31026APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY*
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CITY OF CUPERTINO - BUILDING. ELECTRICAL
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BUILDING DIVISION - APPLICATION/PERMIT .PLUMBING- MECHANICAL.
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BUHAMNG PROJIXT IDENTIFICATION
BUILDINGADDRE S.
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SANITARYNO:'
APPLICATION SUBMITTAL DAN
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ARCHHECT/ENGINEER: LIC NO: _ D ESS; - -
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CONTAL91 PHONE: .UNI a
(, ❑Consultant Fees Paid by Applicant (Initial)
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BUILDING PERMIT INFO
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LICENSED CONTRAC'TOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with forceBec Division3of the Busincxa and PnxlessirmCxde, endmylianseia -
'n full fu¢e and effort, f PERMITISSUANCE -
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Licenu Class Lim. N
Dau� Comrmms APRIANCI3S-RESIDENTIAL
B DESC IPTION
RESIDENTIAC,
❑SFDWL C KITCHEN REMODEL
[]ADDITION [I PLUMBING RE-PIPE
❑MULTI-UNIT ❑STRUCTURAL _
MODIFICATION
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-'•� xi / r ARCHtIECTg DRCLAHATR 0 PANELS-
1 understand my plans shall be used as public mo rds
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UPT0200AMPS
ElINTERIOR ❑CHIMNEYREPAIR
IMPROVEMENT '
❑ BATH RE MO (UR •P IR DE.MOLI
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Licensed Professional2111.IINNIAMPS -
OWNER BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the OVER 1000 AMPS
following resin. (Section 71131.5, 1hisinns and Prolexsiuns Code: Any Myer county SIGNS ELECTRICAL
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which requires a permit . construct, abed improve, demolish, m repair any nmeture
prior to its issuance. also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUIT/MI SC.
Roars, is licensedpursuanno the provixionsofthe Ceraacum, Licensc Law lChaptaa9
C NEW BLDG/ADDITION ❑ DEMOLITION
[]TENANT- ❑FOOD SERVICE
IMPROVEMENT•
C OTHER
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Icnmmencing with Section 700(fof Divieca.3.f Ne Business and Profit sxinns Cnde)m TEMP METER OR POLE INST.
that he is exempt therefrom and the breis for the a11eSN exemption. Any violation of
Section 70315 by any applicant for a permit subjects the applicant to o civil penalty of POWER DEVICES
tot more than live hundred dollars ($500).
I, es ownera(Ihe property. or my employees with wages as their sok cmnpematinn,
ElSWIMMING POOL ELECTRIC
will do the work, and the smumure is not inended proffered forsae (Sec.7 W, Business
and Professions Cale: The Contractors License Law does not apply to an owner of OUTLETS- SWITCHES-FIXTURES
properly who builds or Improves thereon, eel who does such work m
his own employees, provided that such Improvements are not intended or otfercd for NEW RESIDENTIAL ELECTS SQ FT.
deed or offeredfor
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'ale, If, huwevec the buildingor improvement is sold wiihinone year tilannpletime, the
owner-builder will have the burden if proving that he did not build or impinge for pur-
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pxsaeofaale.).
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C 1, as owner of the property, um exclusively contracting with licensed contractors to-
construct hepmject(Sa.7fW, Business and Prifessiom Code:)TIm Contractor's U.
cenu Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
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who contracts for each Pmt,jcats with a cnntmctar(a) licensed pursuunuo the Contractors
Liana Law, s , PF.RMR ISSUANCE
❑ lam exempt under Sec. ,B& P C far this reason
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ER- DRAIN & VENT -WATER(EA)
Owner Data
VALUATION
VALUATION
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WORKER'S COMPENSATION DECLARATION BACK ROW PROTECT. DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
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Ihave aad oil l maintain it Cent freta ofCoa,xm to self-insure for WprkersComper- DHAINS- FLDOR, ROOF, AREA. COND.
sedan, as provided for by Section 3700 of the Tabor Cale, for the performance of the
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TYPC•CONSTRUCf10N
work far which this permit is issued, - FIXTURES -PER TRAP
1 have and will maintain Worker's Compensation Insurance, us required by Section
3700ofthe labor Code, het the perlunnencc of the work forwhich this Permit is issued. GAS -EA. SYSTEM-I INC, 4 OUTLETS
My Worker's ComparsaI.mInnes nccrmer and Policyn nbe re:
Carrier: - --Pnllcy Nu.: {J�f��f+1''/y/���+- GAS-EA. SYSTBMUVER4(19A)-
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:R IFIC TROFEXEMPTION PROM W ERRS /
COMPENSATION INSURANCE GRFASM1,H)USTRL WASTE INTERCEPTOR
(this semina need not be completed if the perm, is baron hundred dolhas($1(111) GREASETRAP or less.)
I eerily Nat in thepdifurmance.fNe work for whichthia permit is issued. I shall tiEWCR-SANITARY-STONM F.A. 21X1 PI'.
not employ any person in tiny manner so as to be ecomsubject to the Worker\ Compen-
ssuion LawsdCniifomia. Date
BUI GDIVISION ZEES
PIANCHECK FEE
ENERGY FEE "
WATER HEATER W/VCNT/ELECfR
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A,IiNOTICE
GRADING FEE
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NOTICP. TO APPLICANT. aOer making this Cenilicme of Bxetnptinn, you should WAT17RSYS rHIMUTREA'1'ING
become subject to the Workers Compensation Immunities of the Lahor Cale, you must
forthwith comply with such previsions or this Permit shall he domed revoked. WpTCRSERVICE
CONSTRUCTION LENDING AGENCY i NEW RES WENTIALPLMB.. SQ. Er'
I hereby affirm thm them is a cunswction lending agency fmthe Performance of -
the work fnr which this permit is iamed (Sec. 3097, Civ. C.)
Lender's Nome
SOILS FEE
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PAID
Data I x Receipt#
TOTAL:
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Lenders Address TOTAL:
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I certify that I have read this application and state that the ul.xve information is
BUILDING FEE
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cdcor".I agree to comply with all ally and county ordinances and state brews relating. QTY MECIIANICALPERMIT FEE
building construction, and hereby authndu representatives ofthis city to enmrupon the
shove-mentioned property for inapation puHroms' PERMIT ISSUANCE
' (Wes) ngrco m save, indemnify and keep M1armleaa the City ol'Cupprtlno against
SELSMICFEE '
CLEC'IRIC PEE
fnI
liabilitics,judgmcros, costs undapcnsn whichmay inany way occme.,uhn said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit.
PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT (TO IgfNp CFM)
g0/UR1,C'E REGULATIONS./.p,/
MCCHANICAL FEC
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-' v i� . /6�%( _ �i1 -� AIR HANDLING UNIT (OVER IO,BMI CFM)
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CONSTRUCTION TAX
SitA a Applicant/Comramo Data EXHAUST HOOD OVI UCr)
' HAZARDOUS MATERIALS DISCLOSURE
HOUSING MITIGATION FEC
_
Will lheaPpliesator human, bulldingmettIcnt stnmor handle mactrdone materia I HHA'I'ING, UNIT(TO lott000 In U) \
as defined by Ne Cupenino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 25532hol HEATING UNIT (OVER 100,11(0 BTU)
FI Yes '. ',y e VENTILATION FAN (SINGLE, RESID) -
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PAID
Will the applicant or future building occupant use equipment or devices which
emu haecokss air canumments as deEoed by the Bay Area Air Quality Management BOILER- COMP CITE OR 100.000 BTU)
Dam ReceiptIt ,
TOTAL:
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E] Yes No s L/IBOILER -COME (OVER100,000 BTU)
I have read the hamolocasll mmcrias requirements under Chapter 695 of the Coli I' AIR CONDITIONER :
Health & Safety Code. Sections 25505, 23533 and 255M.1 umlersmnd th s if the NEW RESIDCNTIAL MECH. SQ. FII
gdmeanotcmore haven learn t it is myresrymsibilitym notify the occupant
L,,f1ho
ISSUANCE DATE
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req' mots whichi lhdy" i6rt arecofaCeuifmte'of0acupancy.
ISSUED BY:
eat [laid TOTAL: .
OFFICE