31145 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO, 31145
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
PUILDIIVG PRtA F.CI'IDENTIFICATION
B' DING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DA'
oZ1ItV`vvs
NER'SNAME: PHONE - 'AC)y CONTRACTOR'S NAME: LIC NO:
1r (_Q_C_ MS'S NIC CONTROL#
ARCHITECT/ENGINEER: ✓J ADDRESS: ❑
CONTACT: /_ PHONE: BUILDING PERMIT INFO
❑ Consultant Firm Paid by Applicant(Initial) BLDG ELECT PhU H MECH
❑ ❑ ❑
LICENSED I amCONTRACTOR'S under DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that am licensed under provisions of Chapter 9lcommencing JOB DESCRIPTION
aZ
with Satian]000)of UivisionJofthe Business and Professions Cale,endo Icense is
at in full farcamed effect. yr PERMITISSUANCE RESIDENTIAL,
aUV License Class Ltd.# ❑SFDWL C1 KITCHEN REMODEL
FzW Date Common, APPLIANCES-RF,SIDENTIAL ❑ADDITION ❑PLUM BING RE-PIPE
t,hFly ARCHITECTS DECLARATION PANELS - ❑MULTI-UNIT ❑STRUC URAL
Zpyz I understand my plans shall be used as public records MODIFICATION
O z-�0 UP TO 20)AMPS E)INTERIOR El CHIMNEY REPAIR
(-4Lu: Licensed Professional 201-IgN)AMI'S IMPROVEMENT
Y f J OWNER-BUILDER DECLARATION
a a Q 1 hereby affirm that 1 am exempt foo the Contractor's License Law for am OVER]MIDAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
X a L F fallowing mason,(Section 71131.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
1+1 us. which requires a permit to consion"alter,improve,demolish,or repair any structure
0Q prior m its issuance,also requirem,the applicant for such permit to rile asigmmometnem SPECIALCIRCUIT/MISC.
En}m l
hW but he is licensed pursuant at the provlsionsnfthd
e Commor's Law Chapter hapter 9
but
with Section 7")of Division 3 ofthe Business and Professions Csde)ar TEMP METER OR POLE INST. COMMERCIAL'
a X c a thin he In exempt mandimn and the basis Pori the alleged exemptima Any sialaden of El NEW BLDG/ADDITION El DEMOLITION,,_r Section]031.5 by any applicant fora permit subject.,the applicant to a civil penahy of POWER DEVICES
cooa more than five hundred dollars($500). ❑TENANT ❑FOOD SERVICE
=Q ❑ 1,as owner of the Property,or my employees with wages as theirsole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
F.. will do the work,and the structure is not intended oraffcred Raoul,Sac.]044,Bosinca []OTHER
a 3 ea and Prufcasions Coda The Contractor's License Law does nm'apply to an owner of OUTLET'S-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements ate not intended or offered for NEW RESIDENTIAL ELECTR SQ FT
sale,IL however,the building or improvement is sold within one year ofeamplction.the SQ,FT.FLOOR AREA $/SQ.FF.
owner-huildcr will have the burden of proving that he did nm build or improve lin Co.
pave of mkJ.
❑1,as owner of the property,ant exclusively contracting with licensed amtmdors in A l D
consumer Ne project(Soca.7014.Business and Professions Code:)The Conuazmr's Li- +�
came Low does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FE 100 ��
who commas larsuch projects with o rmarectons)licensed pursuant o the Conuacmr's
License Law. PERMIT ISSUANCE •ti4�
[] lam exempt under Seo. ,B&PCfor this reason (I
ALTER-DRAIN&VENT-WATER(EA) vf) Yt
DEC[ARATION VUC't�l
WORKER'S COMPENSATION ',N VALUATION
caner BACK FLOW PROTECT.DEVICE nIV
C]I have I hereby affect uaddr penalty of perjury oneof the following deolarutioms.
and will maintain a Cerificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF AREA,CON).
sation,as provided for by Section 3700 of the Libor Code,for the performance of the STORMS TYPE CONS'IRUCTIO
it wok for which this permit is issued FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
371X1 of the LuMrz Code,for the performance of the work for which this permit is ioamd, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AYN
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier: Policy No,: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRI.WASTE IN'IC:RCEYI'OR
phis section need nor dcomple[af athe permit is forone hundreddollars(SIM BUILDING DIVISION MRS
or he".) GREASE]'RAP
I ccnify that in the perfomtance of the work for which this permit is issued,I shall PLANCHECK FEE
not employ any person in any manner so as to become subject o me Workm,Compen. SEWER-SANITARY-STORM EA.2M FT.
cation Laws ofCaltfornlx.Date ENERGY FEE
O WATER HEATER W/OET/E
NLECOt
O
Z Applicant - GRADING FEE
NOTICE TOAPPLICANT:Won If,after Compensation
s Chime, f the
Exemption,aborhoie,you should ATI NO
C4
become subject to the Worker'.,Compenwbon provisions of the Isbor Cork,you must SOILS FEE
forthwith comply with such missions or this permit shall he deemed revoked. WA'T'ER SERVICE,
Z)
Z) z CONSTRUCTIONcm;%acLENDINGng agony N'1'IAL PLM H. SQ.lef. PAID
V k for by which tit that there isaed(Seet 3097.lending agency fbnM pertDrm Date Receipt#
U he weak for which this permit is issued(Sec.309],Civ.C.)
I Leaders Name
O � Leader',AoWrea TOTAL: TOTAL:
y 1 ccnify[list 1 have rend this application and state that the above inhumation is BUILDING FEE
N correct.l agree to comply with all city and county ordinances and state laws crat to QTY. MECHANICAL PERMIT FEE
construction.un
V Z building construction. it herebyautherizc reprnemativesofihis city[oenmr upon the SEISMIC FEE
above mcmioneJ property for inspection purposes, PERMIT ISSUANCE
(We)agree to save,indemnify and keep hmmlexs the City of Cupertino against PLECI RIC FEE
liabilities.judgments,costs and expenses which may in any way accrue against said City
in consequence of rhe granting of this permit. ALTER OR ADD TO MECH. PLUMItING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE RE,ULATIONS. MECHANICAL FEE
\ Y n-t-9 / AIR HANDLING UNITOVFR to."CFM))/ `
CONSTRUCfIONTAX
�! nature ofApplicam/Contractor 1� EXHAUSTHOOD(W/DUC'f)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
u
Will the applicant or future building occupant or handle hazardous material HEWING UNIT TO 100,000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cale,Section 25532(a)] HEATING UNIT(OVER 110,000 BTU)
El Yex No
VENTILATION FAN(SINGLE RPSID) PAID
Will the applicant or linum building oceupan[use equipment or devices which Data Boodle#
Vtit h mallous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP UIHP OR 100,0010 BTU)
Dombup TOTAL:
❑Yes ❑No BOILER-COMP(OVER 100,000 BTU)
I have mail the hazwdous muuorials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
and.Health&Safety Code.Semlans 25505,25533 and 25534,1 understand that if the ISSUANCE DATE
builJingdres an[cement,home a tenon,the[it ism bili[ to dont theoacuant NEW RESIDENTIAL MECH. SQ,FT.
It,rcspmsi y y p
f Ne teuuir� L[ h;hm.mlgmcr prior issuanttofa Ceriftc^a-t�e�Oraf,at
Owl/oeAro/lr-ommum, agent JlD/t TOTAL:
ISSUED BY.
OFFICE