31432U
C
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING• MECHANICAL
BUILDING PROJECT IDENTIFICATION
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PERMIT NO. 31432
1.}
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
O ERS NAME: PHONE:
r
CONTRACIOR'S NAME: LIC NO'.
C 1—iNo �n2` 1 Os
NIC
11
CONTROLM
ARCHITF,CDF.NGINEER: LIC NO:
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CONTACT. PHONE:
❑ Co Midtant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDGPl. ME❑CH
F.LF
K YrfaN
LICENSED CONTRACTOR'S DECLARATION
1 hereby affnm that I am licensed under provisions of Chapter 9 (commencing
wish Snrmm?000)of Division ofthe Business and Professions Code, and my license is
'in full force and cff �_��L�
Game eC Lic.g— O
Dam
QTY ELECTRIC PERMIT FEE
QTY
DESCRIPTION
SFDWL Ll KITCHEN REMODEL
OpDDITION [I PLUMBING RE -PIPE
❑MULTI -UNIT []STRUCTURAL
MODIFICATION
C3 INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
V BATH REMODELMEPAIR El DEMOLITION
VLBATH
.00THER
r
-PERMIT ISSUANCE
APPLIANCES - RESIDENIAL
TS*DECr
DECLARATION
I understood my plans aholi be used as public records
A shah
PANELS
UPTO 200 AMPS
Licensed Professional
OWNER-BUILDERDECLARATION
1 hereby affirm that I
Out I a. exempt from the RATIOlare License Law for the
Contraction's
reason(Section 7031.5, Business and Professions Cade: Any city or county
which ocruirew, a penNt to consumer, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit o rile a signed statement
that be is licensed punumn to the provisions of the Connectors Liceme Lew (Chapter 9
(commencing with Section 7000) of Division 3 of rise Business and Professions Gde)or
that he is Oscmpr therefrom and the basis forme alleged exemption. Any violation of
Section 7031.5 by any apphemnfor. permit suhjects meirldrem ma civil penahy of
not moremaa live hundred dollar(5500),
❑1, as owner of the propcny. or my employers with wages ns lbeir sole compensmion,
will do the work, and the etrm
ucre is not in ended mof cmdt forsale (Sec. 7614, Business
and Professions CWc: The Contmctars License Law does not apply to an owner of
pmpeny who builds Or improves thereon, and who does such work himself or through
his own employees, provided that such improvements ore not intended or annual for
sale. If, however, the building of improvement is sold within one yearnfcompletion,me
owner -builder will have me burden of piovingmar he did nm build or improve torpor.
pose atmlo).
p I, m nuu
owner of the propeny, am exclusively eoting with licensed contractors to
construct are project (Sec. 7044, Business and Professions Coda) ITe Contracmrs Li
cense Law does not apply to an owner of properly who builds or improves thereon, and
who contract forsuch projecus with seminarians) licensed pursuant the Contractors
License Law.
I umexrmpr under Sec. ,B& P C for this moron
201-101MAMPS
OVER 10110 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT(MISC.
TEMP METER OR POLE INST
COMMERCIAL:
O NEW BLDG/ADDITION ODEMOLITION
OTENANT OFOOD SERVICE
IMPROVEMENT
OOTHER
POWER DEVICES
SWIMMINGP LELECTRIC
O SWITCHES -FIXTURES
N' RE IAL ELECTR SQ PT.
SQ. FT. ncd AREA
P V
JAS g RECD
ur VV I WO
S/SQ. FT.
'TOTAL:
QTY. PLUMBING PE IT FEE
PERMIT ISS/NilrtH
ALTER-D AI E -WATER BA)
Owner Date
WORKER'S COMPENSATION DECLARATION
I beteby affirm under pearly of perjuy one of the foilowing drd[m ions:
71 I have and will maintain a Cenificme ofComenr to self -insure for Worker's Cooper.
.tion, as provided for by Section 3700 of the Labperformance
Latin, Code, far me of the
kfor which this Permit is issued.
have sed will maintain Worker's Compensation Insurance, as required by Section
of me Latin, Cash, for the perfmmance.1 the work for which mis permit is issued.
My Worker eati I su enee Policy
canter and Polic 45th
Confer:rR.'neGI' Policy Na/m��
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tom, if.. need. la ermit completed Ome pis Inion hundred dollars S100)
or less)
I certify that in the peffmins 4me work far which mis permit is issued, I doll
not employ any person in any manner m m to become subject to the Workers' Compen-
mind laws of California. Date
Applicant
VALUATION
/t,
v
BACK FLOW PRICE
DRAINS-FLOOR,ROO A EA,COND.
S RIES
TYPE CONSTRUCTION
FIXTURES -PER TRAP
GAS- EA. SYSTEM. I INC. 4 OUTLETS
OCC GROUP
APN
GAS - EA. SYSTEM -OVER 4(EA)
GRF.ASEgN`DUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASETRAP
PLANCHECK FEE
SEWER -SANITARY -STORM EA. 210 FT.
ENERGY FEE
WATER HEATER W/VENT/ELECfR
-
GRADING FEE
NOTICE TO APPLICANT. If, inner making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the labor Cole, you must
formwiN comply with such provisions .,,his Permit shall be deemed revoked.
CONS] RUCTION LENDING AGENCY
I hereby affirm dual hem is a construction lending agency for the performance of
the work for which this parch is issued (Sec. 3097, Civ. C.)
Lender's NameTOTAL:
WATER SYSTEMaREATING
WATER SERVICE
-
SOILS FEE In
PAID
Dare
NEW RESIDENTIAL PLMB. SQ, FT.
Lcndrrs Address
LDING FEE a
1 certify mal I have read this application and state that the above nomination is
coned. l agree m comply vith allcity and rummy ommunccsandamelsornlatingun
building constmdion, and hereby authorrze represematives of this city w enter upon the
above-mentioned propeny for inspection purpami.
agree: In save, indemnify and keep harmless the City of Contemn. againstliabilities,judgmems. costs mid expenses which may in any way acerae againsr said City
consequence of me grantingof this permit.
UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
REGULATIONS.
QTY, MECHANICAL PERMIT FEE
FEE
PERMIT ISSUANCE
CfRIC FEE(We)
ALTER OR ADD TO MECH.in
MBING FIEAPPLICANT
AIR HANDLING UNIT(TO 10,000 CFM)SOURCE
[SEISMIC
HANICA FEE
AIR HANDLING UNIT(OVER 10,001CFM)
STRU TAX
Sigaam. ofApplicarOConumcm, Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant score or handle hanudous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Hwlm and Safety
Coda Section 25532(a)7
C] Yes Azin
I
Will the applicant orfutute building byOccupied eByseea Air Qualitnt or y
us air contaminenta ns JefineJ by the Bey Arca Air Qualiy Mamgemem
Managees ment
emit District?
Dlstra7
[D Yes aFJpNo
I have read the hvrardous mamrieds tN' nota under Chapter 6.95 of me Cali-
fo no Heddi & Safey ode, Sections 05, 533 and 25534 I undenlaM mut if me
building nn a hove uten n, as rte sr iffy notify me sccupant
ofdr Wx tbmM as ustf r to
EXHAUST HOOD(W/DUCT)
SING MITI ION FEE
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID
Dem Receipt M
VENTILATION FAN (SINGLE RESID)
BOILER- COMPOHPOR 100,00UBTU)
TOTAL:
BOILER - COMP (OVER 100,000 BTU)
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY: V V�/� �
NEW RESIDENTIAL MECH. SQ. FT.
Owneraroo o agen ate
TOTAL:
FA
OFFICE