31529 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - ' BUILDING-ELECTRICAL PERMITNO. 31529/�/�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL - K 1 5 /M
BUILDING PROJECT'IDENTIFICATION J i L N
BUILDING ADDRFS ''// �J SANITARY NO. APPLICATION SUBMITTAL DATI
�75
O ER'S NAME: - PHONENT
RAC'IO'R'SINAME: LIC NO:
WVA/ v/&-.J 53�Y-�60 ��N '14&Czssi, w,, N/C CONTROLM -
•ARC ffTECT/ENGINEER: . LIC NO: ADD S: ❑
'040-1-
C
Lc C ACT. PHONE: BUILDING PERMIT INFO
253-1F3�a ❑ Consultant Fees Paid by Applicant(Initial) BLgF _ ELECT PLUMB MECH
�u� EcCc-udEaG 6,Lr Z y1` ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby afenn that I am rocom
licensed under provision.of chapter 9( m
eacing JOB DESCRIPTION
�sl O p
X00 with Section 7000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
in full farce eandcffecL PERMIT ISSUANCE ❑SFDWL , O KITCHEN REMODEL
�U License Class Lic.M APPLIANCES-RESIDENTIAL [D ADDITION C1 PLUMBING RE-PIPE
faa....yyyy 4y Date Contractor
ZOG ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z804 0v2 G l understand my plans shall he used as public secoks �� MODIFICATION
�z App UPT0200AMPS IyINTERIOR ❑CHIMNEY REPAIR
P4� Licensed Professional - 201-IfIWAMP3 JI IMPROVEMENT '
RRWiii a OWNER-BUILDER DECLARATION OVER IBRO AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
GG 1 hereby affirm that I am exempt from the Contractor's License Low for the
x 0i U following reason.(Section 7031:5,Business and Profession,Code:Any city or countySIGNS ELECTRICAL. C]OTHER
aa77 O which re ina a permit to canswd.alter,improve,demolish,or repair any stmemre
prior to as issuance,also requires Ne applicant for such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
pN.•
that he is licensed pursuant tothe previsions ofthe Contm mes Licema Law(Chapter9
`Qp (commoncing with Section 70001 of Division 3 ofthe Business and Profession Code)or
TEMP.METER OR POLE COMMERCIAL:
that he is exempt therefrom and the basis for me alleged exemption,Any violation of ❑NEW BLDG/ADDITION [IDEMOLITION
4• Section]031.5 by any applicant for a pmmit subjects the applicom to a civil penalty of POWER DEVICES
ay not mora man five hundred dollars(5500). ❑IMPROVEMENT TENANT 0FDDD SERVICE
6 I,as owner of the propca ,or my employee with wages as their sole compcnsethm. SWIMMING POOL ELECTRIC
will domewark,andthestrudure isnotinmrded'oroffertdfor sale(Sec.]Oi4,tlusinas ❑OTHER
and Pretensions Coda:no Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
6'3 property who builds or improves me.,..and who does such work himself or through
his own employe.,provided that such improvements are out intended or offered for NEW RESIDENTIAL ELECTR SQ FT. %FEE
sale.
ILhowever,the building or improvement is sold within one year ofcomplation,the rgQ.F-fFLOORAREA $/SQ.PT.
ownervbuilder will hove the M1urden of proving thal he did not build ur improve forAur- P�aN4poseofsalo.f
❑h as owner of the progeny,am exclusively contracting with licensed comm ons to TOTAL �canstmet the pmfed(Sec.7144,Business and Professions Code:)The Ci atmctur'e Li- � ^RALTER
PLUMBI �'PE IT 1�9^
who contracts for such projects with a contractor(s)licensed pursuant to the Cotnmctor's 99
License law. ERMIT ISS U Uh L
❑1 am exempt under Sec. ,tl&P C tar this rw.u'n ur<<I I
Owner Uate -DRAW& - TER(WORKER'S COMPENSATION DECLARATION ACK FLOW PROTECC E
1 hereby affirm under Penalty of perjury ane of me following declarations:
❑Ihave and will maintain a Certificate of Concenttoself-insurefor Worker's Compere DRAINS-FLOOR,ROOF,AREA, D. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Code,for Ne perfo...mnce
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compcnation Insurance,n actuated by Section
3700 of the labor Code,for the performance of the work for whichthis pe.I,is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance comer and Policy number are:
Cartier: Policy No.: GAS-RA.SYSTEM-OVER 4 fEA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FE'
Tlhisacd{oa need not be..,lead if the permit is for one hundreddollva(SIM) GREASETRAP "
or less.? PLANCHECK FEE !
Ittnifythat in theperfonnanceoftheworkfar whlchthispermit isissued,Ishall SEWER-SANITARY-STORM EA.200 FT.
not employ any Person in any manner su as to become subject to the Workers'Compeo- ENERGY FEE
sation Laws of California,Date WATER HEATER W/VENI'/ELECTR
Appli0 - GRADING FEE
NOTICEher
ti NOTICE Tjectto be APPLICANT If,Compensation r visins of of Exemption,you yen
WATER SVSTPMlIREATING
abecome subject m the Worker's Compensation previsions of the labor Code.you must SOILS FEE
{A
forthwith comply with such previsions or this pemtit shall be deemed invoked. WATER SERVICE
a Q
.7z
CONSTRUCTIONLENDINOAGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
DateReceiptIf
U Q Ihertby nBinn that mereem isaconstruction lending agency for the perfunnence of
W.
the work fanor which this permit is is /I
ued(Sw.70')1,Civ.C.)Leander',NameTOTAL:
Leander',
Addre,s TOTAL:
I ceni(y thin I havenand this application and acme mat the above information is BUILDING FEE as
4 l,l correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U building construction,ction,and hereby madam representatives of this city to amen upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,mdemrvfy and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
an consequenceafthe gaming of this permit. PLUMBING FEE
APPICAN' INUF STA AND WILL COM YWI'Tit ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOU E L I!NS -
Vn ✓L . 21, , � AIR HANDLING UNIT(OVER IO,l1110 CFM) CONSTRUCTION TAX
St re ofA •licantl ambecmr J`a �-�`-�- Y%D7t� EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhmdle haardous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532001 HEATING UNIT(OVER 100,000 BTU)
❑Yes No PAID
VENTILATION FAN(SINGLE RFSID) Data Receipt
Will the applicant or fun is
occupant use equipment or devices which
BOILER-COMP(3HP OR 100,000 BTU)
emit herallons air contaminants defined by the Bay Area Air Quality Management - TOTAL: Y
DramcIT
E]yes BOILER=COMP(OVER 100,000 BTU)
Na
I ha
have read the hordo s maudals brain....order Chapter fi 95 of the Cali- AIR CONDITIONER ISSUANCE DATE
1 forms Health&Safety Carlo,Soemax 25505.25533 and 25534.1 undcrsland that if me NEW RESIDENTIAL MECH. SQ.FT.
bui ding I tly�hay5 a meant,hats is my responsibility to no Ne cupant
of ui 'cp7ryjsfhernot "ormissuanceofa Cenifjca`te N, �]/y)�,//,.'�•
wmrorauthon ad agent / Date PP TOTAL: ISSUED BY:
OFFICE