31192 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. a� I�
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL 1 G
BUILDING PROJ[W7p IDENTIFICATION
BUILDING ADDRESS: C SANITARY NO. APPLICATION SUBMITTAL DATE
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�iGHITEf.r/ENGINEIik: LIC NO: ADDRESS 1 1 5I Yd ❑
CONTACT: PI10NE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG E� PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION =ELECTRICELECTRIC PERMIT FEE1 hereby mifrm ilia 1am licensedunder......innsof Chapm.9(commencingJOB DESCRIPTION
OCz with Seldom 700mbofDivision3ufthe Butanes and Proe"")ns Cl JmylicenveieANCE RESIDENTIAL'y� in full GnmundeBr,r+ �anQUU License Cl s `�� Lic.k ❑SFDWL - ❑KITCHEN REMODEL
HQd Dmc Contracmr S-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
faso ARCHIT[CTS DECLARA ON ❑MULTI-UNIT ❑STRUCTURAL
Z I unJerxtanJ my plans shall he used as public recantsZO,n MODIFICATION
OZ0 MPS1-4ta1 Licensed professional 0INTERIOR ❑CHIMNEY REPAIR
PS IMPROVEMENT
C _1 OWNER BUILDER DECLARATION
LC 6I herebyafEnn that I am exempt from the Comraanr'x License Law for 0eMPS ❑BATH REMODEVREPgIg 0 pEM01,ITI0CU billowing reason.(Section]1171.5,Business and Professions Code:Any city or axumySIGNS ELECTRICAL ❑OTHER —7\��7•_—asA/_—�•;�_h
W 3 fy F' whim ruluires a permit to construct,alcor,improve,demoft.h,or repair any sIomeu Fie
FSO prior to its issuance,also requires the applicant for such pemtiuo File a signed statement SPECIAL CIRCUIT/MISC.
C�Gf, that he is licensed paramount o the provisions ofthe Cmtmnnrs License Law(Chapter 9
u1C (commencing with Section nion3 of the Business and Professions Code)or
TEMP.METER OR POLE INST, COMMFRCIAI,
to 6x LL that he is exempt therefrom and the basis for the alleged exemption.Any violation of C3 NEW BLDG/ADDITION [I DEMOLITION
W m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES
=o t mom man five hundred dollars(55W). El TENANT ❑FOOD SERVICE
p 1,as owner oftheproperly,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
Gp. will do the work,and the ntmctum is not imendedmoffered hu sale(Sec.]044,Business ❑OTHER
ro and Professions Cede:IM1e Commn.rs License Low Jocs not apply m un owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves hereum,and who does such work himself or through
his own employees,provided that such improvements not a.l Immaded or offered for NEW RESIDENTIAL ELECT SQ Len
sale,If.however,the building or Improvement is sold wind n ame year of completion,the SUjW PlPp*2�EA SSQ.FT
owner-builder will have the huNcn of proving mat he did not build or improve for pur-
pmse ofsale.}
❑1,as owner of the properly,am exclusively commeting with licensed contractors to TOTAL: ��,• m �
construct he project(Sec.]044.Business and Professions fessns Cull The Comtmcmrs WAY
Li-
cense Law docs not apply to on owner of property who builds or improves thereon,and QTY. PLO GPERMIT FEE
.1novnuactx basach pmjectx withaeommeowd licensed pursuant tube Canvaemrs CTy ut- t,
License Law. PERMIT ISS a UI'tH fINO
l son exempt under Sec. ,B&P C far this reason
Aum R-D ANT-WA '
Owner Dae VALUATION
WORKER nder COMPENSATION DECLARATION BACK FLOW PROT
ffnn F ICE
1 hereby eunder penalty,of perjury one of the following declarations:
❑)have and will mainminu Cenificamof Conscm mselGinsu¢for N'.dels Compen- DRAINS-FLOOR,RO ir. ND.
modow.as provided]far by Section 37W of the,Ia ur Code,for the performnce of the STORIES TYPE CONSTRUCTION
walk for which this .it ix issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700of the Labor Code.for tbe performance of the walk for which this pcmrit is iusued, GAS-EA.SYSTEM-I INC.4 OUTLETS
My Work Comperoaion lnvurance cart:rand Policyp� ts`
OCC.GROUP ALN
Curticr. 1-,�L�Qf�, aPolicy N,,.:B -f 11 GAS-EA.SYSTEM-OVER 4(EA)
CERDFICA'rli OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANC12 GREASFJINDUSTRLWASTE INTERCEPTOR
(This section needmol bcurmpincd if me permit is forme hundred chm ms(SI W) BUILDING DIVISION FEMS
urlccc) GREASETRAP
I ccnify the,in the perfanmmtce ofine work far which this peond a issued,I shall PLANCHECK FEE
Zpersm
not employ any on in any manner as to become subject to IM1e Workers'Conan SEWER-SANITARY-STORM EA.2W FT.
.cation Lows of CAnorm.,Duro ENERGY FEE
Z - WATER HEATER WNEN IDELECB GRADING PEG
Z 0 NOTICE
ay NOTICETOAPPLICANT,e,aftermaking this .Imamuof h Luton,iodyou should WATER SYSTEM REATING
; M1a awillb b]eul w the Wnrkur's Compensation provishms of ilio LuMm Cada,you most SOILS FEE
forthwith cn-Ply with such provision nr Ihis permit shall he Jcmncd revoked.
1 0 WA'IT3R SERVICE _
DZ CONSTRUCTION LENDING AGENCY NEW RESIDEMTIAL PLMR. SQ.PT. PAID
UC) Ihereby affirm flat in a conswetian lending agency for performance of Date Receipt#
the work for which this ed(See.3W].Civ.CJ
0 U lender's Name— 41ou
} W Lender's Address �T TOTAL:
F
CLI ccnify mat I have read this application and seem the,theinformationTOTAL:we information is BUILDING FEE
(/1 correctl agree to comply with all city and county ordinances and.state laws relating to QTY. MECHANICAL PERMIT FEE
U Z building constmction,and hereby amhorize representatives of this city in enter upon the SEISM IC FEE
above-memioned property far inspect inn purposes. PERMIT ISSUANCE
(We)ngme m vavc,indemnify and keep hnmdesa Ilio City of Cupertino against ELECTRIC.Eli
Iiubilitics.judgmems,costs and expenses which may in any wayacerueagainst said City ALTER OR ADDTO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT gift HANDLING UNIT(T'010,000 CFM)
SOURCE REGULATIONS. MECHANICAL.ITE
AIR HANDLING UNIT(OVER I0.000 CFM) CONSTRUCTION TAX
gtgwtum of Applt<anVConuacnr. Date EXHAUST HOOD GNMUC)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT CTO 100,00X)BTU)
as defined by the Catartino Municipal Cede,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'I HEATING UNIT(OVER R#hWO B'fLE
❑Yes .
ry VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or forme building b,,hc B use equipment or devices which Date Receipt#
earn ous air contaminant.as JeGned by the Bay A.Air Quality Management BOILER—COMP(3HP OR 100,1100 BTU)
District?
❑ TOTAL:
Yes Nn BOILER 100,000 BTU)
1 have read the hare, rials
a requirements under Chapter 6.95 of me Cali- AIR CONDITIONER
fn Heahh&Safely Code,Sections 25505,25533 and 25534.1 understand that if the ISSUANCE DATE
btu 1 galixs mol u.enl rot tcoum.that it ism 'befit ar..til the occu t NEW RESIDENT IAL MITCH. SQ.Fr.
y rcvryntai Y Y Pun
u111 IW
"I"".issuance of a col IkcuPancy
Oxmel in io...zed agent Date TOTAL:
ISSUED RY:
OFFICE