31338 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL-POINT PEN ONLY
UITY OF CUPERTINO - BUILDING-ELECTRICAL - PERMIT NO.
BUILDING DI VISION' APPLICATION/PERMIT PLUMBING-MECHANICAL.
' BUILDING PROJECT IDENTIFICATION
^li
BUILDING ADDRESS:.' - SANITARY NO. + APPLICATION SUBMITTALDATE
JO/ !c.
O R' NAMFTl PHONE: y � NT�Ck
- L NO'
NIC CONTROL'b
A ITECT G EE I N j 7 A ❑ S C P J
CONTA + - PH N p q p 0 f 0BUILDING PERMIT INFO
0012 Consultant Fees Paid by Appliearif fnitial) ' BIt1{p�G E ECT PLUMB MECH
A/AA! LICENSED CONTRACTORS DECLARATION t i' I O ❑
I hereby affirm that I m I dsed d- QTY ELECTRIC PERMIT FEE !
y p fchapter9(comma g � JOB DESCRIPTION
C-+�OwithSection]000)of Dr row3 f,he Bus dPr tcsstons Code.unJ my limmeeis - • ' - gFCIDFNTIAIr
fallf rceandeffect. PERMIT ISSUANCE' t
�W U Li '- ❑SFDWL ❑KITCHEN REMODEL
UU Dam Clas ' Lie,# pppLIANCES-RESIDENTIAL
rF�1 Dace 'Contractor ❑ADDTPION ❑PLUMBING RE-PIPE
y ARCHITECTS DECLARATION "❑MULTI-UNIT []STRUCTURAL
z O� PANELS
r? I pnderstand my plans shill be used as public records- •,. '' MODIFICATION
CzeJ S' UPT0200AMPS ,,rr��
D - 76IMPR VEM [I CHIMNEY REPAIR
Licensed ProfesstonaL - 20LR 10AMP5 IMPROVEMENT
OWNER BUILDER DECLARATION OVER 1000AMP5 ❑BATH REMODEDREPAIR ❑DEMOLITION +
I hereby ufbcer N t l a exempt m the C i t l License Law for the 0
following reason (Section construct,
ID 15 Business,adoand Professions Code:Any city or county SIGNS ELECTRICAL, ❑OTHER'� _ 1
Wr/ which its issuance,
s u a permit i airs the applim.cant
improve,forst h Permit0demolish,,File
repair any s orhmc
Cement ..J-
L11y6 priortot n also rey ' N asionso for Contractra's Bense La (Chaemem SPECIAL CIRCUIT/MISC.
i•..11 Nath is tip u tt the pm ' nsof the Convector s Lmerec Loons Code)or
00 (commencing with Section]OIXd fDisi nor mtheegeBusiness xempton.An vi Code)or TEMP.METER OR POLE TEST, COMMERCIAL: e
Nat he is exempt therefrom and the basis for Ne alleged exemption.Any violation of '• t NEW BLDG/ADDITION ❑DEMOLITION'..
PC LL, Section 7031.5 by any applicant for a perm t subjects tit ppl t to a civil penalty of POWER DEVICES
f°l } -❑TENANT ❑FOODSERVICE
noI Nan five hundred dollars y employees
IMPROVEMENT
Q ❑ I a owns fthe propeactra myempl y e, owithro ages tit 1compensation, SWIMMING POOL ELECTRIC ❑OTHER
C andwilProfessions N k dNe a,cmamnot rot d J B df 1 (S o an Buse os
aro ' Code.The Co sthere s L La doe. not work
hit n owmer of OUTLETS-SWITCHES'-FIXTURES 't
4i property who builds or wded that
thereon,end who nts such work himself or through
his own employees,provided that such improvements ere not intended or offered for NEW RESIDENTIAL ELECfRY SQ Ff. f
saleJL however,the builJing orimprovemem is sold within one year oFcotopletion,he SQ.Ff.FLOOR AREA .$/SQ.Ff.
owner-builder will have the burden of proving that he did ort build or improve for put- - {, � '
pose of sale). _ / ' IA
❑I as owner of the property,am exclusively contracting with licensed contractors m
const met the prolecr(Sw]044 Business and Prom,,itas Code)Th Co( to-Ll- Nov ®� t p,
se Law does not apply to an owner of property who builds p N ea and QTY, PLUMBING PERMIT FEE ,g
who contracts for such projextswth a conactar(s)licensed pursuant Ne Contractor's yyU V�J 99g
I. License Lew.
E] r
_
PERMIT ISSUANCE 1 em exempt under Sec. B&P C for this mason UUr
ALTER-DRAIN&VENT-WATER BA) _ UAT10N
.Owner - Date _ '"
WORKER'S COMPENSATION DECLARATION . ,BACKFLOW PROTECT.DEVICE ',R CJ^ ,
I hereby ffirm d penalty of penury one of the following declarations: -
El Herecand will maintain a Certficareof Consent to self-houre for Workers Compen- DRAINS-FLOOR,ROOF.AREA,COND. + S RIES TYPECONSTRUCTION
salion,as provided for by Section 3]00 of the Labor Code,for the perfarater ce of the
mmlifrwh,ahtinparruninismed.' + FIXTURES-PER TRAP
I]1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Cale,fer Nepeffo tante of the work for which this permit is issued GAS-EA'SYSTEM-i INC.40UTLETS OCCGROUP APE
My Worker' s,i c carticr and Policy non�+�r� -
Curtier PolicyNa:_/ J/� GAS-EA.SYSTEMLOVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR -
I ,
(This section need notbe completed if the permit is forone hundred dollars(SIM) BUILDING DIVISION PEES
GREASE TRAP -
or less) _ - PLANCHECK FEE '
.. locally Nat in the performance fthe work for which this permis itissued,I shall SEWER-SANITARY-STORM EA,2W Ff.
not employ any person n y o as to become subject the Workers'Comport- - ENERGY FEE
sham Laws of Califon Date�O Applicant WATER HEATERW/VENT/ELECTR GRADING FEE
In NOTICE TO APPLICANT If,after making this Certificate of Exem van,you should
�t V1 g r WATER SYSTEMRREATING SOILS FEE
I� become subject to the Workers Compensmion provisions of the Labor COJe,you most w ry forthwith comply with suchpmvidsms onhis permit shall be deemed evoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PL PAID
I hereby affirm Net there isaconswction lendin c for Ne rformance of Date Receipt#
U O y g age"y, Pe r 9.
Lks the work for which this permit Is issued(Sec.3097,Civ.C.) _ x" TOTAL:
+Q LwdersName - - _ -
Lwder'sAddess .'0 TOTAL:
1 certify that I have real Nis application and sure in. the above information is BUILDING FEE
it VJ correct.l agree to comply with all city and county ordinances and state laws relating,e QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hani less Ne City of Cupertino against ELECTRIC FEE •! it
Iiabiliticajudgments,casts and expenses which may in any way seems against said City ALTER ORADDTO MECH.� + PLUMBING FEE
I conseq/RF
ran ting ofthis Penni,.
APPLICS NDS DWILL COMPLY WITH/ALLNPO AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE .S. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,006 CFM) ) 4
CONSTRUCTION TAX!
Sign p is vac Date EXHAUST HOOD(WMUCT)
S MATERIALSDISCLOS RE HOUSING MITIGATION FEE
W,llihe app¢ant umre building occupant store or htnalle hazardous material' HEATING UNIT(TO 100,000 BTU)
defined by,he Cupe mo Municipal Came,Chapter 9.12,and the Health and Safety -
Code,Section 25532(a)P HEATING UNIT(GYER�100,000 BTU) ,
❑Yea No
'. NGLE REBID) PAID
' - Receipt#
•Will lite applicam or fulurc building occupant use equipmVENTILATION FAN(SI
en[or devices which BOILER-COMPOHP,OR 100,00(1 BTU) -�
emit hazardous air contaminants as defined by the Bay Area Air Quality Mswgemen, y. TOTAL:
District? TOTAL:
COME(OVER 100,00X)BTU)
Yes . . ❑N .
AIR CONDITIONER'
-1 have read Ne hoz domaterials requirements under Chapter 6.95 of the Cul,- ISSUANCE DATE
fomia Health&Safety Code;Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL Isl SQ.
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the requirements whicb must the met prior to issuance of a Certificate of 0ccupancy.
Owner or authorized agent - Da¢✓ tT. '. TOTAL: ISSUED BY:
OFFICE 1 ,