31047 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 31047
BUILDING DIVISION APPLICATIONIPERMIT PLUMBINGMECHANICALL.
DU . NG OJF' F'N
IDTIFICATION
BUILDING ADDRESS: , SANITARY NO. APPLICATION SUBMITTAL DATI
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OW ME: �� // PHONE: CONTRALTOO�3 NAPE: ,,// LIC NO: NIC Q CONTROL
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RCH E / NGI ECR: LIC NO: ADDRESS: ❑ -
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C(IlYTACP. PHONE: BUILDING PERMIT INFO
}��7 // F-1Consultant Fine;paid by Applicant(Initial) - BLD - ELE PLUMB 'MRCH
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LICENSED CO RACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
MMZI hemby affirm that I sun cenutl umler provisions of Chapter 9(commencing " - JOB DESCRIPTION
WOO with Section 7")of Division 3 ofthe Business and Prafosmmm Code,andmy If..is
FOO id PERMIT ISSUANCE RESIDENTIAL
fun force rood effect.
a3 D ❑SFDWL [I KITCHEN REMODEL.
Q U License Class Lic.a
InQ�]� Date Cammcmr `� APPLIANCES-RESIDENTIAL ❑pDDU70N [I PLUMBING RE-PIPE
ARCHITECTS DECLARATION Of PANELS [I MUCH-UNIT ❑STRUCTURAL.
ZON3 I understand myplans shall h mealm,mblancerds r MODIFICATION
OZ�O UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
I•.4{.11"Ud Licensed Professional 201-1If1t1AMPS IMPROVEMENT
e+lad I.,...II OWNER-BUILDER DECLARATION OVER 1100AMPS ❑BATH REMODEURF �I LIT1ON
Pyy d'�5 6 I hereby offrm that 1 am exempt from the Comramor's License Law far the
X a U fallowing reason.(Section 703 S.5,Business and pmPoasions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
WW W O which requires a permit to construct,aper,improve,demolish,mT repair any structure Ansis
Nice o in issuance.also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUITIMISC. V-01 Z19 orn
{ } Nm he is Licensed pursuamno the provisions of the Contractor's License Law(Chapter 9 Uli
n51 p0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST
that he is exempt therefrom add the basis for the alleged exemption.Any violation of ❑NEW BLD z �'I
IVb 0 DEMOLITION
ftl Y•
Section 7031.5 by any applicant for a permit subjects ES he applicant to a civil penalty of POWER DEVICES ff..,�
y ❑TENANT `lII,I�{){)$ERVICE
FIN not more than live hundred dolWrs(5500). * IMPROVEMENT -svv
C] SWIMMING the worofthe pmpeny,ar myemncendeswithined festhe(Sm.compensation, SWIMMINGPOOL ELECTRIC0
will dothewons amd the atmcmreianotrm's Lienee Law does ret apply to a,Business ❑OTHER
and Professions Code.The Conwetreo License Law does not apply toll owner of OUTLETS—SWITCHES—Fl%TURES
hie am who builds pa improves thereon,and who does such work himself or through -
sal own employees,provided Nat such improvements are oat intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
owner-hewer r.the willhveth buren improvement issoldhedid noneildori improve formic,
SQ.PI'.FLOORAREA 55Q.FT.
owner-builder will have the burden of proving that he did not build or improve for Pur- e r
you of sale.).
El 1,as owner of the property,am exclusively contracting with licensed contmctan to Noaft
r
consumer project(Sm.9004.Business and Professions Cade:)The Com(crows U "` ` -
cause Law dinot apply toanowner ofpmNnywho builds mimproves lhereon,and QTT PLUMBING PERMIT FEE -2^^
who contmem forsuch projects with a contractors)licensed pursuant to the Comranors (/C.t`
License Law. PERMIT ISSUANCE
L]1 am exempt under Sec. ,B&P C for Nix reason
Owner Data LL,, '
ALTER-DRAIN&VENT-WATER(EA) �A{,UpnON
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby effort under Penalty ofampry one of Ne following dale etions:
❑ I have and will maintain a Certificate ofComent to self-nsure for Workers Campen- DRAINS-FLOOR,ROOF,AREA,CONE.
ration,as provided for by Section 37M of the labor Code,for the peromtare,of the STORIESTYPE CONSTRUCTION
work for which this pcmtit is issued. FIXTURES-PER TRAP
fil 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Lobar Code,for the s..."of the work for which this permit is issued. GAS-HA.SYSTEM-I INC.4 OUTLETS OCCGRO APN
My Workc matyn ace carver and Policy namixr au:
/ GaniteT Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
�/CERTI FLCATE OF EXEM rr10N FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR UI G DIVISION FEES
(This uetimaccal not be completed ifthe permit is forone hundaddollors(5100) GREASETRAP
or less. PLANCHECK h t•-11
I certify that in the performance of the work for which this Profit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
son sat
oat employ any perin any manner es to became subject m the Workers'Campen- ENERGY FE /a
OsT. sation Laws of California.Date WATER HEATER WNGNTIELECTR
O Applicvrt - GRADING
F7 VJ NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
a [" become subject to the WorkerSOBS FEE
UJ
Compensation provisions of the Lahor Code,you most _
UJ foMwith comply with such provisions or this Permit shall be,deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Ff. PAID
V 0 I for which tut that Neu issued(S construction lending agency(oohs performance of Date t p -
w .-r the work for which this permit is issued(Sce.3Wl.Co.CJ
O F Lenders Name e T TAL:
WLender's Address L.
1 certify that 1 have read this application end state that the above information is BUILDIN
nFi rod torten.l agree to comply with all city and county ordinances and smut laws relating to QTY. MECHANICAL PERMIT FEE
V building construction,and hereby authorize represenmtives of this city to enter upon the SEISMIC
above-mentioned property far inspection purposes. PERMIT ISSUANCE �1
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECT 1 E f�
liabilities,judgments,costs and expenses which may in anyway aceme against said City ALTER OR ADD TO MECH.in consequence of me grvning of this permit., PLUMBI FEE ,
APPLICANT UNDERSTANDS AND WILL C WI H ALL NON-POINT AIR HANDLING UNIT CIO 10,000 CFM)
50 1 .ATI S MECHANICAL FE
H. C4 IYA AIR HANDLING UNIT(OVER IgIK0 1CFM) CONSTRUCIONTA
Sin plicanVCnnwomr Date I EXHAUST HOOD(WIDUCI')
HAZARDOUS MATERIALS DISCLO RE HOUSING MITIGATIO FEE
Will Ne applicant or future building oecupvm some or handle hnmrdoux material HEATING UNIT(TO 100.000 BTU)
as defnwl by the Cupertino Municipal Code,Chapter 9.12,vad the Health vad Safety
Cade.Section 25532(v)'I HEATING UNIT(OVER 101.000 BTU)
❑Yes C]No VENTILATION FAN(SINGLE RE.SID) PAID
Will thea licant or future building t use equipment or devices which
Data R pt M
pp gby the
BOILER-COMP CHP OR I00,tlK1 BTU)
mit huzvdous air comamiwnts u defined by the Bay Area Air Quality Management TOTAL:
Dntrct1 BOILER-COMP(OVER 10D000BTU) -
❑Yes ❑Na
I have read the hazaWom materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
buildingd9e,ametnexamlyleve.tationt,t m ponsibilitymon'Ythe Pant
of(he mmma Wfrac bt (IM MC Ofa Cenlffatt fife
Owner or authorized t 3 /D Dme m O \ ISSUED BY:
OFFICE