31006 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. - PERMITNO. ^ �OO^FVs
BUILDING DIVISION APPLICATIONIPERMIT - PLUMBING-MECHANICAL JK
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: , SANITARY NO. APPLICATION SUBMITTAL DATE
OWNF 'g � CO CfOR' N /' - r/+F IC NO:
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.�sRC E CNEER: 0
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CO Gr' PHONE: 0fPJ7 BUILDING PERMIT INFO
/a/ Gzj ❑ Consultant Fees Paid by Applicant(Initial) BDG ELECT PLUM ME
LICENSED CONTRACTOR'S DECLARATIONQTY. ELECTRIC PERMIT FEE
1 hemby affirm Nm I em Imensed under pro.atone of Chapter 9(commencing JOB DESCRIPTION
FWOZ with s«uon]oW)of DrvismnJufthe Bustneas end Rofesvons Code,wd my liccnu is r71 RESIDENTIAL
w O in full force and effect PERMIT ISSUANCE J V
scut Licenm Lic.a� y SFDW L [3 KITCHEN REMODEL
rF�a Date�=.�—Conuact., Af'PLIANCFS-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
y ARCHITECTS DECLARATION ❑MULTI-UNIT ;'' ❑STRUCTURAL
O Z J Z 1 understand my plans shall be used u public escorts PANELS MODIFICATION
OP TO 200 AMPS El INTERIOR ❑CHIMNEYREPAIR
Licensed Professimtal 201-IsMAMPS IMPROVEMENT
p$JJ OWNER-BUILDERexempfrom
DECLARATION OVER IWOAMPS ❑BATH REMODEUREPAIR �DIiMOLITION
fy 6 I hereby aRrm Net 1 am exempt from Ne Commcmrs License Law for the
X a
Q.U following Section]031.5,Business and Professions Code:An cit y SIGNS ELECTRICAL ❑OTHER
W g mvsov.f y y or count
LL 'which rtyuires o permit to umawct alter,improve,Jcmolish,nr repair any meucture
� Isorm im issuance,elsoreyuires the applicant mrsuch mortal Iofile o signed smtcment SPECIALCIRCUI
VW
Shy theithe is licensed punuara othe proviaionsofthe Convector's License law(Chaptert)
0 (cummencingwiNSenion]WO)of Divisionlofthe BusincasandP Amsions Code)or TEMP, ER OR LE T. COMMERCIAL:
6 c K
unit he is exempt Nerermm and the basis lou the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Ir•
Section 7011,1 by any applicant for aperultubjecu the applicam w o civil penally or POWER DEVICES k,�ms�!!
^m - �(IEIVANT ❑FOOD SERVICE
F Z Y not mum than five c prop dolman y 50%employees
6 wiLo the work,and
propcnctu myyemployded wiNwages azale(Se.compensation, SWIMMING POOL ELECTRI IMPROVEMENT
O will daNcwork,anJNe awmareiatnot intaens oroffemstdo for sale(Sec.7U_business ❑OTHER
and Professions Code:The Contractor's License law docsnm apply to an owner or OUTLETS-SWITCHES-FIXTU0. s 2�
3 r progeny who build,;or improves thereon,and who does such work himself or through
his own employees,provided Nat such improvements are not intended or a@red roe NEW RESIDENTIAL ELECTR Q
sal,If,however,the building or improvement is sold within one yearn(completion.Be SQ,FT.F"Bilk S/SQ.FT.
ownervbuilder will have the burden of proving that he did not build or improve fur put- Y''
pose of sale.). -
1,as owner of the property,am exclusively convecting with licensed contractors to TOTAL: u..S ��
onstenct Ne projut(S«."/044,Businne anJ ProfessionsCodeJ'I'he Conte«tors Li- MAR 7
ase Law does net apply to an owner ofpmpeny who builds or improves mirem,nad Q'rY. PLUMBING PERMIT FEE
who contracts for such projects with a convacmns)licensed pursuant to the Conwcmr's '}ty
License Taw' PERMIT ISSUANCE Cll l Uf• uUt"LKf'IN
❑ I am exempt under Sec. .B&P C for Nma
is son
Owner Date
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DI3VICE ��t
1 hereby Affirm under penalty of perjury one of the following declarations
•0 l have and will maintain a Ceratiate ofCmaem to self-insum fur Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND.
sation.as provided for by Section 37W of the Labor Code,for as,Perron nee of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PERTRAP '
1 have and will maintain Worker's Compensation Insurance,as requital by Section
)mfthe Labor Cott,for the perfofmance of the work for which this permit is issued, GAS-EA.SYSHIM.I INC.4 OUTLET OCC.GROUP Af'N
My Worker's Compensation Insurance carrier and Policy mamba,ort:
Cattier. Policy Net.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF.ASEANDUSTRL WASTE I MCEPfOR
(This section neednot be completed ifthe Parodi is forone hundred dollars(5100) BUILDING DIVISION FEES
or less.) GRIASE TRAP PLANCHECK FEE
1 certify Not in Ne perfurmenceaf the wmk for which Nis permit is issued,LNall
not employ an A to become subject to the Workers'Cum SEWER-SANITARY- RM EA.2(XI FT.
p y yperson in any manner ) pen- ENERGY FE[ vO
Oz sari..Laws of Cut fomiA.Duro
Z Q Applicant - WATER HEATER ENT/L'LF.CTR
GRADING FEE
fp NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTF REATING
(, become subject to the Worker's Compensation provisions of the Labor Cade,you must -�� 'SOILS FEE
0. forthwith comply with such pmesiams in Oticpermit shall he decmedm—ked, WATERS ICES/�
�z CONSTRUCTION LENDING AGENCY NEW IDENliIALPLMB. SQ,PT, PAIDUma /
Ll0 l hereby affirm dust there is a construction lending agency for performance of eve". 'R
Othe work for which this Penni[is issued(Sec.309],Co,C.) /
Vheaders Name - - 'IV'1'AL:
i<ndcrs Address TOTAL:
As o 1 certify that I have rued Nm N
is application and State the above information is BUILDING FEE Q
Ill c nen.I agree it,comply with all city and county ordinances and nam laws mating to QTY, MECHANICAL PERMIT FEE
U building construction.and hereby euNonx representatives ofthls city to enter upon the SEISMIC FEE -
above-mentioned Property for inspection purposes. a
(We)agree to save,indemnify and keep familiesNe City of Cupertino against PERMIT ISSUANCE 3 �5_0 ELECTRIC FEE a Z
liabil'nics,judgments,costs and expenses which may in any way Accent against mid City ALTER OR ADD 10 MECIL'
in consequen«of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
C '
Sf REG MECHANICAL FEE- &.q-7 AIR HANDLING UNIT(OVER IBIXs)CFM) CONSTRUCTIONTAX
Signorinas o AppiicantlConlraomr Date EXHAUST HOOD OMMUCT) HOUSING MITIGATION FEB
HAZARDOUS MATERIALS DISCLOSURE
-� Will are applicant or future building occupant stare or handle hazardous material HEATING UNIT(TO 100,100 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health And Safety -
CWA.Section 25532ho' HEATING UNH T(OVER UM00O BTU) Aas
E]Yes ;Nm PAID
VENTILATION FAN(SINGLE RIES ID) ate ReceiptX
Will the applicam or nature building occupant use equipment or devices which
t hardous air contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(3HP O11 100,10y)BTU)
aa
01inrict9 TOTAL:
C]Yes `.L.a BOILER-COMP(OVER 1110.00)BTU)
I have red nNe hazaNrlmdsCmsedids myWmments tender Chapter 6.95of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code.Sections 8505.25533 And 8534.I understand Nat if an NEW RESIDENTIAL MECH. SQ.FT.
buildin don nca currenit havea1 4 that it is my maponsibility m notify the upant
of Ne cots et m issuance of A Cenific m of Oce cy.
Own uthenzd agent Date TOTAL: 701 ISSUED BY:
OFFICE