31484 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PBRMITNO. 31484
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL:
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
�35o Ism s Ass . Z-12 9
O 'S NAME: P NE: _ - CONR C^fOq' NAME:1 t-�!� LIC NO:
ARE$R�� N rlTln� NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: 1DI IS:1ry- ,� '❑
CONTACT. PHONE: I tI 11 BUILDING PERMIT INFO
' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
❑ ❑ ❑ LZ
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affect Nat 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�CzO with Section 9010)of Division Sof the Bminexsend Professions CMe,indery,license is RFSIZ� TLAI,_
f• in full force and eft PERMIT ISSUANCE [I SFDWL RESIDE�N [3 KITCHEN REMODEL Licen ass aK? Lic.#
W
d,0. Dam — Convado APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Dw ARCHITECTS DE TION ❑MULTI-UNIT []STRUCTURAL
z O WK 1 understand my plans shall be used as public records PANELS MODIFICATION
Ozw UPT0200AMPS
O [I INTERIOR CCHIMNEYREPAIR
I:�Fyy Licensed promotional IMPROVEMENT
•.•11 Oat I am exempt
from
DECLARATION
I hereby affirm that 1 um exempt from the Contractor's License Law for the OVER TWO AMPS [I BATH REMODEI/REPAIR ❑DEMOLITION
kJ aLU following mesa .(Section?031.5,Business end Pmfeuions Code:Any city or county SIGNS ELECTRICAL OOTHER
F LLO which requires a Permit to cortmct,alter,improve,demolish,or repair any structure
primto its issuance,also requires the applicant for such Permit to file a signed statementSPECIAL CIRCUIT/MISE.
} that he is licensed pursuant to the provisions of the Conwemrs License Law(Chalrr9
p p0 (comencemagwith Section 9000)of Division3ofthe Businessaad AofessionsCode)or TEMP,METER OR POLE INST. COMMORCIAL- ..
a{y y that he is exempt therefrom and tad basis fm the alleged exemption.Avy violation of 0 NEW BLDG/ADDITION ❑DEMOLITION
iC fifers. Sati..9031.5 by anyapplicmt for a permit subjects the applusto to a civil paltyof POWER DEVICES 0 TENANT El FOOD SERVICE
fsr_1 z p, not more than five hundred dollars($5(10). en
Q� 0 Las owner ofthe proeny,
por my cmL ELECTRICployeas with wages m their sole compensation, SWIMMING POOIMPROVEMENT
fC� will do the work,and the immure Isom intended proffered battle(See 7M4.Basi.. ❑OTHER
m� and Professions Cade:The Contractors License law does not apply to an.,all of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the building m improvement is sold within one year o(completion,the SQ.FT.FLOOR AREA S/SQ.FT
owner-builder will have the burden of proving that he did not build or improve for pm,
pare of ale.).
0 I,as owner of the propeny,am exclusively contracting with licensed contractors to TOTAL:
consumer the project(Sec.9044,Business and Professions Code:)The Convectors Li-
cena Law does not apply to on owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT E
who contracts for such projats with a cam mamr(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
M I am exempt under Sec. ,B&P C for this mason
Owner Date ALTER-DRAIN&VENT-WATER IEA) isVALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm
m under under pcnehy of perjury one of Ne fallowing Jedamriar:
❑Ih...end will mainaina C<rtifcmc of Conumtoalf-insum for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. 47STORIFS 11 TYPECONSTRUCDON
&tion,as provided for by Section 3900 of me labor Code,for the performance of the
work for which this permit is famed. FIXTURES-PER TRAP
1 has and will maintain Worker's Compensation Insurance,as required by Section
3900 of the labor Code,for the performance of the wed for which
this permit is issued. GAS-PA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Canierd aCempcnsrijn loT^Scartie polis, I'Icy2yp¢1302M GAS-EA.SYSTEM-OVER 4IRA)
CERTIFICATE.OF EXEMPTION FROM(WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This nation nadnot 4 completed ifthe permit is fm one hundreddollax($100)
or less.) GREASE TRAP PLANCHECK FEE
I certify that in the pertmmunce of the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any Person in any manner so as m become subject are e Workers Compen- ENERGY FEE
,Z salon laws of California.Data WATER HEADER WNENT/ELECfR
12 Applicant GRADING FEE
NOTICII.TO'APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMITR RATING
I"0 becnm'e subject Io the Worker'&Compensation provisions of the Labor Code,you must SOILS FEE
LaLI forthwith comply with such provisions of Nisp.i,shall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID_
L) Ihcreby affirm that thereem is feae constnninn lending agency for Performance of Data Ra p #
!�0 the work for which this permit is issued(Sec.3097.Ci,C.)
0 F-0 Lenders Name _ TAL:
LULL Leader',Address TOTAL:
I modify that 1 have read this application and state that the above information is BUILDING FEE'
Fn!cep torenm.I agree to comply with all city and county ordinances and state laws relating QTY, MECHANICAL PERMIT FEE
U Z building construction,and hereby authorize mpreanmtives of Nis city m enter upon the SEISMIC FEE'
above-mend"M property for inspection purposes. PERMIT ISSUANCE
(We)agree to ave,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way uame against said City ALTERORADDTOMECH.
I.consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL FEE
SOU :REOULATIONS.
AIR HANDLING UNIT(OVER IO,OIO CFM) CONSTRUCTIONTAX Ilk
Lg re nfApplicant/Contructor Det EXHAUST HOOD(W/DUC'q HOUSING MITIGATION FEE
nt
HAZARDOUS MATERI\ DISCLOSUR a.ao
Will the applicaor future building oc stn store or handle hazardous material HEATING UNIT(TO 1010,03a BTU)
as defined by the Cupertino Municipal Care,Chapter 9.12,and the Health and Safety
Coda,Section 25532(a)7 HEATING UNIT(OVER 100,0(0 BTU)
❑Yes C1 No VENTILATION FAN(SINGLE RFSID). PAID
Dare Receipt#
Will the air mu l or future building occupant use equipmentunlit devices which BOILER-COMP(3HP OR 100,000 BTU)
emit hazallous air comaminams os defined by the Bay Ates Air Quality Management TOTAL:
District? BOILER-COMP(OVER 100,000 BTU)
El Yet E]No
I have read the hammers materials mquirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
funis Health&Safety Code,Sections 25505,25533 anti 25534.1 uadersmad that if the NEW RESIDENTIAL MECH. SQ.PT.
building does net comedy have a more.that it is my responsibility to notify to accupaat •� ^•
of the real attendants which must be met prior to issuance of a Cer ifcum of ONmprcy.
Ovenermembodzrdagent Dae TOTAL: ,a1O ISSUED Y.
OFFICE