31485 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 31485
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA
1 \\ 3 \-1v�'� so � ,
O N'S NAME: PHONE: CO R CTO NAME: LIC NO:
_ \ R�O'T O NIC - CONTROL#
ARCHITECT/ENGINEER: LIC NO: OGRESS: ❑
n . s� SS
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant FecS Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑
LICENSED CON'TRACT OR'S DECLARATION - QTY ELECTRIC PERMIT FEE
I hereby auric that I..rcensed under,orwi.inns of chapter 9(imaang m JOB DESCRIPTION
Z with Section lo0lp of Division 3 office Business and Professions Code,and my lice.is
I- y f PERMIT ISSUANCE RESIDENTIAL,
F n full force and c t
<VU Licar Lic.M fl ❑SFDWL ❑PLUMBIKITCHENREMODEI
F-ZQa Gum — Comrnnor APPLIANCES—RESIDENTIAL ❑ADDITION PLUMBING RE-PIPE
F.Dta ARCHITECTS DECL A'ION PANELS
El MULTI-UNIT STRUCTURAL
ZpInZ Iunm
demrJ my plan,,hall he usedun public..,its MODIFICATION
OZN—QQ UP TO 200 AMPS El INTERIOR ❑CHIMNEY REPAIR
1 4LE Licensed Professional 201-IOIIf1AMP5 IMPROVEMENT
6y�J OWNER-BUILDER DECLARATION
a C C I hereby alTimt that 1 am exempt from the Contractor's License Law for the OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
O a.W V following mason.(Section 7031.5.Business and Professions Cook:Any city or cuumy SIGNS Ii1.EC'1'RICAL ❑OTHER
W a ti which reyuirts a Formal to construct,eller,improve,demolish.or repair any smucmm
FC'a+0Q1 prior,,,it
"r) also requim,thempplieam forsvch permiuo rola aalgnulsmmmem SPECIAL CIRCUIT/MISC.
M y NuBe
at he is licensed pursuant provisions of the Contractors License Law(Chapter9
�CpO (commencing with Section 70(shofDivisom3 of the Business and Professions Cale)or TEMP.METER OR POLE INST. COMMERCIAL:
Il%MC that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION El DEMOLITION
W Ito Station 1031.5 by any applicant mor
a permit subjects the applicanto a civil penalty of POWER DEVICES ❑TENANT FOOD SERVICE
ZY not more than five hundred dollars($5(Xp.
Vi=a ❑h as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOI.ELECTRIC IMPROVEMENT
_ will do the work,and live structure is not intended or offered for sale(Sec.]04T Business ❑OTHER
H
W3 andProfessions,who b Col a Cmaramus'a License dodoes notapply toan lfowner of OUTLETS—SWITCHES—FlXTURF_S '
peony won builds or imp ded tha thereon,and who m such wad himself or though for
his own employe,povidcJ ma such improvements arc not immnded or oReoJ for NEW RESIDENTIAL ELECIR SQ FT.
'ac.If,however the building or improvement issold withinome yearofcompl¢tion,the AREA So%FT.
owner-builder will have the burden of proving that he did and build or impose for purFU
-
Pose of cote.).
Ol,as owner of the property,am exclusively contracting with licensed contractors no TOTA
construct the project(See.1041,Business and Professions CuJe:)The Contractors Li- 1� 1 5 1997
Li-
cannot,Law does not apply m an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT F r
who contracts for such projects with a contractors)licensed pursuanto the Contractor's
Llanse Irw. PERMIT ISSUANCE
❑I am exempt under Sec. B&P C for moron
ALTER—DRAIN&VENT—WATER(E-A)
Owner Dam VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 thereby affirm under oautoy of perjury one of the following declarations:
I have and will maintain a Certificate of Consenuo self-iasum fur Workers Cooper- DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTIO
action,as provided for by Section 3100 of the Latus Coda,for the perfummnec of the
wek for which this permit is issued FIXTURES—PER TRAP
I have and will maintain Workers Compensation Insurance,as featured by Section
dal of the Labor Code.for the performance of Ne work for which this permit is hand. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Wor —Com�x lion[awremce carrier and Poli
Cam¢ I--�`)ta M.Policy Nc �' GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE.INTERCEPTOR
('This section need not becompleted if the permit is become hundred dollars($100) BUILDING DIVISION FTFS
or less.) GREASETRAP -
Icenifythat inthe odm
performance the work for which this tis iszued.l shall PLANCHECK FEE
not employ any person many manner so as to become subject m the Workers'Cam SEWER—SANITARY—STORM EA.200 FT.
Z wean Law,of Califomia.Data
) on_ ENERGY FEE
0 O Applicant WATER HEATI'-R WNENT/ELECTR
zy
NOTICE
subject
APPLICANT.theWorker's
after Compensation
this Cisions f the
E Labor
on.youshouldmost WATIiR SYSTEVVfNEATING GRADING FEE
a; become subject to me Worker's Compensation Prov tions of the l,bor Cade,you must SOILS FEE
�
forthwith comply with such provisions or perosis shall be deemed revoked, WATER SERVICE .
a0
UO CONSTRUCUONLENDINOng ager NEW RESIDENTIALPLMB. SQ,FT. PAID
I thereby which'his
that mertissued(Sce.30 len ding agency for the odormance of Date Receipt N
� � lhcwork Gat wM1ichfhisormif it issued(Sec.J1191,Cit,CJ
Lenders Name
f�l.)1 Lenders Address TOTAL: TA
y I cenify that I have read mix application and state that The above information is BUILDING PEE
to cunect.I agree to comply with all city and county mto...cnmdoemlawsnalmingto QTY. MECHANICAL PERMIT FEE
U building construction,and hereby anatomic representatives ofthis city menlerupon the SEISMIC FEE
im ve-memiaaW pmony for inspection puryows. PERMIT ISSUANCP,
(Wd'agree m save,indmnmfy and keep har oks,the City at Cupertino against ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way acerae against said City ALTER OR ADD TO MECH.
in consequence of the gmming of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(1010.0011 CFM) .
SOU GULA'1'IONS,
r5 MECHANICAL FEE
h� /o /1 AIR HANDLING UNIT(OVER 10.WO CFM) CONSTRUCTION TAX
.tg I. of A,,1ivma Cmu.tm Dam '/ EXHAUST HOW(WMUCT)
HAZARDOUS MATERIA S ISCLOSUR HOUSING MITIGATION
Will meopplicmttor f I mbuilding mcupam sem or handle •ar ices material HEATING UNIT(TO 108000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9,I2,and the Health and Safey
Code,Section 25532(u)1 HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE RESID) PAID
Will the air am m or atsa building occupant use ryui it a or devices which - Data Receipt N
emithu,anlous air conmminanxs as defnal by the Bay Area Air Quality Management BOILER—COMP fJHPOR 100,000 tlTU)
minden
TOTAL:
❑Yes FIN. BOILER—COMP(OVER 100,000 BTU)
I have read the havardous matelots meomm uni under Chapter 6.95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
humin Health&Safety Carle.eationn 25505,is my and 25534.1 ufdemaM that if the NE W RESIDENTIAL MECH. SQ.FT. -
building does irecm s,whicythesetome.nxv it icmym,of aC dfic aotifymupancyam ( /
of the fcyuircmem,which most he met pdono issuance of a Cenificme of(hcupancy.
Owner or amhomed agent Data TOTAL: ISSUED BY:
OFFICE