31323 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL. PERMIT No. 3 q 13 L 3 2 3
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. �KJ
BUILDING PRO3P.CT LDRNITF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAG
-7,5-41 i4T�OC+� O2
OWNEU NAM 'ECT'/� CONTµQRRACfOR'S�pdA�M/P��• ISCONTROL a
ARCHITGICL/HRG/c.a/G_G�I LIC NO A`IJS�J9•G/C.�/r/'NK4.�1'6/U,.oAv� ❑
CONTACT. PHONE:
• BUILDING PERMIT INFO
❑ COnsultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED COM'RACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I herehy vffirm than 1 am licensed under provisinns of Chapters)(commencing JOB DESCRIPTION
CG with Semina]1XX f Division?of the Boniness vnd Prnfusninns Code,wJ my licai.zc in PHRMITISSUANCE RESIDENTIAL:
F er� nfullforceas efl _3� /Q ❑SFDWL F1 KITCHEN REMODEL
tI-U V License C ass Lic.a �,,��
toes Date Contmcmr' API'LIANCLS—R[SIDIiNTIAL ❑ADDITION �Q- BBING R&PIPE
ARCHITECTS DECLA ATION ❑MULTI-UNIT OSTRUCTURAL
z p r y7" understand
I my plans shall he used as public stands PANELS MODIFICATION
Oz- UlIT02WAMPS El INTERIOR ❑CHIMNEY REPAIR
r iw,• Licensed Ro mmicnal 201-1000AMPS IMPROVEMENT
gOWNER-BUILDER DECLARATION OVER 11100 AMPS
pp,W I hereby affirm that I am exempt from the Camowoo's License Law for the ❑BATH REMODEUREPAIR ❑DEMOLITION
X 3 t U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER is
YY1I Y. which requires a penNt to construct alter,improve,demolish,or repair any swcmre
O P60Tto its issuance,else requires the applicant for such Permitto file a signed statemem SPECIAL CIRCUIT/M ISC.
} that he is licenxd pursuant to the provisions of Ne Contractor's License law Chafers?
(commencing with Section 7001 Division 3 of the Business and professions Code., TEMP.METER OR POL91 .T. COMMERCIAL•
6 C that he is exnnpt therefrom and the basis for the alleged cxemplion.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4
ySection by tiny applicant for a Nott subjects thenpplicant to a civil penalty of POWER DEVICES TEN FOODSERVICE
�3not more than five hundred dollars($500).
O ❑I,as owner of the proper.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC Q IMPROVEMENT
will da the work.and the structure is not imended proffered Resale(Sec.]1}1.1,Rosiness ❑OTHER
L 3 and Professions Code:The Comment's License law does not apply to an owner of OUTLETS—SWITCHES—FIXTURFS
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 imcmd for NEW RESIDENTIAL ELECTR SQ
sale.ILhnwavec lhebuildingurimprovement k,md within oneyetofcompletion,the SQ.FT.FLOOR AREA $/SQ.IT.
wner-builder will have the burden of proving that he did not build or improve for pup
pose cf sale.).
❑1.as owner of the limper,am exclusively amorm ing with licensed conwemrs to TOTAL:
onstrua the project Sec.7014•Business and Professions CMe:)The Commm.rs Li-
s se law does not apply 10 an owner,"property who builds or improves themon,and Q7y. PLUMBING PERMIT FEE
who contracts for such limpets with u commands)licensed parsuvnt to the Contmatma
License Law, PERMIT ISSUANCE 50
I am exempt under Sec. ,B&P C for reason '
Owner Dam ALTER-DRAW&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTEGE DEVICE
I hereby affirm under penalty of perjury one of the following declarations
❑ I have and will maintain a Certificate of Consent to sebrinsure for Worker's Compete DRAINS-FLOOR.ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
anion,as provided for by Section 39X1 of the Lulxa Cnlc,far the performm�ce of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have end will maintain Worker's Compensation Insurance,as required by Sea .n
3700,(the Labor Code,for the performance of Ne work for which this permit is issued. GAS-EA.SYSTEM-I INC.40UTLETS OCC. APN
My Workers;Compensation Insurance rtricr and Policy number art:
Cartier. Policy Na: GAS-EA.SYSTEM OVER 4(E,) /s
CERTIFICATE OF EXEMPTION FROM WORKERS' V111lI
Ulm uUr :„I INO
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE INTERCEPTOR _ BUILDING DIVISION FEES
sulion need not ed completed lfthc permit is lin ono hundred ddluc(EI W) GREASETRAP or less.)
PLANCHF.CK FEE
'Try any that in the apedry=ince of New rk fur hick this permit iz issued,lshell
n if..Layany person in any ma ¢r. yqt mthe Workeri C,mpem SEWER-SANITARY-STORM BA.20(1 FT. ENERGY FEE
Z ration laws of D (J
O APPlicant�a WATER HEATER WNENDELECIR GRADING RE
to NOTICETUAPPLICANT.KafterallIsdaiig this Certificateof Exemption,you should WATER SYSTEMaREATING
f~ 5 besc.me subject m the Workers Compensation provisions of Wu Lahr Code,you must SOILS EEE
La fordosith comply with such provisions or this permit doll la,deenned ravoked. WATER SERVICE . SQ
c.
UZ CONSTRUCT cIONLENDINGAGENCY NEW NI'SIDLNTIALPLMB. SQ.FT. PAID
U C .I far hi ht hithavhereisacon(Sea 30Vendie.Agrncyfor the perfommnttof Dote ReceiptN
[ks U the work for which this permit is issueA(Sec.3097,Civ.CJ
U Lender's Name TOTAL:
Ll Lender's Address TOTA14
04 1 certify That I have reed this application and store that the above infnnnotion is BUILDING FEE
V) coney l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of ins
Cupertino agat ELECTRIC FEE
liabilities,judgments,costs and expevsas which may in any way accme against said City ALTER OR ADD TO MECH.
in asequence of the granting of this pencil. PLUMBING RE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR IIANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS, MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signature of Applicam/Contmcmr Date EXHAUST HOOD(W/DUCT HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material IIEA'I'INC,UNIT(TO IN1,000 BTU)
as defined by the Cupertino Municipal Code,Chaper 9,12,and the Health and Safety
Code,Section 25532(a)Y HEATING UNIT(OVER 100,000 BTU)
El Yes XNo - PAID
VENTILATION FAN(SINGER RESID) Dene ReaciptN
Will the applicant m fmure building by the
y A ea Air Qu or devices which
•emithazardous vii comaminana as defined by she Bey Area Air Quality Management BOILER—COMP(7HP OR 100,000 BTU) e 0
TOTAL:
Dlspict3
❑Yes )<No BOILER'BOIL =COMP(OVER 1110,000 BTU)
I have read the hazardous materials requirements under Counter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Boom Health&Safely Code,Sections 25505,25533 and 25534.1 uncle dmnd that if the NEW RESIDENTIAL MECH. SQ.FT.
' building does rat currently have aterreathat"s my resp. 'bilitymnotif esacupard /
If
of there a m- Ceri ane peaty. •
Owner romhnrizW ng Elate TOTAL: ISSUEDBY:
OFFICE