31015 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PUII,DING•ELECTRICAI. - PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL - 31015 O C
BUILDING PROJECT IDENTIFICATION J J
jjdJdLDING ADDRESS: SANITARY NO. 2PPLICATION SUBMITTAL DATI
So/yC 7•
E NAME: PHONE C TRA R'S NAME: LIC NO:
N/C CONTROL p
RC ITECf/ENGINEER: LIC NO:
ADDRESS.'
CONTACT: - PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION El 0
G�,Z I hereby affrm Thal 1 am licensed under provisions of Chapter 9(commencing QTY ELECTRIC PERMIT FEE
yy�1C with Said.7000)of Division 3 of the Business and Professions Code,wd my lire.-is JOB DESCRIPTION
F,- m fiallfnaeandeRttt. PERMIT ISSUANCE RESIDENTIAL
% F License Class F.0LION []SFDWL D KITCHEN REMODEL
N<L Date Contractor APPLIANCES-RESIDENTIAL []ADDITION []PLUMBING RE-PIPE
F-E2w ARCHITECTS DECLARATION PANELS []MULTI-UNIT DSTRUCTURAL
QZ^7J- 1 understand my plain shell be used.public rccoNs MODIFICATION
�4F'Cj Licensed Professional UPTO 200 AMPS _ El INTERIOR MODIFICATION
REPAIR
OWNCR-BUILDER DECLARATION 201-I WO AMPS IMPROVEMENT
1 hereby affirm that 1 am 3 exempt from the COnOacmPENrs License Law for the OVER IAMPS ❑
am' ❑BATH REMODEUREPAIR DEMOLITION a e3 following ream 7031,5.(Section7031,5.Business mpr ve.de io li h.m Any city Or county SIGNS ELECTRICAL 'DOTHER
y which requires issuance,permit u co.wet,alter,improves demolish,or repair any swmurc `1 ,
y pat he isuenseelsomtoflue the applicant for such Permit Lie",Law(Statement SPECIAL CIRCUIT/MISC.
y that he is licensed pursuum to the provisions nl We Contractors Licenx Law lChaPmr9
y 00 (commencing with Sretion9Nl0)ofDivision3 ofthe Business and Pmfassions Code)sr TEMP.METER OR POLE INST. COMMERCIALpf Nat he is eaempr therefrom and the basis for the alleged exemption.Any violation of
Y• Section]031.5 by any applicantfor a Permit Subjects the applicant)a civil penalty of POWER DEVICES ONEWBLDG/ADDITION [IDEMOLITION
FiL c not more than Eve hundred dollars($500). []TENANT []FOODSERVICE
❑ L as owner ofthe Proa any y employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
Cyy' will do Ne work,enJ theswcwrcis not intended ornffcredfonule(Sec.]044,Business [:]OTHER
3 and Professions Code:The Canaazmts License Law does not apply to an owner of OUTLEfg-SWITCHES-FlXl'URE$
Property who builds or imroes
pvtharem,end who does such work himself or through
his Own employees,provided that such improvements arc not intended or offered fur NEW RESIDENTIAL ELECTR SQ PT.
var.If,however the building Or improvement is sold within One year ofcompletinn,the - SQ.FT.FLOOI�1[IEA. LSQ.Ff.
owner-builder will have the harden of proving that he did not build or i mprove for par. s 0`J
pose ofsale.), y�
[]1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: 7`
construct the project(Sec.](144,Business and Professions Gvle:)The Conti acmr's Li- �P
cense lnwdoes not apply torn ownerofpmaiarmy who builds orianroves thecan,and QTY, PLUMBING PERMIT FEE 11
who contracts for such projects with a eomracrons)licensed pursuant as the Contractor's
License Last, PERMIT ISSUANCE
01I oro comp under SecP C for His. ,B& reason
OwnerALT(?R-DRAINA VF.T-WATER(EA) 'C� VALUATION
WORKER'S COMP(' SA U DE CATION
1 hereby sffim under penalty nfperjury one oft a following Jcdamminns: BACK FLOW PROTECT.DEVICE
•Dlheve and willmainmin aCertifcam of ConunuoselGimum for Workers Compete DRAINS-FLOOR,ROOF,AREA,COND,
salon,as provided for by Section 371 of the Inbar Code,for use perfomuom of the STORIES TVPE CONSTRUCTION
work for which this Permit is issued. FIX9'URES-PER TRAP -
❑1 have and will mmaimaer Workers Compensation Insurance,.required by Stamen
37W of she Lehr Code,fa the performance of the work for which Nis Permit is issued, GAS-EA.SYSTEM.I I,,,I LETS
My Worker's Compensation Insurance crier and Pal icy number arc: OCC.GROUP AI'N
Cartier: Policy No.: GAS-EA.SYSTEM-OVER J(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASWINDUSTRI,WASTE INTERCEPTOR
(This Science need not be complied lithe permit is for one hundred dollars(1IN) BUILDING DIVISION FEES
or less) GREASE TRAP
I certify that in the performance of the wink l'or which this PLANCHECK FEE
Permirokers'Co.,..one.Law any fC.limnin any mannenmasmbecome Subject to Workers'COmn- SEWER-SANITARY-STORM FA.300 FL ENERGY FEE
z Z Applicant
anwa of Celifamie.Data WATER HFATCR WNENT/ELECTR
z r Applicant - - GRADING FEE
becameNOTICa APPLICANT If,after Compensation
this Cenif.re of Exemption,you should WATER SYSTLM/fREATING
a� become subjen to the Worker's Compensation provisions of the Labor Cnde,you must SOILS FEB
aQ forthwith comply with such provisions or Nis permit shall be dammmed rtvoked. WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ PT. PAID
U (hereby affirm Nm Nem iso construction lendingagency far Ne perfarmarceof Dare R ipsg
V4 F the work for which His permit is issued(See.3097,Ci,O)
C) L) Lender's Name 'TOTAL:
Landers Address TOTAL:
[- M 1 certify that I have read this application and state Nat the above information is BUILDING TLE
C.V] comet.I agree to comply with all city and county oninances and sum laws rdQTY. MECHANICAL PERMIT FEE
m
U 4 building construction,and hereby rahorice representatives of this city to en ia..the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
1 We)agree to save,indemnify Ond keep hamlets the City of Cupertino against ELECTRIC FEE
Iiabilisies,judgmems,casts and expenses which may in any way accrue against said City
in coALTER OR ADD TO MECH.
consequence of the granting of this Perris. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL CQ,MPLY WITH ALL NON-POINT AIR HANDLING UNIT to."CFM)
,REGULATIONS. MECHANICAL FEE
SOURC
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Sign wre of Appliam/COnuacmr at EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS SCLOSURE HOUSING MITIGATION FEE
Will Ne applicant orfultre building accustom store nrhandle hnmrdous insured HEATING UNIT CTO IN."BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)] - HEATING UNIT(OVER 100,000 BTU)
[]Yes MNo
VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt p
emir huardous air contaminants as defined by the Bay Awe Air Quality Management BOILER-COMP(3HPOR 100,00011m)
Distdn9 TOTAL:
❑Yes []No BOILER-COMP(OVER I WON BTU)
I have read the hazardous mammials requirements under Chapter 6 95 of the Cali. AIR CONDITIONER
Intent Health A Safety Code,Sections 255W,25533 vW 25534.1 understand that if the ISSUANCE
building does not currently have a tenant,that it is my responsibility to rally Ne occupant NEW RESIDENTIAL MECH. SQ.FT.
of the re itnuma da which must be met prow m issuance Of a CertiOcare Of Occupancy.
Owner Or amhonzed agent Dam TOTAL:
ISSUED BY:
OFFICE