31233 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATIONMERMIT PLUMBING.MF.CIIANICAI.
BUILDING PROJECT IDENTIF'1GATIOry
BUILUIypADI)RE$SL "k S` 5js SANITARY NO. APPLICATION SUBMITTAL DATI
OWN 'S AME: 1� PHONE: COMI' ACTOR:ti E: LICNO:
/� N/C CONI'ROLN J
R HITECf/IiNG NEER: LICK : pRFSS: V /4 �� ❑ ('1.�, yrX�
CONTACT. 0%117P144GuP AV 7(T-0/ BUILDING PERMITINFO "
❑ Consultant Fees Paid by Applicant(Initial BLDGELPLMECH
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMIT FEE LL117
1 hereby affirm ohm I ern licensed under provisions of Chaplet 9(commencing JOB DESCRIPTION
"Z with Secure7UW)of Division 3mf the Fusinessamel professions Code.and my license is RESIDENTIAL:
OO in fall force rind effect PERMIT ISSUANCE
W�Co�] ❑SFDWL ❑KITCHEN REMODEL.
<L DaLicis—se Class Compactor APPLIANCES-RESIDENTIAL ITION ❑PLUMBING REBIPE
I.Gm ARCHITECTS DECLARATION PANELS MULTI-UNIT ❑STRUCTURAL
z O „Z, I understand my plans shall be used as public records ODIFICATION
oz—, UPT0 2M AMPS �
❑INTERIOR y, NEY RCPAIR
1-44 q Licensed Ponamand 201-INSAMPS IMPROVF.M
C •.1 OWNER-BUILDER DECLARATION
1 hereby off n that 1 am exempt from the Communities License Law for the OVER IIXp AMP r]BA REM A4p f�DEMOLITION
iqS O a O following reason.(Section 7031.5,Business and professions Code:Any say m county ❑tJTHEon SIJ
su'3 WO F which requires n permit to construct,alta,Improve,Jenmiish,or re structure SIGNS ELECTRIC 'Lff�'C ,. "f7/r
yva l repair (��; ,
^�7y;'that he is
punum tquiresrmvisionso f eCont toes Licenseigned smmmcm SPECIAL CIRCUITIMISC.
�Gf
(commencing with
purstion70hc provisions3 i ContractorsnimnserowaC odea, COMMERCIAL:
�DO (cat he
imminh Sectirmin ad of Division of Ne Business
rmi.n.f n,sisCale)or TEMP.METER OR POL INST.
LL o y that he is exempt thert[rom unJ the basis for the alleged exemption.Any vioiminn of ❑NEW BLDG/ADDITION ❑DEMOLITION
Syd k• Section 7031.5 by any applicant for a permit subjects the applicant o o civil penalty of POWER DEVICES
LL7^m ❑TENANT ❑FOOD SERVICE
F Z i- not more than five hundred dollars($500).
176o the we
of thepe somene myemntende with wagesrsaleirmle compensinen. SWIMMING POOL ELECTRIC
IMPROVEMENT
and Jo the work,and the he Contractors
not intended tampered Law
do far sale(Sec.7044, weer of
❑OTHER
m and Ay who
Coda:The C.domra License o it such
not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pmperty who builds or improves thereon,unJ who Jrn.•s such work himulf or through
his own employees,provided that such improvements are not amended m offered for NEW RESIDENTIAL.ELECTS SQ ET.
sale.If,however the buildingimprovement is sold within one SQ.FT.FLOOR AREA LS .Fr.
url pf prom build
or improve
pur- t J,0
owner-builder will have the harden of proving Na he did net buil)or improve for par- O
prise of sale.).
I,as owner of the Employ,am exclusively contracting with licensed conuactors Q, ( I^
onswct the project(Sec.7614,Businev and Professions Code.,The—ronowto.
came Law does not apply to an owroer of proorly who builds or improves Oemon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a commemos)licensed pursunnuo the Contractor's
License Law. PERM IT ISSUANCE
lamexempronder Sec. ,B&PCfor Iliireason
Owner Date ALTER-DRAIN&VENT ) VALUATION
WORKER IS COMPENSATION DECLARATION BACK FLOW PROTE VI
1 hereby affirm under penalty of Pe jury one of the following declarations:ol
I have and will maintain a Certificate of Consento self-insure for Workers Camper- DRAINS-FLOOR.ROOF, W ND STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3710 of the Labor Code,for Ne performance of the
work for which his permit is issued. TEXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,its required by Section
3700 of the labor Cak.for the performance ofthe work for which this permit is lamed. GAS-EA.SYSTEM-I INC.40UTLETS OCC.GROUP APN
My Workers Com Mainion l rand Policy number am:
/ Camec_ Q,tt_ Policy No GAS-EA.SYSTEM-OVER 4(EA)
C17RTIFICAIEOF IiAPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This rection recd not be completed ifNepermit is formic humlmidollars15100) GREASETRAP
or less.) PLANCHECK FEE
Toy any Perhat int he peffmaany
or fficas
becomeork for
bjectch is pennitisissued,Ixhall SEWER-SANITARY-STORM EA.20017.
•
not employ any person in any manner sn us to become subject m the Workenv'Compen- � ENERGY PEE �
O z sanies laws of California,Date WATER HEATER WNENT/ELECTR
O Applicant GRADING FEE
n NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING SOILS FEE
a became subject to the Worker's Compereatidn provisions of the labor Code,you must
D] fonhwith comply with such previsions or this permit shall he decmW revoked WATER SERVICE
4 Q
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ,FT. PAID Date Receipt X -
L) I far
rwhichaffirm that there isaco (Sce.onlendie.agency for the Performance of p
Ur the work for which Nis permit is issued(Sec.1097,Civ.CJ
Landers Name TOTAL.
TOTAL:
LendclMlresx A
certify that I have reed this application and note rho the above information is BUILDING FEE
pal correct i agree to comply with all city and county ordinances andnam laws relatiagm QTY. MECHANICAL PERMIT FEE O
LI z building commuction,and hereby authorize represenanives ofthischyto emerupon the SEISMIC FEE
above-memmirsd property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep homeless the City o(Cuper irm against ELECTRIC FEE
IiahililieCoro iL022
s,judgmear,,Mt.,nd Miacoas which may in any way.m.e.,mard said City ALTER OR ADD'TO MECH. O
in occiurnce of the grunting of this permit PLUMBING FEE
ns
APPLICANT UNDERSTANDS AND 'LL COMPLY WITH ALL NON-POINT AIR HANDLING ON]'1'(TO 10,(X1!1 CFM7 MECHANICALFEF. 10
SORF 'ATIONS.
2 AIR HANDLING UNIT(OVER 10.000 CFMI CONSTRULTIONTAX
es
Signor.of ,dic.5 D a EXHAUST HOOD DVMUCT) ROUSING MITIGATION FEE
H -AR US MATERIALS DISCLOSURE
Will the applir nor luwre building occuprim score or handle humNous mnmrial HEATING UNIT(TO 100.000 BTU)
or defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety _
Code,Section 25532(.)'1 HEATING UNIT(OVER 100,000 BTU)
E]Yea ❑Nn VENTILATION FAN(SINGLE RFSID) PAID
Dam Receipt X
will the applicant or furore building by the B use equipment or devices which BOILER-COMP(3HP OR 100.000 BTU)
I t hazuNnm air contaminants m def sed by the Iluy Area Air Quality Management A,JS2 1
isWctO Yes No BOILER-COMP(OVER 100,000 BTU)
I have mad the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fismia Health&Safety Code,Sections 25505,25533 and 25534,1 understand that if the NEW RESIDENTIAL MECH. SQ.IT.
building docs not currently have a tenant,that it is my responsibility to notify the occupant
of the requirements which must be met prior I.issuance of a Cenificme of Occupancy.
Owner or natio ri,ed agent Dore I ISSUED BY:
OFFICE