31486APFLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPEi RTINO '0, BUILDING. ELECTRICAL
PERMIT NO.
I1
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL
� � �
31486
BUILDING PROJECT IDENTIFICATION
BUILpING ADDRESS: —
SANITARY NO.
APPLICATION SUBMITTAL DATE
O ER'SNAME PHON
S
CO CTOR'S NAME: LIC NO:
In� .
NIC
❑
CONTROL
ARCHITHCT/BNGINEER: - LIC NO: -
ADDRESS:
CONTACT, PHONE: -
-
BUILDIN PERMIT INFO
' 1 -
❑ Consultant Fees Paid by Applicant (Initial)
BLDG P.LE PLUMB C
❑ ❑
LICENSED CONTRACTORS under DECing of CON
1 hereby efface that 1 am licensed under provisions of Chapter 9 (commencing
with Section 9000) of Division 3 of Ne Business cod Professions Code. and my Hetrick
in full forte and -R O a
Licenx Cl a L"' I
Uece Convector
QTY ELECTRIC PERMIT FEE
J4 DESCRIPTION If
RF I-� DENTIAI'
❑ SFDWL ❑ KITCHEN REMODEL
[]ADDITION ❑PLUMBING R&PIPE
❑MULTI -UNIT ❑STRUCTURAL'
MODIFICATION
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECTS DEC L ATION
1 umlersund my plans shalt Named., public records
PANELS
IIPT0200AMPS
'0INTERIOR ❑CHIMNEYREPAIR
IMPROVEMENT,
ATH REMODEUR A ❑DEMOLITION
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm thm 1 nm exempt from the
the he ComnnOrs License Law for the
201-1000AMPS w
OVER IOOOAMPS
SIGNS ELECTRICAL
following reason. (Section 7031.5. Business and Professions Code: Any city or countyHE
which rectums ra Famt con pimprove. th, structure
-
primiing isuance,alsomqircs duetpplicanfurxuch Noun reileesigeduteem
that he is licensed pursuant to the pmvisiom of rhe Contrecures License law (Chapter 9
SPECIAL CIRCUIT/MISC.
TEMP, METER OR POLE INST.
COMMERCIAL:
t NEW BLDG/ADDITION EI DEMOLITION
[]TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
(commencing with Section 7000) of Division 3 ofncc Business and Professions Curtis) or
Net he is exempt therefore and Ne basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of
net mart than five hundred dollms(5500).
❑'Las owner of Ne property, or my employees with wages as their sole compensation,
will do the work, and me summit ixnot amended! proffered for sale (See, 7044, Business
POWER DEVICES
SWIMMING POOL ELECTRIC
and Professions Code: The Convectors License law does not apply t0 an owner of
OUTLETS -SWITCHES -FIXTURES'
property who builds or improves thereon, and who does such work himself m though
his own employces, provided that such improvements um not intended or offered for
NEW RESIDENTIAL ELECTR SQ FL '
sale. If.however, Ne building or improvement is sold within one year 0fcomplelion,the
- t
.SQ. FT. FLOOR AREA.
S/SQ. IT.
e, holder will he. the burden of proving that he did.. build or improve for par.
TOTAL:
❑ 1, as owner of property, am exclusively contracting with licensed con
t (See,
construct the project (Sec. 7044, Business and Professions Code:)The Contractor's Li-
-
-
QTY, PLUMBINGPERMIT FEE
nxLaw does not apply toanowner ofproperty who builds orimpomesassume, and
who contracts for such projects with aconuecmns) Bernard purs ent m the Contractor's
u
'
PERMIT ISSUANCE
License Lugg. •
❑ 1 am exempt under Sec, 'B & P C for this reason
ALTER - DRAIN & VENT -WATER (lin)
�
Overact Dare
VALUATION
WORKER'S COMPENSATION DECLARATION
1 hereby off rm under penally of perjury ane of the following declarations:
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, CONE.
❑ I havennd will mummin a CenificateofConsente, self-moure for Workers Compen-
nation, as provided for by Section 37M of the labor Cale, for Ne performance of the
STORIES
TYPE CONSTRUCTION
FIXTURES -PER TRAP
work for which this permit is ismed. -
1 have and will maintain Worker's Compensation Insurance, as required by Section
of theLabor RRCeeode.ffpmrNePeerrffoorrm�aannce of the work
Yfor �whichthis Permit is isxei.
Work
GAS -EA. SYSTEM- I INCA OUTLETSmy
OCC. GROUP
APN
Caniec-lit \lain "`\ po�ayN _z_0 WL&= a
GAS -EA SYSTEM -OVER 4(EA)'
CERTIFICATE OF EXEMPTION FROM WORKERS'
-
COMPENSATION INSURANCE
action need oar be completed if the permit is for one hundred dollan(i 100)
or less.) • :
Iccnify Na[in Ne performance of rhe work forwhich this pcnnit is iseucdlshall
not employ any person in any manner x ra
as to Itex ae subject to the Workers' Compen.
GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEESOris
GREASE TRAP
-
PLAe1CHECK PEE
SEWER -SANITARY -STORM EA. 20D FT.
ENERGY FEE
WATER HEATER WNENT/ELECfR
ration Laws of Calificrow Dao L
Applicata
GRADING FEE
NOTICE TO APPLICANT. If, after making this Cenificute of Exemption, you should
became subject o the Workers Compensation pximusi c, of the Iabm Code, you mast
WATER SYSTEMII'REATING ,
SOILS FEE
forthwith comply with such pmvixinna m this permit shell be domed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
PAID '
NEW RESIDENTIAL PLMIL SQ. PT. s
I fortby affirm that there iso consuueent, lendingngeMy fine Ne performanceof
Date Receipt#
the work for which this pcnNt is issued (Sec. 3097. Co. C.)
'Lenders Name
'
TOTAL'
Lenders Address -
TOTAL:
1 certify Net 1 have retl this application and stem Nat Ne above information is
BUILDING FEE
correct. I agree to comply with all city and county ordinances and state laws coloring to
building vmatmctinn, unit hereby and ix representatives of this city to enter upon me
QTY, MECHANICAL PERMIT FEE
SEISMIC FEE, -
PERMIT ISSUANCE
above-mentioned property for inspection purposes.
(We) upon, o cove, indemnify and keep harmices the City of Cupertino against
ELECTRIC FEE
arc
himlides,judgments, costs and expenses which may in any way, accme agains gold City
in consequence of the grunting of this permit.
ALTER OR ADD TO MECH..
PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
�OURs�CE °GULATIONS,
AIR HANDLING UNIT (TO 10,0110 CFM) '
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10.000 CFM)
ppp
I (T h-7
—/
&1919-7
CONSTRUCTION TAX
w efAlppllccghmV n7toeor a
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mcupanutox or handle haaerdom material
EXHAUST HOOD(WMUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,IX0 BTU) C3
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(d?
HEATING UNIT (OVER IBBWO BTU)
❑Yes ❑N0
Will the a licarn or future buildin -
pp g by the Bay Area Air Quality
emit heaerdous an mnaminanls as dctnr0 by the Bay Area Air Quality Management
Management
Dis ct?
(]pas - ON. 4
pAID
Dem Receipt #
TOTAL:
VENTILATION FAN (SINGLE RESID)
BOILER-COMP(3HPOR 100,000 BTU) To. 29-0
BOILER - COMP (OVER IOp.glO BTII)
T
1 have orad the heuNouv materials requirements under Chepmr 6.95 of the Cali-
fomia Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that if the
building does not currently have u tenant Nat it is my responsibility to notify the occupant
AIR CO NDITIONER
ISSUANCE DATE
s
NEW RESIDENTIAL MECH. SQ. FT
of Ne requirements which must be met prim to issuance of o Cerldicale of Occuporcy.
ISSUED
Ownerorauthonxdagem Dae
TOTAL:
"OFFICE '