31101APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERT'INO nwt,upoc,. ns.nu nta,wp. I ooliI • . I�
BUILDING DIVISION APPLICATION/PERMIT t I'I.UMRING-MFCHANIC AI. 31
101
OFFICE
FEE
0
BUILDING PERMI'P INFO
I
HUNG ELECT' PLUMB MEOI
1 F -1F -1A ❑
JOB DESCRIPTION
CONTACT: rnurvm
'
❑ADDITION'LUMBINGRE-PIPE
'9 22
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CON 'FRACI'OR'S DECLARATION
I hereby affirm that I am liecmd munder pi -visions of Chapter 9 (commencing
with Section's") of Division 3 of the Business and Professions Code. and my license is
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Littnlsa ClassnJ <ffect.e G Lie. o61' I
Data Cnnnaeor
QTY ELECTRIC PERMIT
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WOO
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O Z.4 0
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
ARCHITECT'S DECLARATION
I understand my plans shall he used mi public records
_
PANELS
UPT0 200 AMPS
1- W
4 bd�-,.1
C 1 C Q
X6 U
613 LL h
�a0
Licensed Professional
OWNER-RUILDER DECLARATION
the Contctnr's ccnm Lw for the
1 hereby affirm that I am exempt fContractor'sLi
following reason. (Section ]031.5. Business and Professions Calc Any city or county
which requires a permit to cnmuact, alter, improve, demolish, or repair any s p cture
prior o itsissuance. aim requires the applicant forsuch Pcnnitto file a signed statement
201-1000AMPS
OVER IIIIN)AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUFI'/M ISC.
that he islicemedpunumatothe provNams(if the Compactor'sLicenml.owChapter 9
W Q
Q. a c ty
(commencing with Section 7")of Division] of the Business and Professions Calc) or
that he is exempt therefrom and he hasis nation alleged exemption. Any violminn of
Section 7031.5 byenyapplicantfora permit subjects the applicant ton civil pcnulty of
TEMP. METER OR POLE INST. 1
POWER DEVICES
ESC❑1,
p..
4 m
not name, than five hundred dollars ($500),
nn ownend the pmpeny, or mYcmpleYee. with wagesatheir sole compensation.
will do the work, and the structure is not intended or offered for sale (Sec. 0044, Business
and Pr inns Calc: The Contractor's License I.aw Jogs not apply to an owner of
SWIMMING POOL EE.ECI'RIC
OUTLET'S- SWI 'ICHIS-FIXTURES
who builds or improves thereon, and who does such work himself or through
NEW RESIDENTIAL ELEC R SQ FT.
pmpony
his own employees, provided that .such improvements ore nm informed or offered for
sale. If, however, the building or improvement is sold within one year of completion. the
-builder will have the burden of proving that he did not build or improve lir pup -
verr
�afame.).
Fl 1, as owner of the pm , part an exclusively contracting with licensed contractors to
TOTAL:
construct the project (Sec. 9044, Business and Pmfcsslam Coda) The Contramor's U.
use Law does not apply to an owner of progeny who builds or improves theater, and
QTY. PLUMBING PERMIT
who contmets for such projects with u cnmremor(s) licensed pursuant come Contractors
PERMIT ISSUANCE
License Law.
❑ 1 am exempt under Scc. . B & P C fur the, reason
ALTER - DRAIN & VENT- WATER (EA)
Owner Data
WOR KER'S COMPENSATION DECLARATION
BACK PLOW PROTEGE. DEVICE
•
1 hereby affirm under penalty of perjury one of the declaraWalker ions:
❑Ihave and will nforb ination37 to of to inllowingsumfor
bor forthe Worker'sConipan-ceofte
DRAINS -F1,00R, ROOF, AREA, COND.
Code,
mons, a provided for by Section J]00 of the Lahr Cttle, for the perfomonc< of the
the
work for which his permit is iamad.
FIXTURES - PER TRAP
Comp oft the w akfar. Immune, h require) by Senior
1 have and will maintain he mr,Performance
J]W of the LaborCWe. 4r the perfonnancc of the work forwhich this permit is issuad.
GAS - GA.SYSTEMd INC. 4OUTLLTS
GAS -17A. SYSTEM.OVIiR4(EA)
My Worker'sQQ top((nmtin 'and Policyy ras[•� •1
Cartier S'YSTP etzrance game, unit ufic ` sn� ('c)
GREASMNDUS'I RL WASTE INO ERCI?PfOR
CERFIFICAI'1: OF IiXL'MPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
(This section need not M completed if the permit is for one hundred dollars ($100)
or loss.)
SEWER -SANITARY -STORM EA. 2W FT.
I ofify that in the performance offm work for which this Permit is issued. )shall
not employ any person in any manner sit as in Ncom, %object to the Workers' Camper -
N
WATER HEATER W/VETMLECTR
O
Date ''
sof Callfumiu. De
Applicant
App
a �
0
UO
F•'
O ULenmm'e
.F.N
NOTICE TO APPLICANT:If, after making this Cenifcaw of Exemption. you should
become sa ijam 1. the Workers Compensation provisions of the l.alwr Cut ,at most
forthwith comply with smf provisionsor this permit shall Na deemed revoked.
CONSONLENDINGAGENCY
1 weary affirm the thereem is rs aa cmmwnron lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Co. C.)
Name
L<nJcls AdJrez.
WATER SYSTF.MITREATING
WATER SERVICE
NEW RESIDENTIAL, PLMR, SQ. FT.
I candy that I have rand this apPllamon and state that the aMve information Is
erect. l agree in comply with all city and county ordinances and state laws miming to
QTY. MECHANICAL PERMIT
U Z
building coronation. and hereby authorize representatives of this city to enter open the
PERMIT ISSUANCE
above-mentioned pailapy for impaction purposes.
(We) agree to save, indemnify and Lapp harmless the Cay of Cupertino against
ALTERORADDTOMECH.
I' mhditics,juJgmemzenstsa paperer which may in anyway acerae against said City
consequence t gran' ""'hap"
af this pent'
APPLICAN ER' ANDS AYIT LCO�'WITH ALL ION.pOINT
AIR HANDLING UNIT (TO I0,t1(IIICFM)
SOUR r L (r/
9
JAR
AIR HANDLING UNII'(OVER IO,OIXICFM)
S' Data
EXHAUST HOOD OYMUCFI
HAZARDOUS MATER( .S DISCI,OSURE
Will the applicant Or future building occupant stare or handle haeardoue material
MEATI NG UNITtTO 1 W,000 III U)
HEATING UNIT (OVER 100.001 BTU)
as defined by the Cuperino Municipal Code, Chapter 9.12, and the Health and Safety
CaR. Section 255320)]
VEVI'IIA'110N FANS INGLE RP_SID)
E] Yet ❑Nu
Will the applicant or future building occupant use equipment or davims which
emit hazardous air rnma rater s as defined by the Hay Arca Air Umbry Mnnagcmem
BOILER-CUMP(Jt{p OR IW,UIX)BTU)
BOILER - COMP (OVER 100.00) BTU)
Distti a?
p Yes E] No
AIR CONDITIONER
I have teed hoz us termly realmomems under Chapter 6.95 of the Cali-
NEW RESIDENTIAL MECH. SQ. FT.
fomia Heehh & S' dy Ie SectmnS.�SITS. 25533 and 2SSJ4. I understand that if the
buildingdoe un yha earyt/4�(i. thmit is my asrymsihiliry tonotify Jtpoccupnnt
OFFICE
FEE
0
BUILDING PERMI'P INFO
I
HUNG ELECT' PLUMB MEOI
1 F -1F -1A ❑
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
O KITCHEN REMODEL
❑ADDITION'LUMBINGRE-PIPE
❑MULTI -UNIT
❑S RUCTURAI.
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
❑ BATT REMODEUREPAIR ❑ DEMOLITION
❑OTHER
COMMERCIAL
❑NEWBLDG/ADDITION ❑DEMOLITION
❑TENANT ❑FOODSERVICH
IMPROVEMENT
El OTHER
SQ.
PAID
)NAR 17 IEC`
GI'I Y Ur uurtrl I INU
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date
TOTAL:
BUILDING FEE
FEF. SEISMICFEE
ELECTRIC FEE
PLUMBING FEE
I HOUSING MITIGATION PCT. 1
PAID
Dam Receipt p