31104 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICALPERMITNO. -3 104
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - - SANITARY NO. APPLICATION SUBMITTAL DATE
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15
O NE ' .}AME: 10th CO AME: LIC NO:
K O O� ^ NIC CONTROL#
RCHITECT 1 CR: _ LI NO: D SS: it, - �^A ,v T o ❑
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CONTACT: - PBONE: BUILDING PERMIT INFO
Zal— ❑ Consultant Fees Paid by.Applicant(Initial) BLDG ELECT PLUMB •SUCH,
UC
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE X ♦al���a�l� /fCL�i'`
1 hereby am Nm licensed under provisions of Chapter 9(commencing PERMIT ISSUANCE. JOB DESCRIPTION
q56
a2 with Section 70(1 Division 3 of the Business and Professions CMe.and my license is RESIDENTIAL:
O -
W�. in full fmcc and effect. ❑SFD WI. ❑KITCHEN REMODEL
�UZR License Class Cost APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
I.6 i Date GenlDECL
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL'
O 2[/1 Z I understand my plans shall be used as public record MODIFICATION
UP TO 200 AMPS MODIFICATION
:1
M - ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-IIXI AMPS IMPROVEMENT
X5 2 OWNER-BUILDERDECLARATIONCe Contractor's
ON OVER 10X)AMPS - XIATH REMODEUREPAIR ❑DEMOLITION
DowCC 1 hereby affirm that 1 am exempt from the Commnor's Liceve Low for the
Wig d U following meson.(Section 7031.5.Business and Promoters Code:Any city or county SIGNS ELECTRICAL ❑OTHE/es-- IT
47 W which requires a permit to construct,alter,improve,demolish,or repair any moure e f L /
ISqfn prior to hxissuance,also requires the applicant for such permit to File a signed statement SPECIAL CIRCUIT/ TSC. ♦♦♦
y that he is licensed pursuant to the provision of the Contractor's License Law(Chapter 9
�C)q (commencing with Section 7")of Division 3 ofthe Business unit Professions Codi or TEMP.METEROR POLE INS . COMMERCIAL:
o LL that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�N Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER I3F.VICES OTENANT ❑FOOD SERVICE
qZ�y of mum Nan five hundred dollars($5001. IMPROVEMENT
i M-.G ❑ I,us owner of the prnpeny,or my empinyces with wages as their sole cnmpensmian, SWIMMING. P.LIiCfRIC
WCC wi11ZEnework.and thenrunure is am intended or offered fm sale(Sec.7044,Business ❑OTHER
and Professions Code:The Contractor's License Law docs net apply to im owner,of Ourt-as-SWITCHES-FIXTURE$
6 3^ property who builds or improves thereon,and who doss such work himself or tbrough
his own employees,provided that such improvements are not intended or offered for NEW RPSIDENTIAL ELECIR SQ PIL -
sale.If.however,the building or improvement is sold within one year ofeumpletioa,the SQ,FT,FLOOR AREA S/SQ.FT.
owncrvhnilder will have Ne burden of proving that he did not build or improve for par-
pose of sale.). -
1,as owner of the property,am exclusively contracting with licensed contractors to
answer the project(Sec.7044.Business and Profusions Code:)The Communes Li- !1 p
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE r1 , D
who commets for such projects with a ctmtrach ran licensed pursueorso the Contractors
License Lawext ' 1 PERM IT ISS DANCE
exempt Mq
❑Tem mpt under See. ,B&PCfnr this reason
Owner Date ALTER-DRAIN&VENT-WATER(EA) Cb �-
Y —VAEU
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE y
I hereby affirm under Penalty of perjury one of the following declarations:
"I]I have and will maintain.Cefdficalenf Consent lneelf-insure fm Wolkcr'a Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES PE CONSTRUCTION
scatter,as provided for by Sutton 37M of the Labor Cuda,for the performance of the
work for which this permit is isxuad. FIXTURES-PERTRAP
❑1 have sod will maintain Workers Compensation Insurance,as required by Section
370(1 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP' APN
My W. ofion Inca ince and Policyrte p
Certiec Policy No
ofp3okj 09A GAS-EA.SYSTEM-OVER 4(EA)
ICERVITCATE OFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FRGS
AS
Ohisstion nee.)not bm
Ise completed if the penit is for mhundred (5100) GREG TRAP
or less) apLANCHECK FEE .,
I ccnify that in the performance of the work for which this permit is ixmed.I shall SEWER-SANITARY-STORM EA.810 FT.
not employ any person in any manner m m ns become subject 0o the Workers'Compen- ENERGY FEE
Z ration laws.(Califomia.Doe WATER HEATER WNIiNT/ELECTR
2Applicant - GRADING FEE
NOTICE TO APPLICANT:If,otter makingthis Cenificam of Exera t should pj p ion,you s WATER SYSTEM/TREATING - SOILS FEE
w
•f'0 ['
thermos,eu
bjcet WorkerCompensation
s provisions of the Labor Croke......uss ry foMwilh complyy with such
provisions mthis permit shell he deemed revoked. WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'IMB. SQ.PC PAID M
>J O (hereby affirm that thereem isis acacons0metion lending agency for the performance of
Ij. the work for which this permil,a issued(See 3097.Civ.Cd
Lenders Name TOTAL:
Lendees Address L
1 ccnify and I have read this application and nine that the move irimmmtion is BUILDINGIN
ycontact.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
7
'V G building construction.undherebyauthorim representatives ofthiscity to enter operate SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree 1.save.indemnify and Earp hnmless the City of Cupertino against PERMIT ISSUANCE CLECTRTC lI -
liebilitie.judgmem,cost and expense which may in any way accrue against said City ALTERORADDTOMECH. r1S
in cmnscqucnce of the granting of Nis permit. PLUMBING FE Gtr/
AP NT UNDERSTANDS AND WILL C, MPL WITH ALI, N-POI T 0 CFM)ATR HANDLING UNIT(TO 10,00
SOURCE 1ULATIONS, MECHANICAL FEE
3 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX'
Signiturco pplicant/Cmtrscmr EXHAUST HOOD(WNUCT)
HAZARDOUS MATERIALS DISCLOSUREHOUSING MITIGATION E
Will Ne applicant or future building meront store or handle does mdtenul HEATINO UNIT(TO 100,000 BTU)
as definul by the Cupeninn Municipal Code,Chapter 9.12 and the Health and Safely
Cade,Section 25532(m)7 HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLERESID) PAID
Dam Receipt#
Will us applicant or future definedding occupant use equipment ar lily Management
which BOILER-COMP CHP OR 100,000 BTU)
emit ice? us air contaminants as defined by the Bey Arca Air Quality Management TOTAL:
,. Dlatricl7 BOILER-COST(OVER 100,000 BTU)
❑Yes No
I have media,ha rdoxw coenak rryuUecarms under Coma,6,93 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomite Health&Safety Code,Sections 25505,25533 and 25534.1 understand that Rate NEW RESIDENTIAL.MECH. SQ.PT.
building dxs not currently have a mama,thvt it is my remomibility to minify the oscop;rm _
L.
Ne reyuam a which musloma pnnnnissmncc aro Qrtifiate of Ocuupwcy. -
Owner err mooned a gent Data TOTALI ISSUED BY:
OFFICE