31449 APPLICANT TO FILL IN INFORMATION WITHINRED LINES-USE BALL POINT PEN ONLY "
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO
BUILDING DIVISION .APPLICATION/PERMIT - PLUMBING-MECHANICAL 31449
' BUILDING PROJECT IDENTIFICATION -
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
DY�d TINE 3 7,7-
OWpEF _ CONT OR' M L NO:
� NIC CONTROLM
ARCHITECT/ENGINEER: LIC NO: - A S: ❑
CONTACT. . PHONE: : e HU LNG PERMIT INFO
re ElCm sn ultaFees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hercby,affrm that I am licensed under provisions of Chapter 9(commencing - JOB DESCRIPTION
0 Cp8 with Sedlon]OW f0ivisi I Or Busineaand Professions Code,and my license is
FWr in full force an �'''�'"� y PERMITISSUANCE RESIDENTIAL, .
UZ U License lass Lic.M �r�-'_ - ❑SFDW L ' 0 KITCHEN REMODEL
HGF Dare �`gCnntrae APPLIANCES-RESIDENTIAL []ADDITION
El PLUMBING RE-PIPE'
p' ARCHITEC I's D A
I_p ca ARCHITECT MUISI-UNIT D$TR URAL
C Z�� 1 understand my plans shall he used es public records PANELS � .
FICATIPA
= UPT02W AMPS
�aww LlcensW Professional
DINTERIGR CHIMNEY REPAIR
"'I"`iiI � OWNER-BUILDER DECLARATION 201-1000AMPS � IMPROVEMENT
1 hereby affirm that I am exempt from the Contractor's License Law for the OVER I WO AMPS [DB ATH REMODEL/REPAIR D DEMOLITION
I
W F following rcasnn.(Seamm 7031.5,Business and Professions Cade:Any city or county SIGNS ELF.LTRICAL 0 OTHER
40 which rcquirev a permit to construct,alter,improve,dnnolish,or reptir my structure '
�y prior to its isoushar.also raquiras the applicant for such Permit to file a signed statement SPECIAL CIRCUIT/MISC:
that he is licensed pursuant to provisions ofthe Contractors License Law(Chapter 9
�GC (commencing with Section]WO)of Division 3ifrhe Bica esstad Professions CMe)car TEMP.METER OR POLE INST.' OM�MFRS7I
14 q m e'Shat he is exempt therefrom and the basis for the alleged exemption.Any violation of -- 0 NEW BLDG/ADDITION 0 DEMOLITION
iC LL, Section 7031.5 by any applicant for a Permit subjects the solicitor to a civil penalty of POWER DEVICES
1W Z>, not more than five hundred dollars($500). 11 so OTENANT FOOD SERVICE,
'J-pgEl [.as owner ofthe property,or my employees with wages ex their sole compensation, SWIMMING POOL ELECTRIC ' IMPROVEMENT.
G2'GC will do the work,and the structure is not intended or offered for sale(Sec.]044,Business DOT ER
W m and Professions Code:The Convector's License Low does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
im '
6'3•' prary who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended car offered for NEW RESIDENTIAL ELECTR SQ FT. -
sed..If.famocom me building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.ET.
owner-builder will have the burden cleansing that he did not build or improve for pun-,
June of eale).
El I,as owner of the property,am exclusively contracting with licensed contmcrors m TOTAL:
consumer the project(Sec.7044,Business and Pmfessions Code:)The Contractor's LI- _
se Law does not apply to an owner of property who builds or improves theme.,add QTY, PLUMBING PERMIT FEE
who contracts for such projects with acontruam(s)licensed pursuant m Ne Contractor's
License Law. PERMITISSUANCE
E]I am exempt under Sce, ',B&PCfbrthisneason -
• Owner Onte ,ALTER-DRAIN&VENT-WATER(HA) VALUATION
WORKER'S COMPENSATION DECLARATION 1 /J�/O
ABACK FLOW PROTECT.DEVICE n!
Ihereby affirmunde penalty teperjuryoneofrhefollowing Workers
Don,as and will forbyaeCertificate of the sent toLabor
self-iCoricnsar the WorkersCompen- DRAINS-FLOOR,ROOF.AREA,COND. DRIES TYPE CONSTRUCTION
cation,as work for hick this
far mi Section 37W of the Labor Code,for the performance of the -
01haveandthispeintain issued. ` FIXTURES' PER TRAP "
❑1 have and will maintain Workers Compensation Insurance,as required by Section '
37M ofthe Labor Cade,fonhe performwce oftheworkfor whichthie lis issued. GAS-EA.SYSTEM-I INC.4OUTLETS t OCOGROUP APN
CartWu(wNy. rsmn ay'ylame Pli4 No.: � GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' - _
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVIS16N FEES
(Thio section need not becompleatlif the permit is fomnehmdrW dollars($1 W) - BUILDING
GREASETRAP
- PLANCHECKFEE ' .
I certify that the pe,mosay. aon rt of s to alkbac for shich ubject 1.pee Woo issued,„'CCompact-
notemplo an SEWER-,SANITARY-STORM EA.20()FT.
y y person in any manner m as to become subject ro the WnrkerK Compen- ENERGY FEE
,Z sabot Laws of California.Dote
O WATER HEATER WNENTBLTR GRA
Applicant
F.0
tiNOTICE TO APPLICANT:Im L making this Certificate Exemption,you should G
a become subject the WorkeComthe
Workers Compensation provisions of the"hot Code,you most WATER SYSTRM/TREATING_ SOILS FEE
LIa r
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMH. SQ.FT �° IC �I
] 'Z I for which rte that them isaeonswal0n lending agency for performance of
^I Date e<eiptq
V.00 thework for which this pumit is issued(Se<.309],Co,CJ N UE, 'IINU 'TOTAL:
0 V Lendefs Name ,
4i) Lender's Address TOTAL:
fy.0 C4 1 comfy the I have read His application and state that the above information i,v BUILDING FEE
i.x fA correct.I agree to comply with all city and county ordinances and sate laws coming to QTY. MECHANICAL PERMIT FEE
G ti building construction,and hereby authorimaprcsenativesofthis city to enter upon the - SEISMIC FEE '
above-mentioned property for inspection purposes.
(We)agree m save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
lirbilhies,judgments.costs and expenses which may in any way accrue against said City ALTERORADDTOMECH.
in ce of the granting efthis permit. PLUMBING FEE t
AP o .A*UNDEJRSTA S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,OWCFM)
U 'E MECHANICALPILE
AIR HANDLING UNIT(OVER FLOW CFM) CONSTRUCTIONTAXng antra rere EXHAUST HOOD(W/DUCT)
US MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant of future building occupant store or handle hazarrious material HEATING UNIT(TO IOO,WO BTU) r
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health rad Safety
CWe,S]yea 25532(a)'l HEATING UNIT(OVER FOO.”BTU)
lYe
VENTILATION PAN(SINGLE RESID) PAID Date Receipr R
Will the applic,: r future building occupant use equipment or devices which BOILER-COMP QHP OR IOO,OW BTU)
emit hazardous air conaminams a, ad by the Bay Area Air Quality Management TOTAL:
District?
❑Yes
No BOILER-COME(OVER IW,000BTU)
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR'CONDITIONER ISSUANCE DATE
fo rna Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.ET. '
bull n does tcurte tlyh Tenant,than it is my responsibilitymnlrify rhe occupant
q c tpnormisannI sem, .nay. ,� �� �( so
Ow r rembariz T
ag r Dam .TOTAL: ISSUED BY:
OFFICE