31034 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMITNO. 1 3.I O3(�,
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS; SANITARY NO. APPLICATION SUBMITTAL DATE
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OWN"V. P F: ,/ _ CONTRACT 'S L
7LLC.Y/)
NIC CONTROL N
�ACHITECT I •ER: LIC NO: AD
CONTACT. rj�� PHONE. 912G(/�� BUILDING PERMIT INFO
•!�/' 0 Consultant Fees Paid by Applicant(Initial) BLD PLUMB MECJi
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LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE /►R'{tI
1 herchy afOrm that I vat licensed under provisions of Chapter 9(rommm�cing JOB DESCRIPTION
O0z with Section 7")at Division J ofthe Businessam feast ns Co dray license is
E�00 PERMIT ISSUANCE
RESIDENTIAL:
!y� infullforceendef a
ju License Cl t ss (// Lic.N ❑SFDWL [I KITCHEN REMODEL
ZW Dem Convacmr APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
I.. on ARCHITECT'S DECLARATION PANELS
[I MULTI-UNIT ❑STRUCTURAL
Z O y$ I undcmunJ my Plmts shall be used as public records MODIFICATION
OZ'-!CC]�� UP 10200 AMPS ❑INTERIOR - El CHIMNEY REPAIR
F.� LicemcJ l'rofneionnl - 201-HXq AMPS IMPROVEMENT
OWNER-BUILDER m Ce Cmil ON OVER I"AMPS 1 hereM1y effrm that I nm exempt from the Contractors License Law for the ❑BATH REMODEVREPAIR ❑DEMGLITIGN
O,U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL C OTHER
Oi" which madras a permit m conewet,alter,improve,demolish,car repair any structure
poor o its issuance.also requires the applicant for such permit o file a signed statement SPECIAL CIRCUIT/MISC.
y C� NoicvnW pursuanuothe pmvisionsmmcenuls
(commencing with Smion]OIXI)ofDivisinn3 ofthe Business and Professions Code)or
--
TEMP.MLrfER OR POLE INST. COMMERCIAL•
as q y that he is exempt therefrom ual the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
at IL
Section 7031.5 by any applicant for a Permit subjects the applicant o a civil penalty of POWER DEVICES
al y not mom then rive hundred dollen(5500). []TENANT ❑FOOD SERVICE
1"?} IMPROVEMENT
� �Lothe work,and property,nr myotimenlodorowagesrsale( m.compensation. SWIMMING FOOL ELECTRIC
W will dothewmk.Curb: structure a to s License aw doesffersed
apply to a Businessi.Q OTHER
W amt Professions Curb:The CantmcuKs License Law does not apply to m owner of OUTLETS-SWITCHES-FlXTURFS
la'3 property,who builds or improves thereon,and who does such work himself or through
his awn employee.,provided that such improvement are not intended or oRerol for NEW RESIDENTIAL ELECTR SQ PT.
sale.ILhowever,the building or improvement issoldwaddroneyearofcompletion,theSQ.FL RAREA S/SQ.FT.
owner-builder will have the hunfen of proving that he did not build or improve for pur- ��/
pomo(sa1eJ. I x
C 1,as owner of the property,un exclusively contracting with licensed contractors to TOTAL
construct the pmjwt(Sm.7044,Business and Professions Cade:)The Contractors Li.
cense Law does not ply it)an owner of propeny who builds or improves thereon,und QTY. PLUMBING PERMIT FEE
who contracts broach projects with a contractor(s)licensed pursuant to the Commnafs
License Low. PERMITISSUANCE
❑I am exempt under tics. ,B&P C for this reason
Owner GasALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE a��
I hereby uffrm under penalty of pcipay one of the following dechanura ��//{5
I have and will maintain uCenifcateofConsenuoself-insurcfor Workers Compere- DRAINS-FLOOR,ROOF,AREA,COND, STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37W of the Labor Code,for the performance of the
Kw k for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,az requital by Section
3] ofthe Labor Coda for the Performance ofthe work for which dui Monislamed. GAS-EA.SYSTEM-I INC.40UTLETS OCC.GROUP pPN
My Werke . na Q Iyyssre cammand Policy nyt4tK o77�1Y GAS-EA.SYSTEM-OVER 4(EA)
Carrier. Policy g v•�"
CERTIFICATE E IINN FROM WORKERS'
COMPENSATION
INSURANCE GRFASInNDUSTRL WASTE INTERCEPTOR
or less.)
(Ibis section need not he completed if the permit is For one hundred dollars(S IWGREASETRAP
) BUILDING DIVISION FEB
PLANCHECK FEE
(certify parism I.Mforsaym num ofthem,I beeramwhichtt eons,mideissued'rilituill SEWER-SANITARY-STORM EA.2W FT.
nonmilitary any .,lib in any manner so os to become subjccno the Workeri Compcm ENERGY FEE
Applicant
Laws of Cali ban.Data WATER HEATER W/VENDELECT0.
0 Applicant GRADING FEE
L11 NOTICE TO APPLICANT.IL ager making this Certificate of Exemption,you should WATER SYS]RMRRF.ATING
abecome subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
[Ta 0 forthwith comply with rash provisions or this permit shall be deemed revoked. Wp]'ER SERVICE ^ i r
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM. SQ,IT. PAID
V 0 Iherehy uffrm that there iv nconswdion lending agency for the performance of Date Receipt
Lk. 1. the work far which this permit is issued(Sm.3097,Ci,C.)
V Lenders Name I JUN Z4ALqU
W Lenders Address TOTAL:
1 coni fy that 1 have read Ibis application and state that the above intonation is BUILDING F E
ra/1 runnel.l agree to comply withal)city and county ordinances and ante laws relating m QTY. MECHANICAL PERMIT FEE
V huildingcoustmetion,and herchy anthofimnepresenutives ofthis city toenterupon Ne I SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)ogme m save,indemnify and keep harmless the City of Cupertino again ELECTRIC TEE
Iiabilitiea,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this Permit. PLUMBING FEE
APPLIC T UNDERSTANDS AND WILL COMPLY WITH LL NON-POINT AIR HANDLING UNIT(To to."CFM)
SOU OULATIONS. MECHANICAL FEE
In AIR HANDLING UNIT(OVER lo,"CFM) CONSTRUCIONTAX
igna mem'Applkanucantmcmr if Date EXHAUST HOOD(W/DUCTJ
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or,furore building occupant store or handle hazardous material HEATING UNIT(TO I art"BTU)
m defined by the Cupertino Municipal Code.Chapter 9.12,and the Hudm and Safety
Code,Section 25532(a)7 HEATING UNIT'(OVER IM."BTU)
❑Yes No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt is
Will the air motor i future building occupant use equipment or devices which
emus hosannas air ttmmminemamdefincd by the Bay Area Air Quality Management BOILER-COMP(JHPOR IW,OOB BTU) ITT-
Diwnct7 ` / BOILER-COMP(OVER HXJWO BTU) TOTAL:
❑Yee M1M,t
AIR CONDITIONER
have rcnJ the hueonlous materials
rcquimnems under Chapter 6.95 of the Culi- t ISSUANCE DATE
fomin Hcolth& ' ty Calc,Sect ons 255(15,255A and 25514 1 understand(hat if the NIEW RIESIDENTIALMECH. SQ.IT.
banklm does tc only hoveetenam drat loamy reapnns M1il'tyt ottfy Ne cecupw1
ofth eq which must he met prioroissuance ufe rtf f cupancy.
ero aha ze n a - Date TOTAL: �" ISSUED BY:
OFFICE