31236 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL ,�,N
11. L
BUILDING PROJECT IDENTIF'ICA'TION
ILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
� 016y MA440 M LII CUPE127/iV0 , CA , oro/4 C� rjtx-�
NER;S NAME PHONE: CONII RACTORS NAME: LIC NO:
I' AL4 R U W/q/L1� AUMagNN 2 NIC CONIROhp
Im ARdII1TEC1'?:NC,INEBR: LIC N ADDRESS: El
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB
ME
LICENSED CON'TRACTOR'S DECLARATION [:] `
I hereby d01rm than 1 mn licensed under Provisions of Chapter 9(commencing QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
OqeZ with Section 7000)uf Division 3 ofthe Business and Proles+ion:Cade,and my license is RESIDENTIAL:
010- PERMITISSUANCE
moi- infullelfin. ❑SFDWL ❑KITCHEN REMODEL
I OF License Class Corr
6 U APPLIANCES-RESIDENTIAL ❑pDDIT10N ❑PLUMBING RE-PIYC
HG Dam Corrector
F.t2rn ARCHI"TEGFS DspubliRATION PANELS ❑MULTI-UNIT ❑SODIFTHRAO
1 understand my plans shall be used as public records MODIFICATION
OZ-Ez
UI'TO 200 AMPS
Fib.u] IiccnscJ l'rofcsshmnl El INTERIOR ❑CHIMNEY REPAIR
201-1000AMPS IMPROVEMENT
OWNE&BUILDER DECLARATION CornmON OVER IBWAMPS ❑BATH REMODEI/REPAIR El DEMOLITION
YY all 1 hereby affirm that 1 am exempt from the Contractor's License Law tier the
ixq4$OaU fallowing mason.(Section 7031.5,Bmine,,wed professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 LL rn which inquires a permit m conswn,alcor,improve.demolish,or repair any smucmre
'hat hor e%l cense p aDore to the the
ovisio so for suchpermitLicense Law
(Chapter
SPECIAL CIRCUIT/MISC.
�yp0that he is cing wiit pursuant to the provisions of the Commit ss nd Pro Law(Chapter 9
(commencing with Section 7tXk))ol Division Jof the Business and Pndessions Corle)nn ('ILMI'.MIiTEROR POLL INS'f. COMMERCIAL:
6 d pC ohm he is exempt therefrom and the basis far Mc alleged exemption.Any violation of ❑NEW BLDG/ADDITI El DEMOLITION
XmI+•
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 14)WER DEVICES
Worn ❑TENANT ❑FOOD SERVICE
no more than lift hundred dollars y amp.
IMPROVEMENT
�56Q 0 Lauowner k.We Propengmmy ematemicswith wages mmkival Im their sole SWIMMING IYX)1.EL
F will do dm work.and the he Corceremai Livensc Law do s ma apply T)44.owner
of
❑OTHER
I�i1"m and Prd'who is Cwlc:the Contractor's Licersc law does nut apply as if owner of OUTLETS-SWITCH S-FIXTI
property who builds or improves thereon,and who does m n sante himself.,Onhrdugh
his own employees.building
that such Improvements within arc nue iyearof or Offerepletiod far NEW RESIDENTIAI.HLE
aide.If,uilder ill hav thebmimpnrvemm�e itatheidone year or
improve
the SQ.FT.FLOOR AREA LSO.FI'.
owner-builder will have the burden of proving thus he did not build or improve for par,
pose of sine.). L /p
0 1.us owner rt the property,am exclusively contracting with licensed connector,to �'110
construct the priciest(Sec.7044,Business and professions CWc:)'Do,Cwwraemrs Li-
moo,Law does not apply to an owner of property who buildsor lniproves thereon,and QTY. PLUMBING PERMIT FEE e
who contracts for such projects with a contracto s)licensed Panama to the Contractor's
License Law. PERMIT ISSUANCE
I an rcpt under ,B&P C for this rectum (�
y r• ALTER-DRAIN&VENT-WATER(EA7 if-r`%/AIf,UAT10N
O %Dole
it WORK: O SATION DECLARATION BACK FLOW PROTECT.DEVICE V
1 hereby affirm under pcnaley of perjury one of We following declarations:
I hrecand will rumnnina Ccnilictimcd Comvn,to-If-insure for Worker',Campen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE.CONSTRUCTION
secion,ns provided for by Section 3700 of the Labor Code.for the perfomtanee of the
work for which this permit is ixmW. FIXTURES-PER'TRAP
O 1 have and will maintain Worker's Compensation Insumace,as required by Section
370()of the LaMmCsle,forthe performance ofthe work for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Worker's Compensation Insumnce carrier and Policy number we
Carrier: Pot icy Na.: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE Op EXEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
(This section aced not be completed if the permit is for one hundred dollars(k 1001 GREASETRAP
or less.] PLANCf{ECK PIiF,
Icenify that In eheperlitnnanceofthe work havel idOn,pennit is i,wL lsholl SEWER—SANITARY—STORM EA,200 F1',
On employ any Person in any runner so as to become subject to the workers'Compen- ENERGY FEE
oZ sarion laws of California.Date WATER HEA I'ER W/VENT/ELECTR GRADING TLE
Z Q Applicant
(•" rNOTICE TO APPLICANT:IL after making this Croaker,of Exemption,you should WATER SYSTEMITREATING
become subject to the Worker's Compensation proviainns of the Lobar Cale,you must SOILS FEE
{aEJ ? limhwith comply w On such provisions or this permit shall he deemed revoked. WATER SERVICE
d Q
7Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.FT. PAID Dote Receipts
L)0 1hcrebyaffi.m that there is.constmninn leadmitribmcy forth,performanceof
D. P the wink for which this permit is issued(Sec.3197,Ci,C.)
cy Landen's Name TOTAL'
U I<ndice,Address TOTAL:
C1 certify that 1 have read this application and state that Be adne information is BUILDING FEE
o-F.VE mrsse.1 agree to comply with all city and county ordinances and state laws mimics to QTY. MECHANICAL PERMIT FEE
U Z building construction,and herebyauthoracc expermnmtives of this city to came upon the SEISMIC FEE
above-mentioned pan,",fur inspection Purpmes. PERMIT ISSUANCE
(We)agree m edemnier
ofc,infy and keep hmits%the City of Cupertino against ELECTRIC PEE
liabilities.judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
/
in consequence of the granting OI this permit.
an
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO HL000 CFM)
MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IBOOL)CFM) CONSTRUCTION TAX
Signature o'ApplicaMCa^wnor Date EXHAUST 11005)(W)DUCTI HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(M 100,000 BTU)
as defined by the CuPanlro Municipal Crtde,Chapter 9.12,and the Health and Solely
Cede,Section 25532(9)! HEATING UNIT(OVER 100,000 BTU)
\ ❑Yes 0N VENTILATION PAN(SINGLE RESID) PAID
OP
�L Will the applicant or(marc huilding oxcupan use equipment nor devices which Nam Receipt N
BOILER-COMP(311P OR IW.IXIII BT
emU)
it hazardous air contaminants as defined by the Bay Arcaa Air Quality Management
MEAL:
Dasulcft
❑Yes ❑No BOILER-COMP(OVER 100.000 BTU)
i
1 have read the bwurdom mmerick requiremen,under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
(amid Health&Safety Cede,Sections 25505.8533 and 25534.1 miderowd Be.if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a mortar.Wan it is my responsibility to notily the occupant
of the imaimmems whi,h must be met Lino.or ismance of a Cer iliewc of occupancy.
Owner or authomted agent Date TOTAL: ISSUED BY:
OFFICE