31098 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 31098
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BUILDING DIVISION APPLICATION/PERMITL. JPLUMBING
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRE.S: SANITARY NO. APPLICATION^SUBMITTAL DAI
OWNE ' AME: PHONIi: CONTRACCOR'SN ME: 5 LIC NO:
a O NlC CONTROLp
�ARCHITECT/ENGINI3F,R: LIC NO: ADDRESS: ._535,-3o71-3
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CONTACT. PHONE: ,qyy OSP, / f� BUILDING PERMIT INFO
E/�f ,BrrrLo.) y?✓-Z Z Z / El Consultant Fees Paid by Applicant(Initial) B1LLDDG EI�CI' PLUMB SUCH
LICENSED CONTRAC'TOR'S DECLARATION QTY. ELECTRIC PERMIT FEE �\ ;&
1 hereby affirm thin 1 am licenced under provisions of Chapter 9(commencing
O al 2 JOB DESCRIPTION
with Sation]0110)of Division 3 of the Business and Profession,Code,and my license is
FOO in fullforcm an v`if I PERMIT ISSUANCE RESIDENTIAL:
CWF -5353,0'7 ❑SFDWI. ITC({EN REMODEL
RF U U License C a Lic,p
NQ6 Date Contra ct - _ n APPLIANCES-RESIDENTIAL ❑ADDITION ❑ LUMBINGRE-PIPE
F,pro ARCHITECTS DECLARATION PANELS
C3MULTI-UNIT ❑STRUCTURAL
2po,z 1undcraaod my plansshun beusednnpublic records MODIFICATION
024— UP 10 2IX1 AMPS
r'4LW IJttnsed Pfofesxional C1 INTERIOR ❑CHIMNEY REPAIR
Q 2'4 2014000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
C^ C 6 I hcrcby a01mtthat I am exempt fire..the Contractor's License Low Inc the OVER IGAIAMPS C:1 BATH REMODEUREPAIR [I DEMOLITION
O 2 U following reason,ISectinn 703 I.S.Business end Professions Cede:Any city in county SIGNS ELECOUCAL ❑OTHER
4] u.E.y which requires a permit to co uruct,she,,improve,demolish or repair any xwcmre
��OQ prior to its issuance,vlsorequires the applicant forsuch pemuuo file a signed statement i SPECIAL CIRCUIT/MISC.
999rtvt��ss�y that her,liccrcedpunuunno thepmvisiom of the Contfacror'n license Law(Chapter 9
CLQ (commencing with Section](I(Jl.fDivision 3of Ne Bramessand Professions Code)., TEMP.METER OR POLE(NST COMMERCIAL
a la,w C that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.56 an applicant for [I NEW BLDG/ADDITION ❑DEMOLITION
y ndpp permit subjects the applicant to penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
CI
r 2
net mom than five hundred dollar,($SUO).
ESG Las owner of the pmpcny.or my employees with wages as their sole compcmation, SWIMMING POOL ELECTRIC IMP OVIiMENT
Fca will Bothe work,and the structure is not intended oroffered forsale(See 70,14,Business ER
a3 m and Professions Code:The Contractor's License Law does not apply m an owner ml IUTLETS-SWITCHES'-FIXTURES
property who builds Dr improves thereon,and w'ho does such work himself m threugh
his own employees,provided that such improvements ate not intended or offered for NEW RESIDENTIAL HLECTR SQ F'T.
sale.IL however the building or improvement is sold within one year efcompletlon,the SQ. RAREA $/SQ.FT.
owner-builder will have the bunter,of proving that he did not build or improve for par.
putt of sale.). j
1,as owner of the property,mot am exclusively curtaxa ng with licensed contractors a T
nmoe the project(Sec.70c14,Business and Profession,Code:)The Contractor's Li- /
cease law docs not apply to an owner of property who builds erimprove.thereon,and QTY. PLUMBING PERMIT FEE
who convects for such projects with a contramr(s)licensed pursuant to the Contractor's
License law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WA'T'ER(EA) VA ATION
owner nate ^
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
IM1<rcby offirm under(rnuhy of perjury one Df the following Jmlamtionr C.C75 a
❑(have rend will mvinmina Ccnificate of ComemmadLinsuref..Worker's Compere- DRAINS-FLOOR,ROOF AREA,GOND, STDRIE TYPE CONSTRUCTIOt
nation,as Provided fur by Section 3](10 of the labor Cede.for the pertormance of the
k for which this permit is issued. FIXTURES-PER TRAP '
VTy-[�'have and will maintain Workeh Compensation Insurance,as required by Section
.or the labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 DOME3$INRG
My Worker's Compensation lmurany�carrier and Policy numJ+9 OCC GROUT' APN
Came fL i1C! Policy'No.:-� If c?3-57 GAS-FA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE IM'ERC
(This section neednot be completed if the permit is foronc hurMmA dollars($10E BUILIIING DIVISION FEtS
or less.) GREASE TRAP ECK FEEI ccnify ohm in theperfnnnanceofthe work for which this permit is issued,I shallnot employ any persn in any mummer sn aster becomesubjeco,the Workers Compere- SIWER-RATS TARY-STORM It.2z, Applilawsaf California.Dam FEE� WATER HEATER W/VENT/ELECTkG FEE
Applicant
NOTICE TO APPLICANT'.1T,alter making This Cenificam of Exemption,you.should WATER SYSTE U7R EAG
TIN
a ? bece omsubject to the Wurkels Compensation provisions of he Labor Cede,you amt SOILS FEE
forthwith comply with such previsions or Nis permit shall Ne deemed revoked. WATER SERVICE
4 A
5 z CONST RUCTION LENDING AGENCY NEW RESIDENIGAI,PLMB. SQ Fr. PAID
U 0 (hereby affirm that them is a construction lending agency for the performance of Dae Recciptk
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the work for which this pemdt is issued(Sec.3097.Civ.C.)
Lender's Name
U TOTAL:
W Lender s Address
p, I ccnify that 1 have read this application and state the the above information is BUILDING FEE
Vlcs rect.l agree to comply with all city and county ordinances and slate laws renting to QTY. MECHANICAL PERMIT E
U ,z building construction,and hereby.authroeu mpresemtatives of this city to enter upon the SEISMIC PEE.
ra nhrve-mentimted property lot inspection purpnaes. PERMITISSUANCE
1.
(We)agree to save.indemnify and keep harmless the City of Cupcnino against ELECTRIC FEE
r liabilities,judguirev,cos¢and expenses which may many way acemeaionam,aid City ALTER OR ADD TO MECH.
in consequence of the graming of this permit, PLUMBING FEE
APPLICANT UNDERSTANDS ANDIVH WITH ALL NON-POINT l
SOURCER ,ULATIONS. AIR HANDLING UNIT(TO 10.00)CFM7 MECHANICAL FEE
AIR HANDLING UNIT(OVER IO."CFM)
CONSTRUCTION TAX
Signature of ApphrantiContmcmr Uam EXHAUST HOOD(W/DUCT)
HAZ RDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicam or future building occupant lore.,handle hazardous material HEATING UNIT CTO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(,)? HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE RESID) PAID
Will the applicam or future building occupant use eptrundrm or devices which Date Receipt p
mit haeudous air contaminanm as defined by the Bay Area Air Quality Management BOILER-COMPOHPOR IMADOBTU)
^Wrier? TOTAL:
❑Ye.v C]No BOILER-COMP(OVER 100,000 BTU)
I base mad the havallous materials fecuiremems under Chapter 6.95 of the Cali- AIR CONDITIONER
is Health&Safety Cede,Sections 25505 25533 and 25534.1 understand Nat if the ISSUANCE DATE
II I enmtcurtemly have nam.th.
,my msryauibility ar notify the mcupant fNF,W RESIDENTIAL MECH. SQ.FT.
u
th l rcmcntS w t h mutt ounce of a ccrud st�Occy(ypC
authomed agent Dae TOTALy ��
ISSUED BY:
OFFICE
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Customer,
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Addreps Phones - MOM a)
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P.O. Number,
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Orta. Job Num or:
DaoLeads
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SKIP Installation Date
-�_ Ilea C ontrootor#s Coming
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IManl You - Enjoy Stvtl
ng Dates
oripUon Order Ild Due
ROW. Del,
Cabinets A
Cablueta 8
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Custom Hoek A
Custom Nark 8
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- - - ---- vvc; r,o0.514 AMERICAN HOME KITCH PAGE 09
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