31022 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES'-USE BALL POINT,PEN ONLY
CITYOFCUPERTINO' 1 'P •,Wf BUILDING-ELECTRICAL PERMIT NO.
',BUILDING DIVISION ' APPLICAUCIN/PERMIT PLUMBING-MECHANICAL 31022
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: h - n SANITARY NO APPLICATION SUBMITTAL DATE
' 10423 LAti3�Ox� . � ►S"f�r ' •`t
OWN 'SHAM , �.� PHONE: _ CONTRACTORSNAME: 11C NO -
MhGr44 .1, N/C CONTROL p
,RCHITECI'/ENGINEER: ' -LIC NO: ADD
I1566, klijE ^•❑
CONTACT: PHONE .� BUILDING PERMIT INFO _
❑ Consultant Fees Paid by Applicant(Initial) " ' , BLDG ELECT, PLUMB MUCH
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that 1 an lice d d previsions f Chapter 9(commencing QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
u��Z witaS t ]00e) 3 fth Bmsi end Pmfesmon Cotle and my lice PERMIT ISSUANCE RF.ID NTIA 7
F m full f and effect.u. r '❑SFDWL TCHEN REMODEL
F�UIIPF.... LicenseCI - Lintr ppp(,IANCES-RESIDENTIAL )r;
N6 Dale - Conhumor , ❑ADDITION- P�^LUMBING RE-PIPE^
CHITECT'S DECLARATION
,Z O r�rn sa I understan y I s shall be used as Public rocords PANELS, ❑MULTI-UNIT' .;[3 STRUCTURAL"
O Z ee �° _ n - • -,t MODIFICATION
UPTO-( )AMPS ❑INTERIOR '[3 CHIMNEY REPAIR
.,{{� Lse dPof 1 201-1000AMPS - IMPROVEMENT ,
Way'•aj 'OWNER'BUILDEk DECLARATION Connector's
+ ❑BATHREMODEUREPAIR El DEMOLITION
yyx i hereby Firm that 1 e rapt from the Cont to Licen a La for the OVER 1000 AMPS
W a d F fallowng annoi.(Section 7031.5,Business add Professions Code A y 'tyo county
^SIGNS ELECTRICAL ❑OTHER '1
W 0 rich q a Perna t 0 um t It p demolish,or repair any auvcture - r
� � Prior to its ileamens.al nomice,do,applicantf h permno file n signed stavating SPECIAL CIRCUIT/MISC. 's
>+ thathe'is licensed ponsualittthe provisiousofthe Contractors License Law(Chapter9
p0 (comm nmagwith Sectio ]000) fD'v io 3ofthe Beainus and Profession Cartier TEMP.METER OR POLE INET. • COMMRR IA .
6 ae th he is exempt therefrom and the bass for the alleged exemption.Any violation of - [I NEW BLDG/ADDITION ❑DEMOLITION
^� Sectl 70315 by any pphcant for u permit subjects the upplit t a civil penalty of POWER DEVICES - -
z� not ma than B e h one'ed dollars(8500) a - (_1 TENANT ❑FOOD SERVICE
❑I, ft
he propeny,ormy employees with wages as their sle compensation, SWIMMING POOL ELECTRIC a IMPROVEMENT
Lr�i7
will do the work,and the mostme isnot intended or offered forsale(Sea 7044 B sines [I OTHER,
and Professions Code The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Q' .r property who builds"tic improves thereon,and who does such work himself or through Vit.
' his own employees,law deo that such improvements ore not intended or offered for NEW RESIDENTIAL ELECTR - SQ FT '
sale If,how,wroar.the budding or improvement is sold within one year ofcompletion,the r f -SQ.ET FL;�REA "S/SQ.ET.
owner-builderwill have the burden of proving that he did not build or improve for for. - p
pose of sa1c).
• ❑1,as owner of the property,our exolucively contracting with licensed contractors to _ A
construct the pro/ect(Sec']044-Businessnil Profeoimw Code)The Committees L. nfRDIs�•r v
cerise Law does not apply to an ass net of property who builds or improves thereon and QTY. PLUMBING PERMIT ?' �' A",I0.V®•''
who c
onfor such projects with a codvacmr(a)licensed pursuant m @e ContractorFEE's gp�pAR I'
License L.w.Law. - ,•
T
„'.a PERMIT ISSUANCE
am '
- ❑ exempt under Sec. ,B&PCfor this reason YGHIINU.
Y'Uh VU
Owner - -
ALTER-DRAIN&VENT-WATER(EA).fro
Date � 'VALUATION .ri,•
WORKERS COMPENSATION DECLARATION BACK FLOW PRO CT'DEVICE
I hereby firm under penalty of pep ry ofthe following declarations:
-
❑Iha and will maintain a Certificate ofCusent to selfinsumfrWork Comped- DRAINS-FL ROOF,AREA.COND. - STORIES .TYPE CONSTRUCTION
sation,as provided for by Section 37M of the Labor Cotle,for the perform mre of the. "
work for which this permit is issued . PIXTURES- RTR '• i
❑I have and will maintain Worker's Compensation Insurance,as required by Section '
37W ofthe Labor Cale,for the performance of the work for'which thispermitisissued. GAS-EA:SYSTEM-IIN TLETS �
My Workers Compensafin.Insurance Cartier and Policy number are: gi.•, - OCC.GROUP APN
Cartier - .Poky Na GAS-EA.-SVER4(E
CERTIFICATE OFEXEMPTION PROMWORKERS'
COMPENSATIONINSURANCE ,3 GREASP/INDUS L RCEPTOR
` (This secure need not be completed tithe permit is forone hundred dollars(S10, Y L BUILDING DIVISION FEES
or lots.) S . GREASE TRAP -
PLANCHECKFEE
1 centy that I.the performance of pe w4,k far whichthispe YissueJ,Ishall SEWER-SANITARY-STORM EA FT.
notempl y Pers n wine s/pl d .object to the Workers'Comped- fz
ENERGY FEE ' 11
,'�
no
Law difor a D 'i
0O Applicant WAIER HEATER WNENT/ELECfR ;GRADING FEE
N .NOTICE TO APPL,1CANTIllf,after making this Cenif,me of Exempmn you should WATER SYSTEM/I'REATING,
H become subject to a Workers Cnmpensmion provisions of the Labor Cnde,you..it - SOUS FEE
LTJ ry N ply with such provision or this permit shall he deemed revokul. '
fon - • WATER,SERVICE
z p CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLACE. SQFT. PAID
1 herelty.ffirm thauherets a construction lending agency for the performance of Data Receipta
- the work far which Nis permit is issued(Sec.3097,Civ.C.)
Q L) Leede Name - „ TOTAL:
yyy Lander s Add
a 1 eetofy that I hav sail this application and state that the above t tee t n is ^ BUILDING FEE
W emovet 1 tisces,m comply with 11 city and county oWinances and state laws relaming to QTY. MECHANICAL PERMIT FEE
U 4 building construction,and hereby conamize representativesofthis 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 l
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ApD TO MECH.
in co se ust of thelm his permit. PLUMBING FEE,
APPLI VT UNDERS ANDS ND WILL COMPLY WITH ALL NON-POINT. qIk HANDLING UNIT(T010,000 CFM) ryjECHANICAL FEE
SOUR GULATfO S.; .. -
AIRHANDLINGUNIT(OVER10,000CFM) CONSTRUCTION TAX
SignatumtfXpplicaContectibr s - Date - EXHAUST HOOD(W/DUCI') - HOUSING MITIGATION ME
MATERIALS DISCLOSURE
Will the applicant or future building occupant store orlandle hazardous materiul HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 912,and the Health and Safety "
Code,Section 25532m)7 ' HEATING UNIT(OVER 100,000 BTU) -
I
Fl Yea ❑N y 1
t VENTILATIONFAN(SINGLERESID)� PAID
Will theppl' t or future building occupant use equipment d es which } Date Receipt M•
.mhitrdoueaircomamiants os defined by the Bay Area Air Quality'Management - � BOILER-COMP(3HP OR 100,000 BTU) . - .
Oiatrici9 - 'TOTAL:
❑Yes " t ❑No• V. BOILER-COMP(OVER 100,000 BTU)
I have read the he serials requirements under Chapter 6.95 of the Cali' AIR CONDITIONER' - - ISSUANCE DATE
fear Ith&Safety C de,Semi ns 25505,25533 antl 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Ff.
but sem curtentl haveat whlM1at it is my reepnnsibilitymnotify Ne occupant
df th meets w ust b met pdono issuance of o Certificateo�Occupnnay. ' ' r,
Owner or authorize gem -J Dote °t ISSUED Y.
OFFICE
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