31440 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY '
CITVOF CUPTyRTINO BUILDING-ELECTRICAL PERMITNO314(,
. ^ .g A /1 O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT mr.srnncm[ON
BUILDPj'iADDREL+, SANITARY NO. APPLICATION SUBMITTAL DATE
NGR'S NAME: PHONIi: 11, ONTRACfOR'S NAME: LIC NO:
\ q�
NC CONTROL%
ARCHITECT/ENGINE : - LIC NO: R
eco y30 M— 011-
CONTACT. PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG T. PLUMB M!
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
G C z -I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
with Section](lU]7 of Division 3 of the Business mtl Pmfessionx Ciale,and my litcnveis
+„4wp - RHSIDENTIAL:
in Fall force and effect PERMITISSUANCE •
�VV License Class Lic.p ❑SFDWL ❑KITCHEN REMODEL
F-<i Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z p�j Z - I understand my plans shall be,omit as public records - MODIFICATION
Oz—pp` UP TO 200 AMPS C1 INTERIOR ❑CHIMNEY REPAIR
Y4 Licensed Professional 201-1000AMPS IMPROVEMENT
Y6 Oat I am exempt
from
m the Contractors
OVER IOW AMPS ❑BATH REMODEUREPAIR 0 DEMOLITION
1 hereby affirm that 1 am exempt from the Cnmmnor'x License Law for Nc
3:0 d U following reason.(Section 7031.5,Basilicas and Professions Cade:Any city or county SIGNS ELECTRICAL []OTHER
41=Ca which requires a permit man
tstme,alto,,improve,demolish,or repwm
air any scta
.i pdarmi.elasnce.0...respires theapplicmt for such pewluo file a signedstmemeat SPECIALCIRCUI TSC.
vWl pN., that heElittnm0 pursuanuo dte provision of the Conwc[ole License Law(Chapter9
Cad frommencing with Sermon]000)of DivicianJalthe Business end Profcssinns Code)or TEMP.METER OR POLE COMMERCIAL:
0.^Oo N Net he is exempt therefrom and the basis for the alleged exemption.Any sodiuon of C NEW BLDG/ADDTG EMOLITION
m LG4 Section 7011.5 by any applicant for u pewit sohjcns the eppliermt to a civil penalty of P(l^m []TENANT ❑FOOD SERVICE
z} not mort Nan rise
' �p0 hundred SSW
C]Lnowner ofthe Pepany,or my
employees wird wages as their sole compensation, SWIMMIN 'OOL IMPROVEMENT
will du the work,and the swcture is not intended oroffeted for sale(See 7 4 .Business COTHER _ /_/y7�
3 and Professions Cade:The Contractors Literate Law docs net apply to an owner of OUTLETS-SWI ES-FI .— -[ -
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 HLMkR SQ PI'. 1
sale.If.however,the building or improvement is sold within one yearofcompletion,the R REA SISQ.TO..
enbuilder will have Be burden of proving that he did not build or improve for pm-
prose of sale.).
C I,as owner of the propeny,am exclusively commeting with licensed convadms to TOTAL: •I xJ ����
smour ct the project(Sec.71194,Business and Prefbasions CMe:)The Continuities - •L `•t
omse Law does not apply to an owner of property whit builds or improves thereon,and QT'Y, PLUMBING PERMIT FEE
whomntmms foramen prefectswith acontmmnot Iicenaedputsaunnothe Contractors INSt�
License law. PERMIT ISSUANCE f EC ION
C 1 an exempt under Sec. .B&P C for this rcawn ❑ DEFgR
Owner pate
ALTER-DRAIN&VENT-WATER(fid) UI FY OF F�TI�6 VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE f,1
t thereby aIT, under penalty offertory one of Ne fallowing declarations: IOdd
❑1 have and will mountain aCertifcate of Conscm to self-insure for Workers Creeper- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3700 of Ne Labor Code,for the forbearance of the
work for which this pemtit is issued. FIXTURES-PERTRAP -
C 1 have and will maintain Worker's Compensation Tro muce,as respired by Section
3700 ufthe labor Code.for the performincmf the work for which
this Permit is issued. GAS-EA.SYSTEMA INC.4 OUTLETS OCGGROUP APN
MY Wark! mpeugaiionln -enj p and Policy No.:ElQ1� GAS-P-A.SYSTEM-OVER Carver. �! .CCA. -'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRBASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION THUS
(This rection need nit be completed ifflue permit is forenehunttreddullars($Imp
or less.) GREASE TRAP PLANCHECK FEE
leenifytharm,hepedonnan..fro,work far which this pe wit is issued,f shall SF.WF,R-SANITARY-S'IY)RM EA.2W IT.not employ any person in any manner wax to become subject to the Wod:ery Compen- ENERGY FEE
Z,'Z anion laws of California.Date WATER HFATER WNENT/ELECTR
O Applicant - - GRADING FEE
)r NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should WATER SYSTEM/IREATING SOfI 9 FEE
become subject to the Worker's Compensation provisions of the Labor Code,you must
fi comply witbiach provisions man,permit shall be deemed revoked. WATER SERVICE
Q
CONSONLENDING AGENCY NEW RESIDENTIAL TIME, SQ.FT. PAID
z' Thereby affirm that thereem is is aComwnion lending agency for the perfurman<e of Dam Receipt
L) 0 the work for which this Perini[is issued(Sec,3097,Civ,C.)
W I'+ Tinkled',Name TOTAL:
L) Lender's Address TOTAL:
Y WBUILDING FEB �/
(r I ccnify That 1 have read this application and sem that the above information is
V) correct.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
G 'Z building construction,and hereby mNorixe representatives ofthis city to enter uPon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE(We)agree to save,indemnify and keep humorless the City of Cupertino against ' ELECTRIC FEE
buthilides.judgmeas,cotroul expenses whichuray in any wayaccrueagainst said City ALTERORADDTOMECH.
in constism.of the gaming of this permitPLUMBING FEC
ry
APPLICANT UNDERSTANDS AND WILL COMPLY WITT(ALL NON-POINT AIR HANDLING UNIT(TO 10,1100 CFM) MECHANICALFEE
AU$��TJJREG}�LATIO 5
I r/ ^ //_ AIR HANDLING UNIT(OVER 10,(X1(1 CFM) CONSTRUCIONTAX
Si nature of Applica onvac or Date EXHAUST'HOOD(W/DUCT) HOUSING MITIGATION FEE
IAZARDOUS MATERIALS DISCLOSURE
Will Neapplicantor future building iscupmt store or handle haaardom maternal HEATING UNIT UG 10001X1 BTU)
n defined by the Cupertino Municipal Gxk,Chapter 9.12,and the Health and Safety
Cade,Section M532m)? HEATING UNIT(OVER I W,000 BTU)
❑Yes 0N VENTILATION FAN(SINGLE RESID) PAID Dale Receiptp 1
Wit)um ippliientlo,future building accupon use cgaipment or devices which BOILER-COMP(JHPOR IW,000 BTU) 1
emit bamrdow air commentators as defined by Ne Bay Area Air Quality Management TOTAL:
District? BOILER-COMP 100,000 BTU)
❑Yes ❑No - .
I have real the haaallops motends teyuircmcntnder uChapter 6.95 of that Cali- AIRCONDITIONER
ISSUANCE DATE
forma Health&Safety Code.Sections 25505,25533 and 25534.1 undersand Nat if the NEW RESIDENTIAL MECH. SQ.FT
building muses not currently haven tenet that it is my responsibility to notify the occupant
of the requirements which must The,ren prior to issuance of a Certificate of Occupancy. ^r��
Ownelmathlonledagent Dam TOTAL: ISSUED BY:
OFFICE