31491 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES-USE BALLPOINT PEN ONLY -
CITYUPCUPERTINO - BUILDING_,ELECTRICAL PERMIT NO,
BUILDING DIVISION' APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 31491,
BUILDING ADDRESS: - ^� SANITARY NO, APPLICATION SUBMITTAL DATE
' WNER'S NAME: v ,PHONE: D RA R'S NAM : LI NO: � `•� ��
aLN4 _ N/C CONTROL# -
ARCHITECT/EN EIU LIC NO: ADDRESS:
Enk
CONTACT,a:' - PHONE: - - - BUILDING P RMIT INFO
' ❑ Consultant Fees Paid by Applicant(Initial) I' BLDG ELECT PLUMB MEC
LICENSED CONTRACTOR'S DECLARATION' QTY. ELECTRIC PERMIT' FEE
E3El
hereby affirm Nat I am Ilcenxd under provisions of Chapter 9(cmm
oencing JOB DESCRIPTION
X00 with Section]000)of Division Sof the Business and Professions Cade,and my licensees RESIDENTIAL:
nfull force and eff _ PERMIT ISSUANCE
�U� Lican (las' Lic.# - ❑SFDWL ❑KITCHEN REMODEL
rF E Dam-fk Cannacwr APPLIANCES-RESIDENTIAL '.D ADDITION [I PLUMBING RE-PIPE.•
,p rn ARCHITECTS DECL ION - ❑MULTI-UNIT ❑STRUCTURAL
z O ' 1 understand my plain shall be used as public records
O Z , PANELSIMODIFICATION'
UP T02W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Lensed Rufesxumel 201-100KAMPS - _ IMPROVEMENT .,
OWNER-BUILDER DECLARATION
I naso affirm Nat para exumpe from the Contractors License Lew for the OVER IOOpAMPS El BATH REMODEL/REPAIR DEMOLITION
0,U following reason.Perot
t to constrict,
Business and Professions Cade:Any city or county - ,❑OTHER
a F SIGNS ELECTRICAL n
� W whicti requires o pemur u c n t t alter,improve,demolish,or report any stmcwre '
+O priorm its issuance also requires the applicant fr suvlh�,admit to rile a signed statement SPECIAL CIRCUIT/MISC. -
;!(a�, that he is licensed uramumt flue provisions of he C ntmctorsLicense Law(Chu
pter9
a i
(commencing wit Section of Divisions fthe Business and Professions Code
❑O )or TEMP.METER ORPOLE INST.i 'COMMP.RCLAf;
Nat he is exempt any applicant ora and the basis forte alleged exemption:Any violation of Ll NEW BLDG/ADDITION ❑DEMOLITION
Section th n by anyreddfor a permit subjects the applicant m e civil penalty of POWER DEVICES
"y t more ten five hundred tlollais($5(N)): C1 TENANT ❑FOOD SERVICE
QLae owner of the proPeny,or my employees wirh wages as their sole compensation, SWIMMING POOL ELECTRIC; IMPROVEMENT J'
will dome work,and the structure is not intended m offered forsele(Sec.7614,Business ❑OTHER
�3 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES- RES
Property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended of offered for NEW RESIDENTIAL)LEC 4 SOFT '
sale.If,howeveyte building or improvement is sold wiling one year ofcompletion,the SQ.FT.FLOOR AREA $/SQ.ET.
owner builder will have the burden of proving that he did not build or improve for Aur- '
pose of sale.). - -
❑1,as owner of the property,am exclusively contracting wit licensed contractors m AL.
construct the project(Sec.7044,Business and Professions Cade.,Tha Contrunors Li.. `
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
whucpmmets for such projects with a contractor(s)licensed pursuant m the Contractor's
License Law.
El I am exempt under Sec.' ,B&P C for this reason PERMIT ISSUANCE "
Owner Date ALTER-DRAIN&VENT-WATER HIA) 'VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under Penalty of perjury one of the following declsixtions:
I have and will maintain a Certificate of Consent to self-insure for Worker's Counter- DRAINS-FLOOR,ROOF,AREA,COND. - STORIES TYPE CONSTRUCTION
sation,as provided for by Section 37W of the Labor Code,for the performance of the
work for whicti this pemuu is issued. FIXTURES-PER TRAP
1 have and will mainmin Worker's Compensation Inaumnce,as required by Section
of the Labor Cale,fur the performance of the work for which tis permit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS DEC.GROUP APN
My Wo r,�Comp�,p�a��ion�1 ecarrier and Policy.➢I�t�}�j��` I,,�r'�
r Carrier. L1111MT M'1C Policy Na:/—ax,y�v-- GAS-EA.SYSTEM-OVER4(EA)
CERTIFIC MPE EXEMPTION FROM WORKERS' - '
' - COOMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR' '
(This.uctioa need not hecompleted if thepermhis fornnehundred dollars(E 10p) - _ BUILDING DIVISION PE&4
or less) GREASE TRAP PLANCHECK FEE ,
leartify that in the performance ofte work for which Nis Permit is issued,I shall SEWER-SANITARYSTORM EA200 FT
not employ any person in any manner so as to Income subject to N - . .
e Workers'Compen- ENERGY FEE -
,7. sation Laws of California.Dateas
Oy O Applicant - - WATER HEATER WNENIUELECTR GRADING FEE
Fl p�j NOTICE TO APPLICANT:If.alter making this Certificate of Exemption,you should ix LAk
WATER SYSTEMffREATING
f~ become subject to the Workers Compensation provisions of me Labor Code,you must, SOILS FEE
fk' forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
�+ N LENDING AGENCY
w.f Z CONSTRUCTION NEW RESIDENTIAL PLMB'. SQ.FT. PAID
I hor which fins
that there isaed(Sect 3097,Cis.agency for Ne performance of Date eipt#
0, the work for which this permit is issued(Sec.3097,Civ.CJ ,
` Lenders Name
O 44Lr Lender's Address - � TOTAL: TOTAL:
pa I certify that I have read this application and site that the above information is BUILDING FEE
rn correct.l agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
LI building consumption,and bandyaminr.representatives of tis city m enterupon the, ."Y SEISMIC FEE
above-mentioned property for inspection purposes. i PERMIT ISSUANCE /
(We)agree to save,indemnify and keep harmless the City of Cupertino against' h - .ELECTRIC PEE ��
liabilities,judgmems,costs and expenses which may in any way accrue against said 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 10,000 CFM) MECHANICAL FEE
50 C=REGULATIONS.
-
L4 3 AIR HANDLING"IT(OVER 10,000&ND CONSTRUCTION TAX -
i -at ApplicantIC-maracmr Da EXHAUST GOOD(WMUCr)
" HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant orfunam building occupant store or handle hamfdous material HEATING UNIT(TO 1W,000 BTU)
as defined by due Cupenind Municipal Code,Chapter 9.12,and be Health and Safety
Code,Season 25532m)? HEATING UNIT(OVER 100,00O '
❑Yes E]No
VENTILATION FAN(SINGLE RESID) PAID
Will me applicant m future building occupant use equipment or devices which, Date Receipt#
mit hmamdous it contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(DRP OR 100,000 BTU)
is0in? TOTAL:
EJ yes = (]NO BOILER-COMP(OVER 100,000 BTU)
I have rend the hazardous mmenals requirements under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomie Dealt&Safery Cade.e a pots ,bad 25533and 25534.1 to notvand thatdme NEW RESIDENTIAL MECH. SQ.FT. 'C O
buddingdoes utema currently havebf met prior
is myresofaCrtificateofy Neoccup t k.J / /
of the reymmmenrs which must be met pnartoissuanceofe Certificate of Occupancy � �
Owner m euthonzed agent Data TOTAL:93,00
ISSUED BY: -
OFFICE