31343APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIUILDING - ELECTRICAL, PERMIT NO. 31343
BUILDING DIVISION APPLICATIONIPERMIT PLUMB ING-MECHANICAI.
�Z L�D I ❑Consultant Fees Paid by Applicant (Initial)
1 hereby aRmm that 1 am licensed under provisions o1 Chapter 9 (comnleneing
acOZ with Section 7")of Division 3o fine Business and Professions Crile, and my license is
i - W O in full force add effect.
N�License Cleo Lic. a
F � W Dam n
Cntracmr
6
ARCHITECT'S DECLARATION
Z ODan
H? I undersand any plans shall he maul us public records
OZ—�
J Licensed Professional
OWNER-RUILDER DECLARATION
C , 1 hereby off lrnt net 1 ran exmnpt from the Commetor's License Law lit the
K, a U following reason. (Section 70315. Business and Professions Codr, Any city or county
W bcy which rata permit to construct. alter, improve, demolish, or repair any stmeare
prim m it., issuance, also requires the applicant for lush permit to file a signed smtemem
that he is licensed pummintto the provisions oftheCourudoesLicenseLaw (Chapler9
W 0 (commencing with Section ]WO)of Division 3 ofthe Businessand ProfessionsCodc)or
Ia. a e C that he is exempt therefrom and the basis for the alleged exemption. Any violation of
mSection 7031.5 by any applicant for a petit subjects the applicant to a evil penalty of
not mote than five hundred dollars CINXIB.
fS ❑
],as owner of the property, or my employees with wages as their sole compensation,
F will do the work, anJlhu suunurc is not amand,dor offered fur sale (Set.]1M4, BmirrNss
Wand Professions Code: The Cionalmr's License law does nal apply m an owner of
a 3 progeny who builds or improves then on, and xbo dm%such work himself or through
his own employees, provided that such improvements an not intituled or offered for
sale. If, however,the huilding or improvement is sold within one year of completion, the
vwnvrlamlder will have the burden of Prov ung that he did not build (ir improve or per-
, pose oGsale.)
❑ I. as owner of the limit am exclusively contracting with licensed contractors m
ouswn the project (Sec. ]IW, Business and Professions Cade:) The Contra lob Li
i-
nse Low does not apply to an owner of propeny who builds or improves thereon, and QTY,
who enntaa, for such project, with a conammr o I canoed parvenu to be Cnuto"ou s
License Law. \
I am exempt under Sec. ,B&P C for this moron
.Owner Date s
WORKER'S COMPENSATION DE LARSHON
1 hereby affirm under penalty oeperjury one o theself insure ing decimation
❑ I hate prod will! for by
a Ci,,a 37 a of he Labor
Code. fart fur Workefs Cnmpen-
weakfas hick flu forrro Section 3]00 of the hMr Cade, for the pcAonwwe of the
work for which Boos permit is iorkJ.
1 havethe
and wit l ode, for Worker's ante of%he w rkfor ce, h his raqPer by Section
Myof the labor Gone, for theurance Cance of the work for wbich this peril i, issued.
My Workers Compensation Insurance tamer and Policy number art:
Carrier. Policy
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
[This section used nal bcmnnpincJ iflhe permit i, for onchundred dollen IS I W)
or less.)
1 certify that in the performance ofthe work for which this permit is issued. I.shall
not employ any goon in any manner so as as become subject o the Workeri Compen-
C) Z, satlan laws of Cutifinmia. Data
Z 0 Applicant
NOTICE TO APPLICANT. If, after making his CeniGcare of Exemption, you should
a , became subject to the Workers Compensation provisions of the labor Code, you must
forthwith comply with such provisions or this permit shallM deemed revoked.
Q
CONSTRUC'OON LENDING AGENCY
U O l hereby affirm that them is a construction lending agency l or the performance of
F the walk for which this petit is issued See. 3097. Civ. C.)
Q U Lenders Name
r M Lend,6AJdresa
0. 1 certify that 1 have read this application and .state that the oboe infrounumn is
rN coned. l agree to comply with all city and county ordinances end stale laws relating to QTY.
V z building construction. mal hereby autbonae reptexntmives of this city to enter upon the
abmvouentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in nse4uence of the granting of this Petit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1. NON -POINT
SOURCEREGULATIONS. /7 / J I J p
HA' ARDOUS MATERIALS DIS OSURC / c
Will Ne apdica or fmure building oecupam st nr handle hazardous material
as tier, tied by the Cnpc 'nn Municipal Code. Chnpm 9.12, and the Health and Safety
Cute, Section 23532U0'I
❑Yes E3 No
Will the applicant or future building ace Z use equipment or devices which
snit hamNous air conmminana m defined by he Buy Arca Air Quality Mamsgement
Dionid?
❑Yea L] No
I have read the hazvdous materials requinments under Chapter 6.95 of the Cali -
h m e health & Safety Code, Sections 25505, 25533 and 25534 1 understand that if the
but lding does not cooendy bossyjX}} n6 th�uyy ray re,ounchility,, notify theaccupam
of he poinmmrnBwhich tri a,,I' /loo im of a Cenificalepf Occupync,
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPT0200AMPS
SIGNS ELECfRI 0.D
SPECIAL CIRC MIS .
'TEMR. MEHF..ROR OLE INST.
POWER DEVICES A
SWIMMING POOL ELECTRIC y
'., -SWITCHES-FIXTURES
NEW RESIDENTIAL F.LECTR SQ PT.
PLUMBING PERMIT
PERMIT ISSUANCE 77
ALTER - DRAIN & VENT- WATER EA)
MACK FLOW PROTECK DEVICE
DRAINS- FLOOR, ROOF. AREA, CONE).
;FIXTURES -PER TRAP Gte
GAS - EA. SYSTEM -I INC.4 OUT LE'I:S
GAS- EA. SYSTEM OVER S (EA)
GREASFIINDUSTRL WASTE INTERCEPTOR
GREASE TRAP
SEWER -SANITARY -STORM EA. 200 FT.
WATER IIFATER W/V EN'DELECfR
WATER SYSTE LTREATING
WATER SERVICE
NI?W RESIDENTIAL, PI.MB, SQ. ET
MECHANICAL PERMIT
OR ADD TO MI!CH.
10,t3WCFM) 1
?R UDXXI CFM)
EXHAUST HOOD (W/DUCT}
❑
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 1110,000 BTU)
VENTILATION FAN (SINGLE REMO)
BOILER - COMP (3HP OR 100,000 BTU)
le
BOH.13R -COMP (OVER 10O.W0 B'Of
AIR CONDITIONER
'ter.
NEW RESIDENTIAL MECIL
SQ. PT
OFFICE
l�-tat 6
Lie,
❑
1 W26_5
BUILDING PERMIT INFO
tlLUG ELECT PLCr UMB MUCH
NEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑AUDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODBUREPAIR ❑ DEMOLITION
❑ OTHER
'ter.
COMM .
❑ ' SW BLDG/A ION ❑ DEMOLITION
'NANT C/ ❑ DSERVICE
IMPROVEME
❑ OTHER
SQ. FT. FLOOR AREA
S/SQ, FT.
FEE
VALUATION
SiG�jc�C7
STORIES
TYPECONSTRUCHON
I�
OCC. GROI'
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U .I GDIVISIONFFF.S
PLANC i,
ENERG 1 F.
GRADING FLEI
SOILS FEE
PAID
Date eipt
FEE
FEE
SEISMICIll
WTO�TAL:BUILDING
ELECTRIC FEEPLUMBING NEE
MECHANICAL FIPA
CONSTRUCTION TAX
HOUSING O
PAID
Date Receipt p (\
ISSUANCE DATE
ISSUEDBY: