31490 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMITNO. O
BUILDING DIVISION APPLICATIOWPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDEM'IFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
I
11-.r) LnoR visTa Qe ,
O R'S NAME: - Ilr�..-PHONE: O RA R'S NAME: LIC NO:
T a?SS Q s- NIC CONTROL#
(� ARCHITECT/FNGINEE0.: LIC NO: A DRESS: ❑
`1 H e
7
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ • ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby afrc that I sup licensed under provisions of Chapter 9(commencing -JOB DESCRIPTION
WOO with Secllon 700(oof Division3ofthe Business unit Professions Code,and my licomris RESIDENTIAL:
I- C in full force adrafte — PERMIT ISSUANCE�Vr Lice s Lia# ❑SFDWL C1 KITCHEN REMODEL
�Z, Dam Comrazmr APPLIANCES-RESIDENTIAL ❑ADDITION [3 PLUMBING RISPIPE
II�.py ARCHITECT'S DECLA TbN PANELS ❑MULTI.UNIT� ❑STRUCTURAL
Zn 7, 1 understand my plans shall be,used u public records - MODIFICATION
O p
:J UPTO200AMPS Z ElINTERIOR ❑CHIMNEY REPAIR
-,� {�t
Licensed Rofeanonal 201-10(1)AMPS IMPROVE
L$i '6j that I a exempt
m Ce ColosON OVER IIk90AMP5 ❑BAT MODEL EPAIR ❑DEMOLITION
er
I hereby affirm that 1 am exempt from the Contractor's Licenu Law far the
50W U following crown.(Section 7031.5,Business and Professions Code:Anyoily or county SIGNS ELECTRICAL HER
Cwhich requires a permit m omwarneL alter,improve,demolish,.tar repair any nromm
Print to in issance.aho requires the.pplicanl far such permit to file.signed.tatement SPECIALCIRCUIT/MISC.
y
That he is licensed pursuant to the provisions of the Contractors License Law(ChapurQi
9
Qp (commencing wird Sttuon]O00)of Divisian3 of Ne Business end Profession CddO or TEMP.METER OR POLE I COMMERCIAL:
1:2
o pf that he is exempt Iherefmm and the buil for the alleged exemption.Any violation of ❑NEW BLDG/ADDRION ❑DEMOLITION
IL Semon 7031.5 by ony applicant fors permit subjcns Nc applicant to a civil penalty of POWER DEVICES Z y not more than five hundred dollen(3500). ❑TENANT - ❑FOOD SERVICE
CpQ I,u owner ofthe IMPROVEMENT
LGA ❑ propny,or my employers wird wages este compensation. SWIMMING ELECTRIC
O will do f e work,and a The Cure artmes ended o Law does n t apply.]044,Business ❑OTHER
and property
who
Code The oviw tacmoa License Law dao not apply to if owner of OUTLETS TfCFiES-FIXTURES
4i 3 properly who huiW.or improves Hereon,end who does such work himself or through
his own employees.provided Nat such Improvements w am not intended ofr or oRcrM for NEW IDENTIAL ELECTR SQ FT.
swe.ILhowever llhave dhe burden
of percent issoldhe lid noncild or
improve
the Q.FT.FL BARBA LSQ.FT.
ower-s
owner-builder will have the burden o(proving that he did not build or improve for Fur-
pose o solo ' PAID
❑ 1,as owner of the properly,am exclusively connecting wird licensed cem.cmrs m TOTAL:
construct the project(Sec:]1144,Business sad Professions Cade:)The Comrinew a Li- /
'cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
License Law. �40V
rywho cenuacu forsuch projects with a conaaaons)licensed punuam to the Contractors a
ElI am exempt under Sec. ,B&P C far Nis recon PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATER(EAT
Owner Data ""--- -
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hcmby affirm under penalty affect.,o0 of Ne following declarations:
❑ Ih.ve and will maimuina Cerlificem of ConaenunsdGinsure for Workeia Comped- DRAINS-FLOOR,ROOF AREA,COND.
seated,n provided for by Section 37M of the labor Carter.for The performance of the _ S RTES TYPE CONSTRUCTION
o for which Nis permit is issued. MIXTURES-PER TRAP
hove and will maintain Workeh Compensation Insurance,as required by Section
37M of Be Lobar Cade.far the performance of Ne work I.,which
this
�pmmit is issued. GAS-EA.SYSTEM-I INC.40 S - OCC.GROUP APN
MyWoCanierrk<'ia�amrc`yypn.nallpg9q ymePoln No.ul - u,/I GAS-EA.SYSTEM-OVER 4 A)
C3CCETIRTIFICAATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEONDUSTRL TE INTERCEPTOR
(This smlion need nen he completed ifthe peris fordo handled doll..($100) BUILDING DIVISION FEES
or leas.) mit GREASE TRAP PIANCHECK FEE
Icenify that in the performance ofNe work forwhich this permit is issued,l shall SEWER- ITARY-STORM EA.20st
not employ any Front in any manner so as to become subject to the Workers'Compen- ENERGY FEE
0 ,Z san..Laws m'Calilmnia.'Date Wq HEATER WNENT/ELE=
Q Applicant GRADINGME
tiNOTICE TO APPLICANT:If,after making this Certificate of Exemption,you shouldpTER$VSTEM/fREATING
F^ become subject m the Workers Compensation provisions of the Labor Cade,you moat SOILS HE
Lal.) forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
�z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID Rceiptg
V Q Ihereby.ffnn that hem is a construction lending agency for the prfom.na of
He work for which this permit is issued(Sec.3097,Civ.C.) ,
Lenders Name TOTAL:
Lender's Address TOTAL:
yi L codify that I have mail this application and state that the above information is BUILDING FEE
V7) correct.l agree to comply with all city and county ordinances and shite lows binding to QTY MECHANICAL PERMIT I FEE
V F7 building commuction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)ngrae m s.ve,indemnify and keep hmmNd
less e City Cupertino against ELECTRIC FEE
liabilities,judgmenu,cosuand expenses which may unity way.ccme.gainsl said City ALTER OR ADD TO quMECH. PLUMBING FEE
I.consequence of the running of this Fall .
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO BLOW CFM) MECHANICAL FEE
.OU F GULATIONS. I
Lyll(](_ _ AIR HANDLING UNIT(OVER IO,o00 CFM) CONSTRUCfIONTAX
5 to of Applicam/Conessor OOaUt 7�V1 EXHAUST HOOD OAMUCT) -
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will Ne applicant or future building recupant stem or handle formal material HEATING UNIT(D)100,"BTU)
as defined by the CUFenin t Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(e)? HEATING UNIT(OVER 100.000 BTU) r W •fq
❑Yes 7 N - PAID
VENTILATION FAN(SINGLE RESID) Date Receipt is
Will the applicant or future building occupant use equipment or devices which BOILERCOMP(3HP OR 100.000BTU)
emit h.aardws air contaminants aminants defined by Ne Bay Ar -
ea Air Quality Management TOTAL:
DisldnT
Fl yes ON. BOILER-COME(OVER 100,000 BTU) 1- jGzs
I have read The hazardous materials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sessions 255G5.25533 and 25534.1 understand That if Ore NEW RESIDENTIAL MECH. SQ.Fr.building docs not currently have a tenant,that it is my respomibiliry to notify the occupant
of the requirements which mut be.1 prior m iaumtee of a Certificate of Occupancy.
�l
Owner or authorized agent Dam TOTAL: 5.0 ISSUED 11 :
OFFICE