 3GCo 13 GC�
CONTRACTOR'S NAME:+
tu, I O
Np;
O
NIC
❑
CONTROL #
Aosllni I.IEN.INMK:LIGNO: ADDS SS `
J e,- N 2�e
V.
CONTACT: - PHONE :
'
...
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
❑ ❑ ❑
-
.- LICENSED CONTRACTOR'S DECLARATION
- 1 hereby affirm that I am licensed um
trader pvlslons of Chapter 9 (ww
mmdngr
with Sectiun]O(1(pof Divisi 3ofthe Business dProfessions Code,an hcenaeie
n full force and t.
QTY ELECTRIC PERMIT
PERMIT ISSUANCE
FEE
JOE DESCRIPTION
RESIDENTIAL
IT!j License Class. .Lio.# _.JSL\�
❑SFDWL' El KITCHEN REMODEL
Date Commmor
APPLIANCES - RESIDENTIAL
[]ADDITION sR PLUMBING RE -PIPE
❑ MULTLUNIT ❑ STRUCTURAL ,
- MODIFICATION
❑ INTERIOR . ❑ CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEVREPAIR ❑ DEMOLITION
OTHER
- , ARCHITECT'S DECLARATION
I understand my plans shall he used as public records t PANELS •
UP TO, 200 AMPS
J Licensed Profeaem id „
..11
m Ce Corm ON
Oat I ma exempt from
Q I hereby affirm that 1 nm exempt from the feomancara Licence Law coo the
following reason. (Section p031 5, Business and Professions Code: Any city or county
which toa pwmit to construct, alter, improve, demolish, m repair amy structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
E matheislicensedpuauanuoden... isionsofthe Contractor's License Law (CI,,tv,9
(commencing with Section]00spifDivision 3 of the Businessand Professions Code).,
tl that Ire Is exempt therefrom and the basis for Ne alleged exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
not mom than five hundred dollars ($5W).
❑'1 -as owner of the property, or my ampleyws with wages as their sole compensation,
will do the work, and the structure is not intended or offerW farsa]e (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not, apply to an owner of
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
sale. If, however, the building or improvement is sold within one yearot' completionthe
owner -builder will have the burden of proving that he did not build or improve for par-
pose of sule.).
201 -IOW AMPS
OVER RMAMPS - -
_
SIGNS ELECTRICAL
,SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES - -
SWIMMING POOL ELECT RI
OUTLETS - SWITCHES - FIX, E
NEW RESIDENTIAL ELECIB S
-
-
OMM R "IA
[I NEW BLDG/ADDITION �,� DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENTS ”
El OTHER
A A is _
QPFT. FLOOR AREA
VV {D
A�e — L! ����
$/SQ. ET.
❑has owner of the pmpeny, am exclusively connecting with licensed contractors m
+ TOTAL:
-
the project and The Contractors Li-
wcle
))
La to an ownerof
cense Law does not apply to an owner of properly who builds m improves thereon, and -
applyny who builds
who cammms for such projects withecomtmmnr(s)licensed pursuantmthe Cnntmcmr's
License Law.
QTY, PLUMBING PERMIT
FEE
! Uf V
UUrtM I IBV
-'
'
❑ I am exempt under Sec. ,B& P C for this reason
PERMIT ISSUANCE
Owner ,Date - -
ALTER - DRAIN & VENT - WATER (EA)
VALUATION
• WORKER'S COMPENSATION DECLARATIONs
Thereby ufFinn ander penalty of pejury one of the following declamtions
❑ I have and will maintain a Certificmc of Consonto self-insum for Workers Compem
cation, as provided far by Section 3'700 of the tabor Cole, for the performance of the
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF AREA, GOND.
STORIES
'TYPE CONSTRUCTION
work for which this permit is issued,
F-11 have end will maintain Worker's Compensation Insurance, as required by Section
370Oofthem r We,forthcpe otrnance of the work for which this permit is issued.
My Worker' no riga Is a e canter and Policy no I c,
FlXTURES - PER TRAP.
GAS-EA.SYSTEM-IINC.4OUTLETS
-
OCC. GROUP
qPN
Carrier: C ' Policy No.:
GAS - EA. SYSTEM -OVER 4 (EA) -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE •
GREASMNDUSTRLWASTL INTERCEPTOR
BUILDING DIVISION FEES
(Thissection neeIdmnbe cont leted ifthe
P permit is forona bumthW dollars (SIM) or ices] -
(certify that inthe anymannce ro astobche work for subject
not employ any person in any manner so as m become eubjca to the Workers' Campion.
bjech tto the W ekesued. I ' Campion.
inof California. Date 'j'
,Applcantt
Applicant
GREASE TRAP
SEWER -SANITARY -STORM EA. 2M FT
WATER HEATER WNENT/ELELTR
PLANCHECK ME
ENERGY FEE
GRADING ME
NOTICETOAPPLICANTtheWor&.s after Compiakationrng this Certificate m Exemption you must
become subject y the Workers Compensation provisions of Ne Labor Code, you must'
faMwith comply wish such provisions or this permit shall be deemed revoked.
WATER SYSTEMITREATING
WATER SERVICE
'
SOILS PEE -
CONSTRUCTION LENDING AGENCY
I hereby affirm that thea is a construction lending agency for the performance of
the work for which this Permit is issued(Seo. 3007. Civ. C.) r
NEW RESIDENTIAL PLMB' SQ. FT.
- _
-
PAID'
Dale' Receipt#
Leaders Name
Lenders Address -TA
TOTAL:
I icrtify that I have read this application and state that the.hove information is
covert. l agree to comply watch city and county ordinances and state laws relating to
building constmniom, and hereby authorize representatives ofthis city to carer upon the
aoosonaentiemed property for inspection purposes., I
(We) agree to save, indemnify and keep harmless the City of Cupertino against'
liabilities,judgments, costs and expenses which may in any way ecemeagmmsl said City
incousequerecofthegraoting fthlspermit. -
QTY MECHANICAL PERMIT
PERMIT ISSUANCE _
ALTER OR ADD TO MECH.
FEE
BUILDING PEE.
SEISMIC FEE _
ELECTRIC ME.
PLUMBING FEE O
,T
V
APPLICAN UNLESS N S AND WILL COMPLY WITH ALL NON -POINT
SO GULATI
AIR HANDLING UNIT (TO IO,OW CFM)
MECHANICALFEE
AIR HANDLING UNIT (OVER 10,00) CFM). _
CONSTRUCTION TAX
Si tore of it U o rte ,- Date
HAZAR US MATERfALS'DISCLOSURE
;fit,
EXHAUST HOOD(WMUCT)'
HOUSING MITIGATTON FEE
Willt applicant or future building occupant store or handle menders material
by he Capertion Municipal Cade, Chapter 9.12, and the Health and Safety
Cade, Section 25532(.)?
❑Yes 0 N ..
HEATING UNIT (TO IW,OW BTU)
HEATING xNIT (OVER Hien" BTU)
"
-
Will the applicant or future building occupant use equipment or devices which
VENTILATION FAN (SINGLE RESID) •
-
PAID
Dam - Receipt #
emir hamrdoue it imamminants as defined by the Bay Asea Air Quality Management
District?
BOILER- COMP(3HP OR I W,OW BTU)
TOTAL.
- ❑ Yes ❑ No '-
- BOILER, COMP (OVER 100,000 BTU) -
u
I have read the hazardous mammals requirements under Chapter 6.95 of the Cali.
fomite Healde & Safety Cale, Sections 25505, 25533 and 25534: I undeonsird that if the
building Area net ctitiemly have. tenant, that it is my responsibility m notify the o.cupant
of the requirements which must be met prim'r Int ixeuance non Certificate of Occupancy.
t
AIR CONDITIONER. •'
NEW RESIDENTIAL MECH. 'SQ. FT.
t
'
�. ISSUANCE DATE
ISSUED BY:
Owner or authonzed agent, Date - NOTAL:
OFFICE "