31076 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. ^ ,g 0.S
BUILDING DIVISION APPLICATION/PERMIT311 PLUMBING-MECHANICAL 1 6
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
!o 17ANILg
OW�NCRSNAME: PHONE: C/ppy�'1�RACTOR'SNAME: /fit/ LIC NO:
::5, N4 N/C CONTROL p
ARCHITECT/ENGINEER: LIC NO: Ayi / / 5f El
f.ts�n L� 17I�
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant F"S Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
1:1 El )ppc.r-'� ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby af(ip that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
D00 with Section 7000 of Division 3 afthe Business and Professions Code,and license is
wt fall force y PERMITISSUANCE RESIDENTIAL:
Iy LiceneClass deflect. OSFDWL O KITCHEN REMODEL
�Vz License Class Contractor
APPLIANCES-RESIDENTIAL
Date Commmmr ❑ADDITION -4r*PMBING
ZO yZ
PIPE
CQ'S DECLARATION PANELS OMULTIANIT STRUCTURAL
1uokemndmypl.a than beusedos public reemrds MODIFICATION
OZpp— iceUPT0200AMP5 ❑INTERIOR ❑CHIMNEY REPAIR
0,4 t Lnsed Professional ed 999 OWNER-BUILDER DECLARATION 201-IfKK1AMP5 IMPROVEMENT
ag
'y+fd 6 1 hereby affirm that I am exempt from the Contractor's License Law for the OVER 1000AMPS [IBATH REMODEIBEPAIR 0 DEMOLITION
x a 0.V following reason,(Section 7031.5,Business and Professions Code:Any city m county SIGNS ELECTRICAL OOTHER
lil LLtL O�Q which requires a permit to construct,altar,improve,demolish,or repair any mo etum
m.l prior to its issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUCOMISC.
po Nat he is licensed pursuant)the provisions of the Contractors License Law(Chapter 9
(commencing with Section 7")of Division 3ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION
X�
Section 7031.5 by any applicant for u perm otbjectstheapplicantto.civil penalty of POWER DEVICES
I1+s77 } nm om data five hundred dollars(55W). ❑7Pv`1ANT El FOOD SERVICE
tn
1^3Q 01,as owner of the property,or my employees with wages m their sole compensation,. SWIMMING POOL ELECTRIC y IMPROVEMENT
G will do the work.and the structure is not intended orn0'ered for sale(Sec.7044,Business ❑OTHER
end Professions Cade:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-T XTUR
propcny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such inrprovemenure anrn intendlTe
ed or nreJ for NEW RESIDP.NTIAL EL
crk SQ FT.
.Me.If.however.the building or improvement is sold within one year ofcompletion,the SQ.ROFIQOgysp$p USQ.FT.
owncrbuilder will have the burden of proving that he did not build or improve for put-
post of".1a.)
E]1,as owner of the property,um exclusively contracting with licensed contractor m TOTAL NARanswctthe project(Sec.]M4,nosiness and Professions CNet)The Contractors Li-
came 11 �[(Ss�
came Low does not apply to an owner of property who builds or improves ereon,and QTY, PLUMBING PERMIT FEE REcp
who contracts for such Projects with a con memo.)licensed puts umn e,the Comrucmr's CITY
License Law.
I ton exempt under Sec. Nisas
B&P C far reon Uf
PERMIT ISSUANCE (;UNEHI INU
Own<r Data ALTER-DRAIN&VENT-WATER(CA) VALUATION
WORKER'S COMPENSATION DECLAMATION BACK FLOW PROTECT,DEVICE
I hereby affirm under penalty of perjury one of the following deductions:
0]have and will mainmina Certificate of Conssnuo sslf-insure for Workers Compere- DRAINS-FLOOR,ROOK AREA,GOND, STORIES TYPO CONSTRUCTION
sation,as Provided for by Section 37M of thmta
e Labor Cade,for the perfonce of the
work far which this permit is issued. / FIXTURES-PI?R TRAP
0 I have and will maintain Worker's Compensation Insurance,u required by Section
37M of the Labor Cole,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
MyW OCC.GROUP " APIS
Caber sCnmpem-I nlnsmrunce cmricraN]'slimy 6omher a3G� GAS-VA.SYSTEM OVER 4 E1O
Carrier: Policy No.: Alf
cRTIFlCA :ONEXEMFf10N MOM WORKERS'
COMPENSAT]ON INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
or less.)(This suction need not bemompleuxl Box,pepir is formal hundred dollaoll GREASE TRAP BUILDING DIVISION FEES
PLANCHECK FEE
Ioy my Rutin hemin perforzmy
nnce erof theork becom whichthis theWokam'Compact.
SEWER-SANITARY-STORM EA.21X)IH'.
not employ any person in any manner so all,become subject the Workers Compere ENERGY FCC
Z sation laws erCuffomia.Data
WATER HEATER W/VENf/F.LF.CTR
O NOTIApplCE GRADING FF.G
NOTICEbj APPLICANT.-If,after looking this Cisions fol Exemption,you should WATER SYSTL'M?RGTING
i.>
becomeh comply
with
Compensation provisions ofrhe Lahr Coke,you most SOILS FEE
CL, fmnhwith comply with inch provisions or this permit shall he deemeJ revoked. WpTF.N SERVICE
4Q
CONSTRUCTION LFIJDINGAGIgNCY NEW RESIDENTIAL PLMB. SQ.FC PAID
LLP I far
that thereisacd(See.0lending agency for pedbnnance of Date ReceiptM
(A the sums for which this permit is issued(Sec.J89],Civ.C.)
O landeName TOTAL:
LU Lendc rn Address
I T
0. certify that 1 have read this application and ante that the shove information it BUILDING PGE
N correct.l agree to comply with all city and c....yordinmoce,and stem laws relating to QTY MECHANICALPERMIT FEE
U building construction,and hereby authorize representatives ofthis city to enter own the SEISMIC FEE
abovcmendenc l property for inspection purposes. PERMIT ISSUANCE.
(We)agree to save.indemnify and keep hapless Be City of Caperton against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City pLTE0.OR ADD TO MECH.
in asequence of the gmming of this permit. PLUMBING FGE
P CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('f010,g1U CFM)
SOU Poll
CE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
Signature of ApplicanUConuacmr Date EXHAUST HOOD(W/DUCO HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Neapplicant or future building mcupant.omem handle hazardous ma[ed.] HEATING UNIT(TO 100,008 BTU)
as defined by the Cupertino Municipal CNe,Chapter 9.12,and the health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 HTIE
❑Yes ❑em VENTILATION FAN(SINGLE RESID) PAID
Dam Ruccipt0
Will the applicant cont atoms.building by the B use equipment Quality
Managemewhichnt
BOILER-COMP(3HPOR 100.0 [UpTE
emit hazardous air comamiroenu rev defined by the Dry Area Air Quality Management TOTAL
District?
OYes E]No HOILP.R-COMP(OVER IIXI,(Np RFU)
I have real the hourdom materials aquimmm's Me,Chapter 6.95 mFine Cali AIR CONDITIONER ISSUANCE DATE
fornia Health&Safety Code,Sections 25505,25533 and 2.5534.1 understood that if the NEW RESIDENTIAL MECIL SQ.IIT.
building does not currently have a tcnanr,that it is my responsibility to notify the occupant
of Ne requirements which most be met prim to issuance of a Cani garde of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE STIM