31003 & 31155 t APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERh31'P N0 31155
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING-MECHANICAL
y, BUILDING PROJECT IDBNTIFICAI'ION
BUILDINGADDRESSSANITARY NO, APPLICATION SURMUTAL,DATE
i0
OWNER NAME:�sr� P� yl.: COhTRACT(lR'SynM1fE LIC NO:
U,J S N/C CONTROLN
ARCHITECT'ENGINHER: LIC NO: ADDR)fS a .���� l � �� ❑
CONTACT: PHONE: JSIAY,k'T BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MI7CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
h SI hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OaZ witev ior700OMDivicor3ofine Duninc,,:md
FCQOUUOFU Pmfds....m Cade,amyliencn PERMITISSUANCE
meae
RESIDENTIAL
LicenseCa « Lie. ElSFDWL :
O KITCHEN REMODEL
APPLIANCES-RESIDENTIAL. []ADDITION ❑PLUMBING RE-PIPE
+n 6 a Dam Contractor
F,O h ARCHITF=5 DECLARATION PANELS O MULTI-UNIT O STRUCTURAL
Z O Z 1 understand my plans shall he used us public records 1 MODIFICATION
OZ�M \ UPTO 200 AMPS OINTIiR10R ^ ❑CHIMNEY REPAIR
FW Licensed Professional 201-1600AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 1000AMPS OBATHI a REPAIR 0DEMOLITION
C Cd Q 1 hereby uffin i Iham I um exempt(mol lie Coulasu is Licence Law lOr We p
�a(06U followingrw...(Section 7031.5.Business aad Professions Code:Any city or county SIGNS ELECTRICAL OOTHI/t
1x13LLF' which ardor, pannam conarixt. II P damolikh.armixtirymmarone
prior to isu 1:o requires the pplc tfar such pc tto file a signed tenement SPECIAL CIRCUITIMISC.
E�(y that he is licensed pt to the prusisions oftl CominscloryL Low(Chapmr9
W��O� (commencng with Section 7")of Division 3 of the Bushes.and Prof .C(de)or TEMP METER OR POLE INST. COMMERCIAL
a ey 'bat he is exempt Wemfrom and Ilene basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DIiMOLITION
non Section 703 L5 by any applicant for a permit subjcns the applican to a civil penalty of POWER DEVICES OTENANT ❑FOODSERVICE
=6 on more than five hundred dollars(5500). IMPROVEMENT
O Lax owner of the pmpety,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC
C F-�o will do e work,and thavaccmre is not intended oroffered for sale(Sed.7M .Business ❑OTHER
rh
m and Pinfic,doa,Code '".Contractor's Li«me Law docs not apply to Ira nwmd ul' OUTL61'S-SWI'T'CHES-FIXTURES
property who builds or improves thereon,and whereas such work loimulf or through
baron cridoyees,provide)that such improvandnlr um tort intended Or ofkmd for NEW RESIDENTIAL EIACTR SQ FT.
sale.If.howev«,the building or improvement is sold within one year of completion.the SQ.I FL R SISQ.FT.
ter-builder will have the burden of proving that he did not build or improve for put.
owner-builder
1 of oats). 2 9 REC`0
co 1,as own«of that Sec.70,1 ,a.B excessively contesting wish Ilttnxd contractors In APR
Ise La the project apply
o an Business and rty who
Cale:) liepro Contractor's I.i
cense Law ease not epplyman owner of pmany who builds or improves Wemm.and QTY. PLUMBING PERMIT PEE
who contracts lin such projects ,ith a contampursuant orts)licensed pursuano the Commit.e.s CIN ur wetKONO
License Lrw. PERMIT ISSUANCE
❑ teat ceempl under Sri. .B A 1'C fur this edaawn
ALTER-DRAIN&VENT-WATER BE U VALUATION
wData
en WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby Infirm under penalty of perjury one of the following declarations:
O l have and will maintain eCerfficate of Consent mxlf-Imam for Workers Compete DRAINS-FLOOR.ROUR AREA.COAD. STORIES 11TYPECONSTRUCTION
sation,as provided for by Section 37(X1 of the Labor Code,for the performance of the
Is rk for which this permit is issued FIXTURES-PER'I'RAP
I have and will maintain Worker's Coa,e Imo Insurance,as required by Section
3 )(if the Labor Code,for petlinorance of Ilia work for which this permit is issued GAS-12A.SYSTEM-IINC.40UTLETS DCC.GROUP APN
CMy arncrrk ' ycryp/ensu sp fv&ficYN.:numbcram:
9�(/L✓J Y..4 GAS-IiA.SYSTEM-OVER 4(BA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This.section need not becumpleted if the permit is for one hundred dollars(4100) GREASETRAP
or Icss) PLANCfIF.CK FEE
I cmify Nutm the performance of the weak far which this permit is issuad.)shall SEWER-SANITARY-STORM FA.200 FT.
not employ any person in any manner m as m become subject m the Workers'Compen- ENERGY FEE
O Z sarion bows of California.Dam WATER HEATER W/VENT/ELEC R GRADING FEE
C) Applicant
y NOTICE TO APPLICANT: making this Certificate of Exemption.you should WATER SYS'rEWfREATING
F become subject m the Workers Compensation provisions of the Labor Crda you must SOILS IEE
forthwith comply with such pnskio dor his.unit shall be decradre,Oked WATER SERVICE
0
.ati. z
CONS]RUCTION LENDING AGENCY NIiW RESIUIiNT1A1.PhMB. SQ.FT. PAID m «ciptp
U O Thereby affirm that Were is a conwucdan lending agency for the perfammnce of
the work for which this .it ms issucdljec )97, IBJ
C) F .� TOTAL.:
OV Lender.Name ,�
,yI Lemder.naare.a nIrAL:
y 1«nay that 1 have mad wa application and state Wen me above minemmmn is ewLnlNc e
y cored«.I agree m comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z building constmctinn.and hereby authorize representatives of This vi ty m enter upon the SEISMIC PEE
above-mentioned property for inspection purposes. PERMIT'ISSUANCE
(We)agree to xm'c.indemnity and keep hornless the City of Cupcnino agaiml ELECTRIC FEIi
Iiahilitics,judgment.costs and expenses which may in anyway accme against said City AUITRORADDTOSIECH. PLUMBING FEF.
in mdquendc of the 6mone,Of mhis permit.
APPLICANT UNDERSTANDS AN 'ILL COMPL ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM) MECHANICAL FEE
SOURCE REGULATIONS. 1//
AIR HANDLING UNIT(OVER I0.OIXI CFM) CONSTRUCTION TAX
Signature of Appl' tacnmr Data EXHAUST HOOD(W/DUCT) HOUSINGMITIGATIO, FEE
HAZARDOUS MATERIAE. .CLOSURE
Will the applicant or future building hal alxtumur handla htom, material HHATINGUNHr(TO IOOIOOBTU)
ovaefined by the Cupertino Municipal Cale, ha deo 9.12,uncithe Health mad Safety
Code.Section 25532(a)'.' HEATING UNIT(OVER 100,(N)O BTU)
,1Yes ON. pglO
J VIPN ILATION FAN(SINGLE.RpSID) Date Receipt p
Will the applicant or future building occupant use equipment or devices which
emit bozumlous air cnnmminums us defnal by the Bay Area Air Qtolity Management BOILER-COMP UIIP OR 100,000 BTU) TOTAL
District? BOILER-COMP(OVER 100.0(RI BTU)
OYes No
I have hand We hmallous railviruilk"incomes,under Chapter 6.95 of,hc Cali AIR CONDITIONER ISSUANCE DATE
understand
formegit.&Safety Cade.S«tions255115.Mayand25531.1mmarry m boat If the NEW RESIDENTIAL MECH. SQ.FT.
(wilding Jure eta currently have a¢note.Be,it Isrmy respomi an,Y m naifY We occupant
of the rcyuiremems which run he nx wisxunnce cm to
Owararaulhmimdagent al T(J FAL 1SSUEf)DN
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DATE: �r�I 9 REVISED
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