S 31120
0
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATIONMERMIT
BUILDING - ELIOMRICN.
PLUMBING - MECHANICAL.
BUILDING PROJECT IIPNUBTcATION
PE IT NO.
3112
BUILDING ADDRESS:
2 X335 C+ e/." Ca
SANITARY NO.
APPLICATION SUHMI'E'AL DATE
OWNER' N Mli PHONE:
CO TRACTOR'
NPJNE: IILIC_'N
�b l
1/6
NIC
❑
CONTROLp
ARCHITECTIENGINHER: LIC NO:
ADIC[/NIrS.:
CONTACT: PHONE:
❑
Ci n athant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PIWU MECH
ED EDIJ ❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby urBna that I ren licensed under provisions of Chapter 9 (cntmmm'bg
with Section Min) af Dlvi.sion 3ofthe Businessand Professions Cade, and mylicen.ce is
full forcoand cit
License Cln-lc #� �
C�
ANCIIIIiCTSDECLAkA ON
I ndcrsumA nsy plans shallbeused as public records
QTY.
ELECTRIC PERMIT
PEE
JOB DESCRIPTION
RESIDENTIAL'
❑spam. ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING HE PIPEInc
❑MULTI -UNIT ❑STRUCTURAL.
MOI3IFICA'fION
El INTERIOR El CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
❑ BATH RF.MODEUREPAIR ❑ DEMOLITION
❑OTHER (}}
/lAW q&.q_, i
PIiRMIT ISSUANCE
APPLIANCES—RESIDENTIAL
PANELS
UP TO 200 AMPS
Licensed fissional
DECLAMATION
Oat I am exempt from
I hereby affirm on 1 am exempt Irons the Contractors License Law co the
' following reason. (Section 91111.5, Business and Professions Caste: Any city or county
which requires is permit to transient, man, improve, demolish, or repair any ewcturc
priorlo its ismancemsomgviesthe applicant forsmeh pmant1. Fe.,igneJsmtement
that he is licensed pursuant In the pmv s of the Committees License Law (Chapter 9
(commencing with Section 7") of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for me Ata rdl exemption. Any violation of
Section 11131.5 by any applicant for o permii subjects the applicant to a civil penalty of
nut more Nun five hundred Jnllmx (SSW).
Lo the work, the pmperty,onnyemntended wlthwagesas to (Sete compensation,
will dothework, and she he Cni isnot intended oraw du for to(See
License Law aces not apply s if owner of
to owner
and Pmfessio bit
Cale: imp Con thereon,
property who builds or improves thereon, and who aces such work himself or IhrougM1
his own antloyew, provided! rim such improvements are not intended m offered for
is sold withinlour b ild o(if impro completion, the
owns mildevar, thewllh have
caner-huilJcr will In:ve the huNcn of proving that he did not build or improve for pur-
th harden of
Fotenftalc.).
❑ I, on owner of the property, ren exclusively contracting with licensed cnmtmemn I,,
msmun the pmjecl (Sec. 71144, Business and 14ofessirne Us..... T'he Gantradors ....
nse law does not apply it, an ownerofpmperty who builds m improves lhercon,and
who contracts lir such projects with o contractors) licensed pursuantto the Contractors
Litmus Law,
❑ I ma exempt under Seo. .B& P C far this reason
201-1000AMPS
OVER I(IfIOAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
^wQ �
�`I—:[E
1 `-�
TEM P. MITER OR POLE INST.
COMMERCIAL'
❑ NEW BLDG/ADDITION ❑ DEMOLITION
TENANT ❑FOOD SERVICE
1 ROVF.MENT
THER
. POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLL•TS— SWITCHES —FlXTURFS
NEW RESIDENTIAL ELECTR 5Q I'll
'
SQ. Pr. MOOR AREA
$ISQ, Ff.
MAI"
QTY. PLUMBING PERMIT
FEE
PERMIT ISSUANCE
ALTER—DRAIN & VENT — WATER (FA)
Owner Data
VALUATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of padury one of the following declaetions:
❑ I have and will maintain o CertifcamofConsent to self -insure for Worker's Conpnr
s inion, as Provided for by Section 3100 of Ne Labor "a, for the Performance of the
r rwhichthis permit is issued.
o nave and will maintain Workers Compensation Insurance, as required by Section
3100olthe Labs Code, for the permuccoceofthe work fpoor ryw�hic�h �thpis permit is �issued.
My Wor is Co non hyumn rand Policy
Cem¢�[1QK f Policy No: .]S
Cli IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Trois senior need nal Ile completed if me permit is Talions hundred Julian (SIINII
or las.)
Iccnify Erol in lheperfurmanceofthe work forwhich this permit i.vi.usued, l shall
nal employ any peru n in any nnmnerso as m become subject m the Workers' Coulter-
salon Laws uT California Data
Applicant
BACK FLOW PROTECT. DEVICE
DRAINS— FLOOR, ROOF AREA. COND.
STORIES
TYPE CONSTRUCTION
FUKTLRES — PER TRAP
GAS —EA,.SYSTEM-1 INC. 4 OUTLETS
OCC. GROUP
APN
GAS—EA. SYSTEM -OVER 4IEA)
GREASFJINDUSTRL WASTE INTERCEPTOR
ILDI ISION FEES
PIANCIIECKInil
GREASE TRAP
SEWER—SANITARY—STORM FA. 200 FF.
.N 2G4F5M9@
WATER HEATER W/VENT/ELECI'R
GRADING FEE
NOTICE 10 APPLICAN'P'. If, after making this Certificate of Exemption, you should
hecnmo xubjeel ,, the Workers Compensation provisions of the Latina Cole, you next
forthwith comply with such pruvknox minis permit shall be dcemedoevoked.
CONST RUM [ON LENDING AGENCY
I herehyaflinn thntthere iso amsanction lendingogency fm the pinfomanee of
the work for which this permit is issued (Sec. 3ER, Civ, C.)
Lenders Namev
WAIR SYSTEM?RENTING
WATER SERVICE
SOILS FEE
PAID
Date Recei #
NEW RESIDENTIAL FILMS . SQ. FT.
TOTAL:
Lenders Address
TOTA L:
s
BUILDING FEE ,
1 certify that 1 have read this application and state that the above information is
amount. T agree to comply with all city and county ordinances and state laws relating it)
building tonnection, and hereby su borire representatives of this city m enter upon the
abwe-mentionN Property, for inspection purposes.
(We)agree m save. indemnify and keep hamilese the City of Cupertino against
liabilities.judgments, costs and expenses which may in any way acerae against said City
in consequence of the graming of this penis. -
APPLICANT IINUI' iS'TANDS AND WILL COMPLY WITH ALL NON -POINT
SOURGII I (' 1 tLA'1' )NS,
1rY/✓ jlS
QTY.
MECHANICAL PERMIT
FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC HE
ALTER OR ADD TO MECH.O
PLUMBING FEE
AR HANDLING UNIT(TO 10,"CFM)
MECHANICAL MV
AIN HANDLING UNIT (OVER 10,IX0 CFM)
CONSTRUCTION TAX
Sipmanclul AppliemmCmuncmr Doc
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or lhmrc handingdccupuntnos.,h.cdl.haaardoasrtmcrlal
as defined by ilia Cupertino Municipal Code, Chapter 9.12, and the Hcullh and Safety
Code, Section 2553200!
❑Yes E] No
e Will the applicant or future building occupant use equipment or devices which
mil hamNom air contaminants us definW by the Bay Area Air Quality Maeagentent
District'
❑Yes ❑No
I have rtml the hvnrdaus ntoterials requirements under Chupmr 6.95 of the Cali
forma Health & Safety Code. Sections 25505.25533 and 25534. 1 mrdentaol that if tau
brildingdoes not currently have a tenant, that it is my responsibility to unify the occupant
ofthe requiremeno which must be met prior to issuance ofa Certificate Occu racy.
u -
EX14AUST HOOD OODUCI)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100.00 BTU)
HLOA'UNG UNIT (OVER 100,000 B'I'U)
PAID
pate ReceiptN
kif
VENTILATION PAN (SINGLE RESID)
BOILER—COMP (3HP OR 100.1100 BTU)
BOILER—COMP (OVER 1000110 B'f U)
AIR CONDITIONER
/// ISSUANCE DATE vvv���
7 oy
/� 5;'/
( ` i
ISSUED BY.
NEW RESIDENTIAL MECH. SQ. IT
TOTAL:
Owne-m inithunced agent A rte
OFFICE