31087 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 31087 1 O H 7
RUIIAINODIVIS10N APPLICATION/PERMIT PLUMBING-MECHANICAL JK
BUILDING PROJECT IDENTIFICATION
BUILDING Cc/NM 6v..P SANITARY NO. APPLICATION SUBMITTAL DAT[
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N �S�C ������ PM NZ`�� CONTRACTOR'S`LG LIC NO: 1
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NIC CONTROLp
�ARCHITECT/FNGINBGR: LIC NO: AUDkCSS: - ❑
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- PHGNE:' BUILDING PERMIT INFO
Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
,�uCE an I a CONTRACroRB DECLARATION QTY ELECTRIC PERMIT FEEy affirm that I am licensed under provisions of Clupter 9(commencing JOB DESCRIPTION
000)af Division 3ofncfirdr,asovd Professions Cafe,and my licensees RESIDENTIAL:O PERMIT ISSUANCE
ly nJ effect. ❑SFDWL ❑ CHEN REMODEL
UU Lic.M gppL1ANCES-RESIDENTIAL ❑ADDITION BING R&PIPE
ZaWMContractor llllll������jjjjjj
F�7y ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STR CTURAL
Z O ; 1 understand my plans shall he used as public records MODIFICATION
OZ—O UPTO 20a)AMPS El INTERIOR ❑CHIMNEY REPAIR
r4ta1 Licensed Professor...I 201-1000AMPS IMPROVEMENT
gggF OWNER-BUILDER DECLARATION OVER 10310 AMPS [I BATH REMODEIIREPAIR ❑DEMOLITION
R'dd a I hereby affirm that 1 an exempt form the Contractors License Lou,for me
fiy5O W, following reams.(Section 7031.5.Business and Professions Cale.Any city Lir county SIGNS ELECTRICAL. ❑OTHER
W WO y which requires a permit to conswe6 alter,improve,demolixh,or rtparf any swcwm A
pd.,to it. OF.requires Ne applicant far such pemdaa NeaslgnW nnemem SPECIAL CIRCUIT/MISC.
;!1 y Nn he is licensed pursuant m Ne provisions of the Contractor's License Law(Chapter9 Less
nape (commencing with Section 901)of Division J ofthe Business and Professions Code)or TBMP.MEEROR POLE INST. COMMERCIAL:
P. qq that he is exempt therefrom and the basis for the alleged excoriated.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
pg Zy Section 7031.5 by any applicant fora permh ubjeeta Ne trimheart Lou penaltyof POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than rive hundred dollars(S50T.
W
F.Z Y IMPROVEMENT
q Q ❑L�a owner of he
propeny,armyemplended wiNwages rtalei(Sm.rota,Business SWIMMING POOL ELECTRIC
O
Will da fe wad,and the he Core is not,,weed m Law
do for Out
army
1.an Business OTHER
aad Professions Code:The errs theor's Licenhc Ldw does nrn apply to if owner of OUTLETS-SWITCHES-Fl%TURFS 00
progeny who builJs or improves thercnn,Lind who d.es such work himself or through
his own employees.Provided that such improvements arc not intended or offered 1'nr NEW RESIDENflAL ELECTR SQ ET.
sie.If,h„Wever,be building or improvement is sold within ane year ofcomplellon,thc SQ.PT.FLOOR AREA ASQ.FT.
Poncobuilder will have the burden of proving that he did not build or improve for put. p
se of sale.). 4* A r
❑1,as owner of the property,am eaelusively comraning with licensed c.ntmnars t. TOTAL:
tmmsuun the project(Sec.70,14,Business and Professions Cede:)The Convactor's Li-
cense law does nm apply to an owner of progeny who builds or improves Hereon,end QTY, PLUMBING PERMIT FEE /l
who contracts for such projects with a eontmcons)licensed pmsuanuo the Commem's Ae 13
License Law. PERMIT IS
/s II[II u
❑tarn exempt under Sec. ,B&PC for rhisrc nn C�fy
(Owner Date ALTER-DRAIN&VENT-WATER IEA)
WOffF.R'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury ane of the following declarations:
71 [have and will maintain a Certificate of Consenuo self-insum for Worker's Comped- BRAINS-FLOOR,ROOF AREA.COND.
anion,v provided for by Section 3700 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for abala bis permh is issued. IL TIXTURFS-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
37Mofthe Labor Code,for the performance offe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
' Carrier: Pol icy Nn: GAS-EA.SYSTEM-OVER 4 TEA) -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(TTis sec0nn need not he armpinul if the permhis 4rrone hundred tlaliws(Slo) GREASETRAP
orinsJ - PLANCH[CK FEB
I certify that in rhe performance ofrhe work for which this permit is nxucd,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner mus to became ietum,us rhe Workers'Carper- ENERGY FEB ,
0 z sation Laws ofCalifornia,Dare WATER HEATER WNENT/ELECTR
O Applicant GRADING FEE
pJ NOTICE TO APPLICANT:IL after making this Cenif am of Exemption,you shouldTF, TING
abecome subject m the Workrex Compensation provisions of the Labor Cade,you must SOILS FEE
41a fonhwif comply with such previsions or Nis permit shall he deemed revoked. WATER SERVICE'
p A
CONST,is.emNLENDINGAGENCY NE IDENTIAL PLMB. SQ,Ff. PAID
V4. � Iherthy uRrm thnfcreisac.nswnion lending agency for feperlannanc<of Dtc Receiptp
fie work for which this permit is issued(Sec.3097,Co,C.)
0 f' Under'a Name TOTAL:
U Lender”Address T
W ort I certify Bou 1 have mad this application and ,are torr,the above information is BUILD( FEE
In correct.l agree to comply with all city and county ordinances and state laws reladmgm QTY. MECHANICAL PERMIT FEE
V building construction,and hemby authorize expreaormtives of this city m enter upon the SEISMI
above-mentioned property for inspection Improves. PERMIT ISSUANCE ELECTRIC FEE
(We)agree m save,indemnify and keep humorless the City of Cuper .inn against \
liabilities,judgmenu,cons and expenses which may in any way ammo against Laud City AT.TERORADDTOMECH.
If
in consequence of the gmming of this permit. PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(T(310,000 CFM)
SOURCEREGULATI NS MECHANIC FEE
SS`J� , S//r AIR HANDLING UNIT(OVER 10.100 CFM) CONSTRU IONTAX
Stynameof ra te�eIll Commoveor Data? EXHAUSTHOOD(W/DUCq HOUSING RIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future ovildingonuprmsmreor,handle haxaaNus material HEATING UNIT ITO 100.00 BTU)
as derined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532nd? HEATING UNIT(OVER 100,M)BTU)
❑Yes ON.
W s VENTILATION FAN(SINGLE.RESID) PAID Date Receiptp
d the applicant future occupant use equipment or devices which
emit haNvous air romaminama as defined by the Bay Area Air Quality Management BOILER-COMP(JHPOR I00.011U BTU) AL.
Disuiet? BOILER-COMP(OVER IOBOOO BTU)
Ell Yea ❑N.
I have read the hazardous materials requirements Linder Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma HeuIN&Safety Cale.Sections 23305,25333 aria 255.4.I uMeronnd far if the NEW RESIDENTIAL MECH. SQ.FT.
building does not eirrre if b v<a mnant,fot iru my responsibility to notify the occ Pant
of e requiremrn6 w c ust be met for roissuance of a Cenifm (kcu
_S4 T F7
Owner or nuton'zed agent �� a TOTAL: ISSUED BY:
OFFICE