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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO . BUILDING - ELECTRICAL.
. PERMIT, NO. /I
'1O /� n
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
31084
31 VX4
BUILDING PROJF,CT IDENTIFICATION
BUILDINGADDRMS:
-
SANITARY NO,
APPLICATION SUBMITTAL DATE
�a
/10 / J
OWMC: P NH:
CON CTORS LICNO:
NIC
❑
CONTROLh
mA.%
ART/ENGINEERLIC NO
ADDRESS
CONTACT: PHONE:
BUILDING PERMIT INFO
•
❑ Consultant Fees Paid by Applicant(Initial)
BLDG ELECTPLUMBPLUMB MECH
❑ U� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chvpmr 9 (commencing
QTY, ELECTRIC PERMIT FEE
JOB DESCRIPTION
with Section 7l)00)of Divisinn3of Rte Buaineas and lhofessionx Code. vndmyhemaxeis
i.fall fnmeandcffa't.
License Cl a Lie
RESIDENTIAL
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION, ❑ PLUMBING REPIPE
❑MULTI-UNIT ❑STRUCTURAL.
MODIFICATION
PERMIT ISSUANCE
APPLIANCES—RESIDENTIAL
Date - mm
WADE
l underct 1'
%s PANELS
LicensedP ional
OWNER -BUILDER DECLARATION
ON
I hereby air,,. that I exempt from thee Contractor's License law for the
following reason. (Section 7031.5. Business and Professions Cale: Any city or county
UP T02W AMPS
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT
s
❑ BATH REMODEUBEPAIR C] DEMOLITION
❑ OTHER
NII-1"AMPS
OVER 1000AMPS
SIGNS ELECTRICAL
which requires a Permit to construct. alter, improve, demolish, or repair wry structure
priorm its issuance, also requires the applicant for such permiuo file a signed statement
SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions ofthe Convectors License Law (Chapter 9
TEMP. METER OR MULE INST.
COMMERCIAL:
(commencing with Section 70(1() of Division 3 ofthe Business and Professions Code) or
that he is exempt therefrom end the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section7031.5 byony applicant Por. permit subjects the applicant too civil penalty of
t mare than five hundred dors
lla($500).
❑1, ss owner ofthe property. or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered favele (Sec. 7644, Business
❑TENANT ❑FOODSERVICE
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
OUTLETS — SWITCHES — FIXTURES
end Professions Code: The Contractor's License Law docs not apply to an owner of
property who huilds or improves tMreon, and who does such work himself of through
his own employees, providedthat such improvements ..or intended or offered far
sale. If. however, the building or improvement isiold withinone yearafcompletion,the
NEW RLSIDENTIALELECTR SQ pT.
SQ. PT. FLOOR AJEb
$/SQ. Fr
caner -builder will have the burden of proving that he did not build or improve for pur-
P _A
pose of sole.).
❑ 1, as owner of the property, em exclusively contracting with licensed contract s to
conswct the facia, (See 7f,PL Bm usiness and Prafasions CadeJTnm Crarmacm's Li.
cense Law does not apply an owner of progeny who builds or improves thereon, and
R}�1r�•
MAR 12+ RLC'D
-
TOTAL:
QTY PLUMBING PERMIT FEE
who contract. far such pmjects with acontramgs) licensed ps m tmu m the Contractor's
PERMIT ISSUANCE
License Law.
❑ limar.mptumlmsee. ,B&PCforthlsoricom
IiIIY Ur sUr'r h I IN
Date
ALTER — DRAIN & VENT— WATER SA)
BACK FLOW PROTECT DEVICE
VALUATION
'Owner
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
DRAINS— FLOOR, ROOF, AREA. COND.
I have and will maintain a Ceftidcate ofConsentto self -insure for Worker's Compen-
cation, as provided for by Section 37M of the labra Gyle, for the perform... of the
work for which this permit is issued.
IrORIES
TYPE CONSTRUCTION
FIXTURES -PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this perou, is issued.
GAS — EA. SYSTEM -I INC. 4 OUTLETS
IF OCCGROUP
APN
C Workefi5•C�ny�ns.io8eirrance cmrierwi Policy Vu�hc;F!65I / 9
Cartier. V Policy No.: re./" al0'1
GAS — EA. SYSTEM -OVER 4(EA)
CERTIFICATE OF EXEMFUON FROM WORKERS'
COMPENSATION INSURANCE
GRFASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thlssadonnadnot hecomp ¢dlf Na permit is farone hundred dellun($100)
or less.)
GREASETRAP
PLANCHECK FEE
lomifythntin Ne pofo of work fol ihieh this permit is issued, l shall
net employ any Person in any t m bee subject to wk 'i Compen
SEWER—SANITARY—STORM EA. 2W FT.
ENERGY FEF.
section taws of Calif,mia. D
Applicant
WATER HEATER W/VPNDELECTR -
GRADING FEE
NOTICE TO APPLICANT ILa erma is Ccndic a of L'xempdan. you should
,atom,; subject to the War ces Compensation provisions of the Labor Code, you must
WATERSYSTEMOKEATING
SOILS FEE - r
forthwith comply with such provisiarts or this pmnaub,hdl be deemed! revoked.
WATER SERVICE.
NEW RESIDENTIAL PLMIL SQ, FT.
CONSTRUCTION LENDING AGENCY
I herebyaffirmsbat Nem isacanstmcuon lendingagency for the performancem'
PAID
Doe Raeiptk
the work far which Nis permit is issued (Sec. 3097. Civ. CJ
Lenders Name
TOTAL:
Lende,,Address
TOTAL:
BUILDING FEE
1 certify No 1 have read this application and state that Na above informal. is
QTY, MECHANICAL PERMIT FEE
SEISMIC PER
correct.I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby a damiza representatives of this city to enter upon the
PERMIT ISSUANCE
ELECTRIC FIRE
above-mentioned pmpeny for inspection purposes,
(We) agree no save, indemnify and keep harmless the City of Cupertino against
ALTER ORADDTO MECH.
PLUMBING WEin
liabilities,judgments, costs and expenses which may inany way accrue against said City
consequence of the granting of this permit
AIR HANDLING UNIT (TO I0,0W CFM)
MECHANICAL IRE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER If," CFM)
CONSTRUCI'ION'TAX
Signature of Applicant/Contmcmr Data
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOLD(WIDUCT)
HOUSING MITIGATION FEE
HEATING UNIT (To IDkSM BTU)
Will the applicant or future building ocu,nor"tore orhandle haa.dous material
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
Cade, Section 25532(.)7
HEATING UNIT (OVER 110,0)0 BTU)
❑Ya No r
Will the applicant or future building occupant use equipment or devices which
mit haoa air contaminants as defined by the Bay Area Air Quality Management
nN
VENTILATION FAN (SINGLE RESID)
PAID
Dote; Receipt a
BOILER— COMP(3HP OR IOgOfII1BTU)
TOTAL:
BOILER —CGMP (OVER 100,000 BTU)
Dutnn7
C] Yes C] No
-
AIR CONDITIONER
4hhea rr.ten requirements under Chapmrfi95of Ne Cali-
Hem echo Is 505,2553.3 and2s5341arermaandsion if Ne
ata it is my responsibility to notify Ne avcupum
ISSUANwEfomia
NEW RESIDENTIAL MECH. SQ.
1Fs ainm n(p CertlRC tenfOecuF
ISSUED BY:
ent Dme
TOTAL:
OFFICE