31031 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMIT NO. 31031.S11 O^`{Jas
11
BUILDING DIVISION APPLICATION/PERMI•C PLUMBING.MECHANICAL. 31
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO, APPLICATION SUBMITTAL DATE
OWNS AME: p}I N§ C s T 'S NAM CN
:JL 5- 141-1- NIC
CONTROLp
ARCHITECUENGINEER: LIC NO: ADDRESS: a
�a.a,� ?19ID.
CONTACT: asiaot ' - PHONE: BU ILDINGPERMIT•INFO
❑ Consultant Fees Paid by Applicant(Initial) BLD EL r,, PLUMB MEr/I
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE k4h1 riUFi
2 1 him by affirm Nast 1 an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Ihsfrum IN )ef 3ofthe Businessand oeesions Cod,and my license is RESIDENTIAL:
�O wt x PFiRMi'f ISSUANCE full tome and eR !
�FUZV License Class s n Lica ❑SFDWL ❑KITCHIiN REMODEL
NQS DatesqlCnnvannr APPLIANCES-RESIDENTIAL ❑ADDITION - ❑PLUMBING RE-PIPE
[F-spy ARCHITECTS DECLARATION PANELS ❑MULTI.UNIT ❑STRUCTURAL
x O 5 7J 1 understand my phms shall he used as public records MODIFICATION
pZees UPT02MAMPS El INTERIOR • ❑CHIMNEY REPAIR
�4 MLicensed Professional 201.1000AMPS IMPROVEMENT
0.{'' OWNER-BUILDER DECLARATION
W Q I hereby afrrm that I nm exempt from the Contractors License Law for the OVER IWOAMPS [I BATH REMOUEIIREPAIR [I DEMOLITION
bei U t'ullowingmason.(Section7031.5.Business and Professions Code:Any city ,,counlySIGNS ELECTRICAL
[]OTHERLLLLa.77
11. which which reyuims o permit to constmm,ober,improve,d1mori sh,ce repair any snooze
Ho
prior to its issuance,also requires the applicant far such permit m file a signed statement SPECIAL CIRCUITNUSC.
5A 9. that heirlicenacdpu....___
the pro visions of theeBusiness License WwlC Code)
;hammeneingwiNSereiromadth basis for
oftheeged essanJon.Any
Cale)or TEMP.METER OR POLE IN52 COMMERCIAL:
that he is exempt Zany a oat and the basis for Ne ch;the
exemption.Any violation of ❑NEW BLDG/AUDITION El DEMOLITION
Y•
Station 703 LS by any applicant fora Permit subjce¢Ne epplicammacivil Penalty of POWE0.DEVICES
y ❑TC ❑FOOD SERVICE
nal more than five hundred dollars($SW).
F�>' IMPROVEMENT
p < wi Lo the vara!Ne propeny,re my atimimttswiNwegesas Neirsole 0,----m-i--- SWIMMING POOL ELECTRIC
will dofework,and the heCo structure Licens nr offdoes not
to an,Business ❑OTHER
and Professions Cade:The Contractor's License Law Jbci not apply to an owner of OUTLETS-SWITCHES-PIXY S
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such.improvements are not intended or offered for NEW RESIDENTIAL ELECfR ' FT.
sale.If,however,are building or Improvement is sold within one yearofeompletion,the SQ.PF.FLOOR AREA $/SQ.E-n
ownw,builder will have the burden of proving that he did not build or improve for put-
pose of sated.
❑ 1,unero
r of the ppeny,am exclusively contracting with licensed convenors to TOT
i —
V.
cinstruct the (Sec.7014,Business and Professions Code:)The Contractor's Li-
cense law does not apply to an owner of property who builds or improves Neuron.and QTY. PLUMBING PERMIT �EE
who contracts for such projects with a cnntraaons)licensed pursuant to the Contractor's ,
License Idw. PERMIT ISSUANCE
C3I um exempt under Sec, ,B&P C for this reason -
Owner Data ALTER-DRAIN&VENT-WATER(EA) ypLUAT10N-
WORKER'S COMPENSATION DECLARATION
'BACK FLOW PROTECT.DEVICE
1 hand willTmai under Certificate
perjuryencofthefollowing declarations
ns:
❑(have and idedfll orbyneCion 37 re of are ent Labor Code,
for to performance
eceuipan-of
DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
nation,as provided for by Section 3]W of the Labor Caiq far the performance of the
0i for
hfor which Nie permit is issued. FIXTURES-PER TRAP
have and will maintain Worker's Compensation Irk for h,It required by Section
3 Wnf the Labor Cala,for One penormonce ofthe work for which Nis ermit is issued. GAS-EA,SYSTEM-I INC.4OUTLETS OCG GROUP APN
My Worksy�yE p�Jn�sutry��ptce currier unJ Policy V GAS-EA.SYSTEM-OVER 4(EA)
Carrier. ( /AIM( PNicy No.: B
' CERTIFICATEOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE.INTERCEPTOR
BUILDING DIVISION FEES
(This vection need notbemmplemJ ifthcpermit is fornne hundred dollars(pled) GRF.ASETRAP s
or less.) PLANCHECK FEE
(certify that in performance of the work for which this permit is issued,lshall SEWER-SANITARY-STORM EA.2W IT.
not employ any person in any manner m as to become subject m Ne Worknk Cmnpem - ENERGY TEE
Z xation Paws of California.Data z WATER HEATER WNENT/ELECTR O Applicum � � - GRADING E
(n NOTICE TO APPLICANT.If,alter making this Cenlfic br of Exempt on,you should WATER SYSTEM/TREATING
i~ became subject to the Worker's Compensation provisions of the Lobar Code,you must SOI
im
forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
UJ 2 5 BID
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMSQ.FF.
V 0 D.I hereby affirm that is a convection lending agency for the performance of Y U—fDU,, H psis
the work for which this permit is issued(Sec.3W7,Civ.C.) _
Qf~ Lcnd,ex Name - TOTAL:
L) tender's Address TOTAL:
I certify that I have read this application and ,are Not Ne obeve Information is BUILDING FEE ..
o-_sIn cunect.l agree to comply wiNall city and counryerdimnces and state laws relating to QTY. MECHANICAL PERMIT FEE
L)4 building construction,and hereby authorize representatives in this city to enter ulvm the SEISMIC FEE
above-mentioned property for imitation purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and kelp harmless the City of Cupertino ogaimt MEELeCIRIC e
liabildies,judgmems,costs and expenses which may in any way aceme against said City ALTER OR ADD TO MECH.
in emmequence of the painting of this permtiPLUMBING FEE
APPLICANT_114DERSTANDS AND WILL COMPLY WITH ALL 0 POINT AIR HANDLING UNI I(TO 10.000 CFM) MECHANICAL IEE
SOUR • G(LATIONS.
AIR HANDLING UNIT(OVER 10,00IClad) CONSTRUCTION TAX
Signal of ApplicansCenhuctm Date/ EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE "
Will the applicant or future building occupantntam or handle hazardous material HEATING UNIT TO I00,000 BTU)
as defined by be Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 253320)? HEATING UNIT(OVER 100.000 BTU)
❑Yes XNo VENTILNUON PAN(SINGLE RESID) PAID
Will thea applicant or future building t use component or devices which Date Receipt 0
pp d by the B equip BOILER-COMP QHP OR I W,(loll BTU)
emit havvduos air mnmrrdnents as defined by the Bay Arce Air Quality Management TOTAL:
DiancR
11 Yes BOILER-COMP(OVER IW,00)BTU)
„
AIR CONDITIONER
1 have read the horrendous materials requirements under Chapter 6.95 of the Cali ISSUANCE DATE
forma Health&Safety Code,Sections 25505.25533 and 21534.I understand that if the NEW RESIDENTIAL MECH, SQ.ET.
buildingdoe currently have a tenant that it is my responsibility to notify are mate aut L(O
of to w ich must be met prior to issuance of a Camfeat Df
^.
rte n u agent ale TOTAL: ISSUED BY:
OFFICE