31232 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 31232 A
BUILDING DIVISION APPLICATIONJPERMIT PLUMBING..MECHANICAL
�K! Il L J<L
BUILDING ADDRESSBUILDING PROJECT'IDENTIFICATION
: SANITARY NO. APPLICATION SUBMITTAL DATE
gal C/ e- -{7,10
OESNONCO ACTyS LIC NO:
i / vs, /Y// JUI sin N/C CONTROL
4RCHITF,CGENGINEER: LIC NO: ADDRESS V ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION I
EJ El
QTY ELECTRIC PERMIT FEE
I hemby alarm that 1 an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
yaI 0 -Rtl1
with Section0)mf Division 3oflhe Bueinesaand Professions Cmde,.md my license is
1-au0Z in full three and effect. PERMIT ISSUANCE, RESIDENTIAL
IDENTIA
�UU License Class Lie.# ❑SFDWL ❑KITCHEN REMODEL
QL Date Commcror APPLIANCES-RESIDENTIAL
❑ADDITION El PLUMBING REPIPE
ZO=z I understand my plar,,ARCHITECTS
ll be usd a,pblicc mcol PANELS ❑MULTI-UNIT ❑STRUCTURAL
r- MODIFICATION
O Z L C OTTO 21X1 AMPS
N�f.ul Lmensed Prnfess:oml ❑INTERIOR ❑CHIMNEY REPAIR
C yI; OWNEk-BUILDER DECLARATION 201-I000AMPS IMPROVEMENT
—y W Q I hereby affirm that 1 am exempt from the Contractor's License Law for she OVER 1000 AMPS ❑BATH REMO E /REP 1 01
3 a Ei a
following mann.(Section]0315.Business and Professions Code:Any city or county SIGNS E ❑LECTRICAL OTHER
'i- which mquims a permit to construct,alms,improve,demolish,Or mmu,any someone,0prior to its isvaance,also munims the applicant for such pemnii m file a signed stummtm
N 5 SPECIAL CIRCUIT/MISC.
C�Qfthat he is licensedpursn
uann the provisions ofthe Contraenrx License Law(Chapmr9
H 0 (commencing with Section 7")of Division 3 ofhe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
a y c= that he is exempt therefrom and da,basis for the alleged exemption.Any violation of
X^LL Section 7031.5 by an ❑NEW BLDG/ADDITION ❑DEMOLITION
��y yapplicam fora permit mhjeasthc applicant mu civil pe..try of POWER DEVICES
❑TENAN
= Y not mom than handred r my employees
El FOOD SERVICP,
❑ Las owner Ofthe pommy,onnytmntended withwagesfor Nei(sole com Business
SWIMMING POOL ELECTRIC IMPROVIiMIiNT
F will dolhewak.and sheeweumisnotim's Lienee Law it.,
TIH4,Business ❑OTHER
23 m and Professions Cale:Thc thereon.
License law dors not apply s if owner of OUTLETS-SWITCHES-FIXTURES
progeny who builds or improves t thereon,and who nts such work himself or WOugh
his own employees.e provided that psuchros improvements are not intended or offers)fm NEW RESIDENTIAL F,LF.CfR SQ FT.
side.If.rmider willhaethegrdor enof vnnent isat he iid nt build or imprvelfortht SQ,PLI FLOOR ARP.A $ISQ.PT.
er-builder will have the hardenof proving Net he did urn build or improve for pus-
P
s„
p,,seygsale)
LL1.'{� owner of one property,am exclusively contracting wish licensed contractors to TOTAL
construct
the po l(Sec.7014,Business and Professions Coneor
:)The Commcts Li-
censeLawdoes not applymw
an onerofpropertywhobuild.,,,improve,dimeon,and QTY. PLUMBING PERMIT FEE AY1 +
who tonuacta for such mojells withu conur,ban,)licensed pursu.Or m lM1e Comments �/a q�
License Law, PERMIT ISSUANCE t#�t/ u
❑' �emhyffirmundmp
. ,B&PCm,thi,mmmn g/
Owner Dale ALTER-DRAIN&VENT-W'ATE (E Uri VALU
M(614a
ER'g COMPENSATION DECLARATION BACKFLOW PROTECT.DEVICE enally of perjury one of the following declarations:
❑ I haveond will maintain.Cenificamof Comsemmsc,hrom for Workers Cooper. DRAINS-FLOOR,ROOF.ARFA.COND.
.firm a pmvided for by Section 3]0( of the labor Cone,for the performance Of the / STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
Tits)of the Labor Cone,nor 14, of the work for which this permit i s issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
My Worker's Compensation Insurance envier and Pol icy number are: OCC.GROUP APN
Cartier, Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE.INTERCEPTOR
(His section need not he completed it he permit Is for one hundred dollars(S I W) BUILDING DIVISION FRES
or less) GREASE TRAP
I certify that in the perfonnancc of the work for which this t is issued,I shall PLANCHECK FEE
not employ an perm: SEWER-SANITARY-STORM EA.200 FT.
P Y person iany mama,,suits m home subject to she WOrkrn'Compen- ENERGY FEE
Z Z Applicant
Laws of California,aDam WATER HEATER W/VENT/ELECIR
Z Q NOTICE
nl GRADING FI;H
w. y NOTICE TO APPLICANT:If,nfmr making his C ld..,n fof Exemption,you Should WATER SYSTEM/TREATING
F
forthwith
subject re the Worker's Croons or this provisions of the meed Calc,you most
forthwith comply with such previsions or this panni)shall he Deemed rcvokN, SOILS FEE
W� 0 WATER SERVICE-
;Z?
ERVICE
� Z CONSTRUCTION LENDING AGENCY NEWRF_SIDENTIALPLMB. SQ.IT. PAID
U 0 I hereby affirm that them w a continua firn lending agency for the performance of D: c Retain#
P the work for which this permil is issued(Sec.3097,Civ.C.)
U Lender's Name
Lenders AJdmss TOTAL:
F y I certify that I have mad this application and sum that she
above information 1S TOTAL: BUILDING FEE
h emidim lagrce to comply mid with all rmvand county ordinances and state rarerlu
U ,2 buildin.emswminn,and heren minting QTY MECHANICAL PERMIT FEE
b frothy ercpresentaliveaof lM1iscitymcnittupm the SEISMIC EEE ,
above mentionede) fire to save for emnify an keep hs. PERMIT ISSUANCE
(We)agree to save.indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgmems.costs and expenses which may in any way acarus,against said City ALTER OR ADD TO MECH.
Dose menet of the granting of N' foil, PLUMBING FEE
APP ATUNDERST AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO to."CFM)
kCF EGULATIO
?gmmofApp1imqWComAvrmr
MECHANICAL FEF.AIR HANDLING UNIT(OVER 10,000 CFM)11e CONSTRUCTION'TAX
HAZARDOUS MATERIALS DISCLOSURE EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
Willy the Cticanl or fu ureunibuildingoplde Chapter
x9,12.ore handle th,flub and Safe,, HEATING UNIT OO 110Jg0 BTU)
a defined Section
the Cupenlnn Municipal COJv,Chapmr'>.12,and the HCJILh.nil Safely
Cede.Sccdnn 25532(nl^ HEATING UNIT gNF'AN
MIDI
VTU)
❑Yea ❑No
FAN(SINGLESID) PAID
Will the applicant or future building occupant use equipment or devices whichDnle ,Receipt
coulDi,oraxondc`xaircnnum:inain,ass defined by the Bay Arc.Air Quality Management BTD)Fl TOTAL.TU)1Mvem Naha ousmae alsmquiremenlsundefChaplef6.95nftheCali-fomio Health&Softly Cone,Saloons 25505,25533 and 25534,1 undcraand that if NeISSUANCE DATE
building docs not currently hove a tenant,thin itis mymspombilityro notifylhe:s,.bantISQ.Un
of the requirements which must be met prior m ixsomme Of a Cenificam of Occupancy.
Owner or.uthodaed ro col Date
TOTAL ISSUED BY:
OFFICE