31423 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATIONWERMITPLUMBING-MECHANICAL 31423
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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OW':R:SN ME: PNE CONTRACTOR'S NAME: LIC NO:
Chh DHOS52 112L -Cal .LLCpys 632,954 WC (///�}}�..�CO�NTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: �� El
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CONTACT: i PHONE: BUILDING PERMIT INFO
Moony ehvm163 63$3 Consultant Fees Paid by Applicant(Initial) BLDG 11 um MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE /On
;l (
I hereby affirm Lha I am licensed under provisions or Chapter 9(commencing JOB DESCRIPTION
Metz Section7")of Division 3 ofthe Business and Professions Code,and my license is PERMIT ISSUANCE RESIDENTIAL-
in
ClamF full forcLic.M and effect.
aVV License Cl:,,aElSFDWL E3 KITCHEN REMODEL
yzw DateConuacmr APPLIANCES-RESIDENTIAL /<AADDITION DPLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL
Z O-Z I underxwsh
nd my plans all lie uscol as public records MODIFICATION
O Z En G UP TO 200 AMPS
F 4 f'm Licensed Pontoons.) D INTERIOR D CHIMNEY REPAIR
OWNERBUILDERDECLARATION 201-HMAMPS IMPROVEMENT
a W 6 1 henchy affirm that I am exempt from the Contractor's License Law for the OVER 1003AMPS D BATH REMODEUREPAIR D DEMOLITION
XOeF following reason,ISecllon]03L5,Business and I'ndessions Calc:AnY city or county SIC,NS ELECTRICAL DOTHER
y which reyuires u permit m ennarvcl::Jler,improve,Jemolixh,or repair any vwaure
0�
Frorto it, Iso y ob .
II gamem
that SPECIAL CIRCUIT/MISC.licensed pursuant provisions of the Contractor%LicenseLaw
(Chror9
annagh Section DivisionlfB „ aJPl :ions Codc7orW5:m0 TEMP.METER OR POLE N
STCOMMERCIAL
dd
c that he is exempt Therefrom and the basis for the alleged exemption.Any violation of D DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant a civil penally of POWER DEVICES ❑NEW BLDG/ADDITION
F Z} not more Than five hundred dollar($500). D TENANT D FOOD SERVICE
F=G D1.as owner of The property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC ,IMPROVEMENT
it will do the work,and the structure is not imendcdoro(fend for.1,(Sa,70TH.Busitias TH
3 m and frm es m v Codm The Contractors License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pmpeny who builds or improves thereon,and who dries such work himself or mmugh
his own however
The Provided That such mens ise old within ore nm intended or onered for NF,W RESIDLNTIAL ELECI'R SQ Fr.
salowner bower will hhuil hebur improvement itht hidon wild or improve
The $Q.Fr FLOOR AREA $/$Q.FI'.
builder will have the burden of proving that be did rent build or improve for par A.
-
n [.;is
��� t ge{�
I] I,ns owner of the property,am exclusively mimmning with liecnced aimmaars m L: tJ
construct The p tifect(Sat.7144,Business and Professions Code:)The Contmcmda Li-
ame law doesnol apply to an owner of pronerty who build%or infroves thereon,and QTY. PLUMBING PERMIT PEE 8
who contracts for such projeeb with a nmttnaons)licensed pursuum to the Contractor's
Liceroc Law.
❑ I am exempt under Sec. ,B&PC6rthism,snn PERMIT ISSUANCE
IV
Name• D ALTER-DRAIN&VENT-WATER(EA)
f VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE CIFY Ut �� }l�q' �._
I hereby affirm under penally of perjury one of the Brllowfng dalarationr (�uf.�� 1 �t w
CI Ihavcand will mainmina Certificate of ConscmmulGinsurcfor Wohers Compcn- DRAINS- I V(
L L
cation,as Provided for by Section 37X1 of the Labor Code,for the performance of me FLOOR.ROOF,AREA.GOND. STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Lobo Code,for The peAonumme of the work for which this permit is is...of GAS-EA.SYSTEM-I INC.4 OUTLETS pry OCC.GROUP
My Workers Compensation Insurance carrier and Policy nvndar are: APN
Carrier: Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CF.k'TIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WAMINTERCE"ORIlliis.uct ion need not T completed if the pemtil is for one hundred dollars(SIW) BUILDING DMS NFEES
Iesc.1 GREASE TRAPPLANCHECK FEELoy any Ola in the performaany=oncso stohe ork for Iscromewhbject t.c permit isis 'ed,TonsilCounter- SEW17R-SANITARY-Soat employ any person in any manner so as m become subject ni me Workers Compere- ERGY FEEZration laws of Cnlifnmia.Date WATER HEATER WIN S4 O ApplicantZ r GRADING FEE
NOTICE bi APPLICANT:IL afar making This Certificate of Exemption,you should WATER SYSTEMYT EAbooms suomp m the Workers Compeor this provisions of the Lahr Cade,you mustSOILS FEE
� Q
forthwith comply with such previsions pctmii shall he deemed revoked. WATER SERVICE
a
Uz CONSTRUCTIONLENDINGNGAGENCY NEW kESIDENTIALPLMB. SQ.Ff. PAID
L) O If whirffirmi Pemere iillmd(aue.30lending agrncyfonhe performance of Recciptp
V.0 F the work for which This pemtil is issued(Sec.3099,Cr,Cd
Lenders Nonce
Wbenders AJArees T TOTAL:
y 1 ccnil'y Thai I base read this application and state III;,,the above attenuation is
BUILDING FEE
ti conecl.l aster menlnPly with an city and county orJinanan onA.vute cows relaingm QTY. MECHANICAL PERMIT FEF, r
L) Z building cintareinn,and hereby authorize repreaentaivesofthis city wenrerupuraw SEISMIC FEE
r
above mentioned property for inspection puryorsa. PERMIT ISSUANCE
(We)agree hs save,indemnify and keep harmless the City of Cupenino against ELECTRIC FEE
liabilitics,judgments,costs and expenses which may in any way accrue againsssaid City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0
SOURCE REGULATIONS. 00 CFM)
MECHANICAL FF;
AIR HANDLING UNIT(OVER TO.”CFM)
CONSTRUCTION AX
Slgnaurcaf ApphcanVCommaor DateEXHAUSTHOOD(W/DUCq
I IAZ RDOUS MATERIALS DISCLOSURE HOUSING MITIGATION IEE
Will the applicant or future building occupant Blore or handle hazardous material HEATING ON]I(TO I W."BTU)
Its defined by the Cupertino Municipal Coofe.Chapter 9.12,and the Health and Safety
Code.Section 255320ir1 HEATING UNIT(OVER I W,IXMI BTU)
• ❑Yes DNo
VPNTIhA'I'ION FAN(SINGLE.kESID) PAID
Will the applicant or future building by the B use ea Air Qu or JM'ana which Dam Recei #
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP CHIP OR 100,000 BTU)
District] TOTAL:
❑Yes ❑No BOILER-COMP(OVER 100.1100 BTU)
AIR CONDITIONER I L
1 have read the hazardous macd S S,25533 ms under Chapter ti 95 d That
Calle 1 ISSUANCE DATE
fomia Health&Safety Coda.base
25505,3533es,3Af.I undersand that if the NEW RESIDENTIAL MECH. SQ.Fr.
building docs not iscurrentlywhich have a reasons,p mal o is ca responsibility ca e o fy the occupant
of the mryircments whits muni be ma prior m iswatxe ora Ccnificam of Qcupancy.
Owner or authonud agent Date ALS ISSUED BY: J
OFFICE