31199 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEiRTINO BUILDING-ELECTRICAL PERMITNO. 31199
11l I-11JV
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT TDEN'FIFICATION
BUILDING ADDNESS: SANITARY NO. APPLICATION SUBMITTAL DATE
)r,4 _,Ir s s �o�g C'CQ
OWNHq NAMB: PH E: CONTRACTOR'S NAME: LIC NO.
0437 11 N/C CONTNOLN
gi
ARCHITECT/F.NGI ER: LIC NO: ADDRESS M� ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT U MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9lcmnmencing " JOB DESCRIPTION
1000 with Seclion700taid!Division 3ofthe Businowid Professions Codc,md my license is RFSIDFNTIAL'
FOO in wt full farce and effect it L , D PERMIT ISSUANCE f�lltrr�
�UE License Class
C Lic.N ❑SFDWL ��wI���f��a.^���t�aa'TCHIS REMODEL
rF�a Uma Canwcmr APPLIANCES-RESIDENTIAL. ❑pDDIT10N vIBING RE-PIPE
ARCHITECT'S DECLARATION [I MULTI-UNIT /❑STRUCTURAL
F2Z 1understoodm I PANELS
Z O ,� y plans shall be used w public records MODIFICATION
0z UP UP TO 200 AMPS [3 INTERIOR E' CHIMNEY REPAIR
FWtLicensedPdexsianal 201-IO00AMPS IMPROVEMENT
a .•]4 OWNER-BUILDERDECLARATIONCe Contractor's
OVER IOOIIAMPS ❑BATH REMODEUREPAIR (]DEMOLITION
C�y Y� I hereby affirm that I oro.Burin from the C anion Co Liana Law for the
pd
03 yF which
remain.(Section construct,alter
Professions demolish,
COde:ep t t [I OTHER _
YY1I following y city or county SIGNS ELECTRICAL
0_2which requires a permit re cores the plan improve,demolish,or repair any structure
'hat heor its 0 newt pursuant to also the t mvisions nt ofLn ouch Nrrtino fiiansle aa L w B71t¢mem SPECIAL CIRCUIT/MISC.
j�p. thus he is licensed leoion to the provisions of the Contractors Y Llcemae Lew(Chapmr9
ca that he is xempth Sem roan and
th basis for
al Business and Professions idmir)or TEMP.METER OR POLE INST. COMMERCIAL:
dyx c K that. is exempt thertfrom and the boric for the alleged exemption.Any viproof,of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^y not mom31.3by any vichumodd.lims($permit suhjecls the upPlicammacivil penalty of POWER DEVICES ❑TENANT (]FOODSERVICE
y wt more than Bvehuprope ddmrsyem0). IMPROVEMENT
6I]Lo the wor of the property, with wages avhe(soleSm. 0,14,Bsiness SWIMMING POOL ELECTRIC411,
y. O will dmhewmk;C and
e:The Cum is noes Licenso Law ell dos r aidenot apply
to an Nosiness []OTHER
W and Rvfecsions Cade:The Commcmrs License law dos not apply to m owner of OUTLETS-SWITCHF,S-FIXTUREg
d a^ property who buddia or improves Hereon.and who does such work himself or through
his own employees,provided Nat such improvements arc not intended Or.acted for NEW RESIDENTIAL ELECfR SQ pT.
sale.If,howeveq the building or improvement is sold within one year ofcompletion,the SQ.FT.F1_OORftEjD VSD FT.
owner-builder will have the burden of proving that he did not build or improve for par.
❑1,as owner of the Terrific",sm exclusively contracting with licensed contractors m TOTAL: t ate Lg
mnstmcl the pmdact(Sm.7044.Busimaa and Professions Code)The Contractors Li. Il
cena Law does not apply to an owner of property who huilds or improves thereon,and QW.. PLUMBING PERMIT FEE /�
who cuntmcrs fm such projects with a contruaur(s)licensed pursuant to the Ciamos tars teUf-C
License Law. PERMIT ISSUANCE H/�hG
❑I am exempt under Sec. .B&P C for this reason
no
Owner Date ALTER-DRA IN VENT-WATER(Hot VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1 hereby affirm under penalty of perjury one of Ne following declarations:
❑I have add will maintain.Ccttificae of Conscnuo self-insurt far Worker's Compcn- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPF.CONSTRUCION
cation,aw provider(for by Section 37M of the labor Code.for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ I have and will maintain Workers Compensation Insumnce,as required by Section
37M nftha L.bor CW"for the perform ceafthewnrkfor whichthis permrdI isissued. GAS-EA.SYSTEM.)INC.4 OUTLETS .00C.GROUP APN
My W.:rkcex pen at on I tree c a,on,
d Policy�y' {ar. !f G]�/
(1 Policy N.,Ts �`s�u,`z7 GAS-EA.SYSTEM-OVER 4(PA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIINDUSTRL WASTE INTCR
COMPENSATION INSURANCE. BUILDING DIVISION MIES
(This section need not be completed ifthe permit is for me,hundred dollars 15100) GREASETRAP
or less.) PLANCHECK FEE
I cenifythat in the pecomtanceofthe work for which this permit is issued,Ishot) SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to bt
ecome subjec ,,the Worker,'Co.,.- ENERGY HE
C z satiot Laws of California.Dam WATER HEATER WNHYPELECTR GRADING FEE
Z Applicata
fA NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTENIOREATING SOILS FEE
a5 come subject to the Workers Compensation provisions of the Labor Cole,you t
Gil forthwith comply wird such pmvisions or this permit shall he dcemal revoked. WATER SERVICE
d A
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V I he
rebywhichaffirm that there isost Ser.construction30 lending agency for the Nrfonnemc of Date Receipt
k" I! the work for which this permit is ivued(Sec.309].Civ.CJ
O V Landers Name TOTAL:
{iI tanners Address
y wart
certify Nm 1 have read this appllemion and state thm the above information is BUILDING FEE
rA corer.l agree to comply with all city and county ordinances and state laws minting t. QTY. MECHANICAL PERMIT FEE
(.J building construction,and hereby authorize representatives.(this city to enter upon the SEISMIC FEE
shove-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
ELECTRIC FEE
liabilitiea,judgmems,c se expenseswhichmayinany way....acagainstsaid City ALTER OR ADD TO MECH.
zz
inconsequence. VRAI
ng of this permit. _ PLUMBING HE
APPLICANT DS AND COMPLY WITH ALL NO POINT Alli HANDLING UNIT(TO MIXED CFM)
SOURC :.l /r MECHANICAL FEE
S// AIR HANDLING UNIT(OVER 10,gq CFM) CONSTRUCOON TAX
Si of pplicant/Contmm.. Date EXHAUST HOOD(W]DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIA S DISCLOSURE
Willtheappli,.mmf.turebtildingce pant scam orhmdle hazardous mamrisl HEATING UNIT(TO IffljW BTU)
as defined by the Cupertino Municipal Cale,Chap e,9.12,and the Health and Safety
Code,Section 23532(x)? ....���kk[[[[/'''�� HEATING UNIT(OVER 100,000 BTU)
Yes I7(No
� VENTILATION FAN(SINGLE RESID) PAID Date Receiptp
Will the applicant or future building occupant use equipment or devices which BOILCR-COMP(JHP OR 1110,00(1 BTU)
emit hamNous air contaminants as defined by the Bay Am Air Quality Management TOTAL:
District? K� �N. BOILER-COMP(OVER PRIME BTU)
❑Yes IRF
1 have it99,
pals requirementsunder Chapter 695 ofthe Cali- AIR CONDITIONER ISSUANCE DATE
fbmia Ileahh&S
,cry
05,255".
13 and 25334.I urgcrstand that if the NEW RLSIDEMIAL MECH. SQ.FT.
huildingdas that yrtsof.Casitymwtify arc pmt
nfthe isuamm�fa Cilityt �u y
O r authoriz ager Uam TOTAL: ISSUED tlY:
OFFICE