31349 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMI'PNO.
BUILDING DIVISION APPLICATION/PERM313 w /�
IT PLUMBING.MECHANICAL ' J{, 34 VM
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - - - SANITARY NO. APPLICATION SUBMITTAL DATE
Z Z 3-31
OW[JE \ 1 O� I'110NH: C R'S NA
Z)� 9e— iC\ C- 1(4 OCR
Il. `J.`^I^�` s 'f NIC CONTROLp
ARCHTIECUENGINEER: V LIC NO, ADDR' S: - ❑
CONTACT. PHONE: - BUILDING PERMIT INFO
' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT " PLUMB MECH
�. ❑ ❑ ❑
LICENSEE)CON'TRACTOR'S DECLARATION QpY ELIiCTRIC PERMIT FEE
I hereby aRrm that I am licensed under provisions of Chapter 9 fmmmencidg JOB DESCRIPTION
•' Qaz with Section 7000d afDivision 3 refine Business and Professlnas Cele,and my license is
{ 00 in full force and effect, p 1 PERMIT ISSUANCE RFS•-_,_SIDENTIAI
QF D Z ❑SFDWL ❑KITCHEN REMODEL
U U Liemse CIT@.--..r�((�Lic.p - -
" ��a Omn-11G11�_Comrucmr APPLIANCES-RISIDIiN'ItAL � � ' []ADDITION C1 PLUMBING RE-PIPE
or) ARCHITECTS DECLARATI DMULTI-UNIT 'DSTRUCTURAh
z 0E24 I understand my plans shall be used as public recit PANELS MODIFICATION
oz-, - l- - UP TO 200 AMPS DIN'TERIOR, DCHIMNEYREPAUt
Licensed Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION I -
C I hereby affirm that I am cxetdpi from the Contractor's License Law for tire' OVER 1HX)AMI'S
e' D BATH RF:MODF-UREPAIR D DEMOLITION
ipS,DWU following reToa(Second 703 I.S.Businenmal Pmfessiona Cafe:Any city or county SIGNS ELECTRICAL [I OTHER
which reduires a permit to construct,after,improve,demolish,or repair any somehow
prof to its issuance,also requires the apphatiol far such pi no rile a signed statement SPECIAL CIRCUHUMISC. 1
that he is licensed pursuant to the provisions ofthe Contracmr's License Law(Chapter 9
Sn� (commencing with Swchon]1100)w(Division Jnf the Businessaml Pr afessmo,Code),,, 'I'EMPER.MHTORPOLEINST. COMMERCIAL:
ym ah that he is exempt then from and the basis for the alleged exemption.Any violation of D NEW BLDG/ADDITION El DEMOLITION
xx 4• Section]031.5 by any applicant for a Permit subjs¢theapplicamma civil penaltyrf POWER DEVICES
ul—rn CITENANT El FOOD SERVICE
nal more Ihun live nwldral Dollars ISSINp.
Lav ownerofthe n,arm to ms with we ea us their hole roc hsetinn, SWIMMING POOL ELECTRIC OTHER❑ Prose cl YemP Y 8 R
Sa II Jothe mations Corbcand esmamurereno'net License
icenstended re offemd Lawdos rsalelply town.Business ❑OTHER
6, m and Professions Ction imp Cb,theme's Licenselaws such
ran apply toanowner nl' OUTLIiTS-SWI')CHCS-pl%'I ORES
hispocam,own who Indiction improves thereon,and who rices such work himself art through
his own entpinyees,provided ince such improvements are not intended or offered ter NEW RESIDEM'IAL ELCCTR SQ FT.
.It.If.however,the tumbling.,improvement is.old withmone ymrrifusindelmd,theSQ.IT.FLOOR AREA $/SQ.FL
owner-builder will have the burden of proving that he did not build or improve for pur-
pafne . - .,.
s000 .,
❑,Laowrle). of the property,am exdu I, amwcting heti liccnsW nonennrsm 'TOTAL:
. conswct the project(Sec.7M4.Business and Prafessians Com:):Mc Contractors Li- PO A D
w elawdoes not apply loan owner ofpropery who builds or Improves atemon,and QTY. PLUMBING PERMIT FEE �/
who commel,forsuch pmjeco wild uom
cracmr(s)licensed pursuant h the Conwclors
E] I a
Law. PERMIT ISSUANCE:' wo
❑ mexempt diner gee. ;D&1'Cfor
this rcunnn vi e Y
Owner
ALTER-DRAIN&VP.NT'-WATER(EA) CIIY.y) VALUATIGN
WORKER'S COMPENSATION DECLARAITON "BACK FLOW PROTECT'.DEVICE LUrLr ll ll'O
I hereby affirm under Penalty of perjury one of the following deductions
•Dlhavc and will naintuinu Cenirinrte afConsemmself-insurefnr WorkeCs Cnmlu'n- DRAINS-FLOOR.ROOF,AREA,COND. STORIES 'TYPE CONSTRUCTION
,«tido,as provided lou by Section 37M of the Labor Cattle.for the perfmnc
orae of the
work for which this permit is issued FIXTURES-PER TRAP
D I have and will maintain Worker's Compemmlon Insurance,as required by Section "
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLE'I:q
OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number arc: -
Carrier. Policy No.: GAS=EA.SYSTEM-OV HR 4(EA)
CERTIFICATE OF EXEMPTION MOM WORKERS, -
' COMPENSATION INSURANCEGREA,SFANDUSTRL WASTE INTERCEPTOR
(Thin section need not Eeemdpleted if lose permit is for ane hundred dollars also - BUILDING DIVISION(TIES
or ices.) GREASE.TRAP PLANCHECK FEE
I certify that in the performance oflhe work for which this permit is issued,I nhnllSEWER-SANI'T'ARY STORM EA.21X1 ET.
not employ any pecan in any mannerpnTmyew hjcm to the Worker'Compan- ENERGYFEEI '
z union Lawn ref Co�'foata,Dau Isl' I S-�b
'T,q,r,,,�JI� WATER HEATER W/VENT/EI.I:CI'R
Z
Q Applicant 49r•,A - - GRADING FEE
y' NOTICE TO APPLICAN'C Lafter making t is Cerificme of Eiremption.you should WATER SYSTEAVTREATTNG -
a became subject to the Worker.Compensation provisions of the Labor Cale,you most I SOILS FEE
� {'y forthwith mmplywitn such provisions or this pemtitsha116e dermad revoked. WATER SERVICE
a Q
r. .- CONhem isa'IONLENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.PI'. PAID
V0 I for
rwhich rut thin there issedt(Sm.309lending agency for performance of Dam Rcci
0Lt. (~ the work for which this permit is issued(Sm.3090.Civ.CJ
U Ixnder's Name ' TOTAL:
Lenders cenifys TOTAL: _
1 certify Nal 1 have cad this application and sum that the nMrve information is BUILDING
Tap tercet.l agree to comply with all city and county rnlinanees and state laws rclatiug a, QTY. MEC)IANICAL PL'RMIT FEE
U z building constructed,and hereby authmire orpresenlatives oflhis airy to enter upon the SHISM]CFEAft
'••' aMive-mentioned irm,amy for inspection pmpwses. I'IiRMIT ISSUANCE;
(We)agree m eve,indemnify amJ keep h nddcT the City of Cupertino against ELECTRIC PCP,
Iiabilities,judgmems.cons and expenses which may immy way..,against said City AITERORADDTOMECH.
n cbdsegnr,we of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) -
SOURCERF. TIONS. MECHANICAL FEE
1' MR HANDLING UMT(OVER 10,000 CPM) CONSTRUCT ION TAX
Sib,+lure of A,pli,mV mmcwr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
MATERIALS ISCL(ISURE
Will the applicant or future building oecupact store or handle hadadnus musical HEATING UNIT(TO 1011.03 BTU)
as derided by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Snrcty
Com,Section 25532fe70'-, i IIEATINO UNIT(OVER 100.000 BTU) -
C]Yes DNo _ VENTILATION FAN(SINGLE RESID), PAID
Date Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER-GGMP(3HEDR IOO.fXq BTU)
�mil hazardous air contaminants as ddned by the Bay Area Air Quality Management,. TOTAL:
UlxtdFR BOILER-COMP(OVER 100,0X1 BTU) '
❑Yes DNo '�
I have madme humnlousmaterials requirnmenta under Chapter 6.9501 me Cali- 'AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Calc.Satiate 25505,25513 sural255.34.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. `'y^•�'-
building doT mots lbach hoobeructlLthat it ismsce of xiimifilonotifOccuacupum t VNI�
brine mlue,net cum hhave. md Priorm issuance of Celit,mocaic My the ocdcy.
Owner moullariecdvgcdl Date w' TOTAL: ISSUED BY:
OFFICE