31505 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES—USE BALL POINT PEN ONLY
CITY OF CUPE RTINO BUILDING.-ELECTRICAL. PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
21 cl 0 ph Ld 1\-a-il
OWNER'SN E PHONE: CONTRACTOR SNA LIC NO:
NIC CONTROL
ARCEIITECIII ied INEF:R: LIC NO. gODR_S. ❑
CONTACT.. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ElLICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby of i ren that 1 am licensed under provision..of Cmmer 9 aammmdn9 JOB D SCRIPTION
QWO,=Z with Section 1000)of Divislon3 ofthe Business and Professions Code,mdmylicenseis RESIDENTIAL:
F-1= in full forcernl effect. PERMIT ISSUANCE ❑SFDWI, ❑KITCHIiN REMODEL
aUU Ciccone Class hic'M APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
F Z 6 Date Cunlnctor
'�
V' ARCHITECT'S DECLARATION PANELS ❑MULTIUNIT [I STRUCTURAL
F
Z C In Z 1 unJennnd my clan.sM1:JI R u.ad sax public runmis MODIFICATION
C Z� UP TO 200 AMPS
I:.4Fuud Licensed Professional L1 INTERIOR ❑CHIAfN1iY RF.I'AIR
201-If1IX)AMPS IMPROVEMENT
Y f'� UWNER.I{UILDIiR DF;ChARAI'ION OVER 1000 AMPS 11 BATH RHMOOLWEPyR EMOLITION
o w< 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
C c6 U following moan,reasons 7031.5.Business and Profcsxions Calc Any city or county"F which requires a permit to construct,ulor,imprnse,demolish,or repair any suucmre
E�'LL'C en
pdorto its issuance,also requires the applicant for uch permit to file a signed srtermat SPECIAL CIRCUIT/MISC.
pa�} that he is licensed pumuanfto the provisions ofthe Contractors License Law(Chapter 9
W GD (commencing with Section 900(tof Division Sol'the Hunineas anJ Pro2ssiens Code)or TI?MP.MIT I'ER OR POLE INST. COMMERCIAL:
a d Q y than he is exempt therermm and the Msis for the alleged eacmption.Any violation of EW BLDG/ADDITION []DEMOLITIONX^u. Section 7031.5 by any applicant for a Permit subjects the applicantto a civil penalty of POWER DEVICES
alum ❑ 'h N'I' [I FOOD SERVICE
intrinsic than live due
M,x dollars y amp. IMPROVEMENT
=O ❑Lo the work.the pe smoct r myemployeeswtowages
red for ale(Se le compensation. SWIMMING POOL F,LECTNIC
F
will eo thework,and the he Contisnot intandrim,Law does not apply
Business ❑OTHER
6 3 m and ProRsno b Code The Qmatrmmre License Law does not apply to if owner of OUTLETS-SWITCHES-FI%TURP,E
property who builds or int t s thereon,and who aces such work or or through
his own employees,be do, that psuchrov improvements are not intended fcser placd for NIiW RESIDF,NTIAI.ELECfR SV FT
owner-bower. will
boll dmburden of
that hewithin on build or improve
the � SQ.IT,FLOOR AREA fISQ.f4.
pma.buileer win nave the Women of Proving that he did not build or improve for pur-
e of xmenc
❑I,as owner cal be Sec.70,1,vat Business
ine sivald contracting with li The Contractor's
tat Tense
consumerthed es not Jett apply
Iowa,owner
of and rty wh profession,Code:)The contractor's Li- ,/v1
who
wdts forschpytoa nwnermpmporty who bud pursuant to
thereon.and Q'I'Y. PLUMBING PERMIT' ,E
win tommer rat noon projects with a comracmd.)licensed pnrnaam m me eomncmra
License law. PERMIT ISSUANCE
Of to Z pride,`ec. , r / ,B&I P C lin this reason
Owne, n� s JL4 Zh ALTER-DRAIN&VENT-WATER Hiss) VALUATION
I� VlORKER'S COMP17NSATION DECLARATION�C BACK FLOW PROTECT.DEVICE
1 hereby mina under penalty of perjury one of the following dcclarafirms:
❑ Ihave and will maintain aCmiOcae nfConmmmttllinsum fur Worker's Comlen- DRAINS-FLOOR.ROOF,AREA.COND. TYPECONSTRUCTION
ration,an provided for by Section 37W of the labor Calc,for the performance of the
work for which this serinit is issued. FIXTURES-PER TRAP
❑I have aM will maintain Wmkcra Compensation Inmn er,u ngnired by Section �+
37W of the Labor Code,for the per6nmaceof the work for whichthis permit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS
OCC. OUP
My Worker's G�mpcnsmion Insurance conic Poicy No.:numhcr sem:
Curie[ Polity No.: GAS-EA.STSTFld-OVER4(EA)I' O L
CERTII'ICATEOI'EXEMPTIONI[ONIIWWORKERS'COMIiNSA'1'ION INSURANCE GREAeI%INWSTRL WASTE INTERCEPTOR
'ISION
(This ratios nee¬ to completed ifthe permit odor ma,hundred Jolles IS I W) TIDING DRFEES
or Its+.1 GREASE T RAP PLANCHECK IEE
I certify that in the performance ofthe work fisrwhich this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
wt employ my person in any manner so u to become subject m the Worker'Convince. ENERGY FEE
z ,Z ration luwsorctlifnmiu.Date WATER HEATER W/VEN'PHLEC'IR
Applicant GRADING FEE
.N.. NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,you should WATER SYSTEMCTREATING aSOILS FEE' Executive subject to the Worker's Compensation provisions of the Iattor Code,you must
Qforthwith comply with such Provisions or this permit shall be deaned revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
a
U O I hembyuBirm that Nem is a construct inn lending agency for the perfonnaraceof Dae ReceipN
V. F the work for which this permit is issued(Sec.3091.Civ.C.)
C) U Unders Name TDIAL:
(S] lenders Addre, TUTAL:
ps 1 emify that I have mad this application and emte that the above information is BUILDING FEE
fn correct,1 agree n.comply with all city and eouny on inances:red state laws relating to Q'ry. MECHANICAL,PERMIT FEE
U Z building cunstiunion,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-menioned property(or inspection purposes.
(We)agree to save,indemnify and keep harmless the city car Cupertino ngain.st PERMIT ISSUANCE ELECTRIC FITE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTERORADDTOMF,CH.
in conacnuenca or the grating of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON[*[(TO 10,000CFM) '
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONS1'RUCTIONTAX
Signature of ApplicantCcomector Date EXHAUST HOOD(WOUCD HOUSING MITIGATION FEE
MATERIAL S DISCLOSURE
Will theapplicnnt or future building occupant tote car handle bumrdous material HEATING UNITED I W.000 BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,media Health and Safety
Cade,Section 25532W)1 HEATING UNIT(OVER 1 W,IXIp BTU)
❑Yrs [-1 No VENTILATION VEILATION PAN(SINGLE RESID)
r Will Net applicant or future building t use t or device:which Dute RmcipU
pP gby loth enu it Qu HOILER-COMP Q HP OR 100,00 B'CU)
mit District?
ous air commninunu sae def nnl by slit IIaY Anent Air Qualify Mnnvgannn TOTAL:
Dis ct!
C3 Ye. ❑No ROILF.R-COMP(OVER 100,001)BTU)
I have dad the havudous matedab renimments under Chiper 6.95 of the Calm AIR CONDI I TONER ISSUANCE DATE
fomia Health&Safety Qdc,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ,FT.
boilding does notcurrently hovertenumt.NwIt is ny mxpumihilny er notify dwoweupamt
of the nnuirements which must h,met prior to issuance ofa Certificate of Occupancy.
Owner m mthorimd ogcat Data TOTAL: ISSUED BY:
OFFICE