31012APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL PERMIT N0
31012
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
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�%RCHfrECT/EN EER: LIC XIII
ADDRESS:
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CONTACT : PHONE:
BUILDING PERMIT INFO
VALUATION
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❑ Consultant Fecs Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CON TRACTOR'S DECLARATION IQTY.
1 hereby afthm that 1 am licensed under provisions of chapter 9 (commencing
with Senium]1111(8 of siun3of,her Business and Professions Ede. and mylicenxis
in full force and effect.
Liccnsc Class Lic.p
Dale Co..,.,
ELECTRIC PERMIT FEE
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FIXTURES - PER TRAP
JOB DESCRIPTION
RESIDENTIAL:
C] KITCHEN REMODEL.
[]ADDITION [I PLUMBING RF: PIPE
❑MULTI -UNIT OSTRUCTURAL
MODIFICATION
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECTS DECLARATION
IundersmnJ any plans shall heated as public reenact;PANELS
GREASFANDUSTRL WASTE. INTERCEPTOR
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ly
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�LL�((OaU
3
GRF,ASETRAP
UPT'0200 AMPS
[I INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR C1 DEMOLITION
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❑OTHER
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm on 1 am exempt from the Comracmr's License Law for the
folknomime. 7031.5. Cook: Any city or county
201-1000AMPS
OVER IINNIAMPS
SIGNS ELECTRICAL
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ver, demolish.
which ngnires a permit ,n uma,rvcl, alien infpnrvc, dmnnli.vM1, nr repair any structure
aIstrhit t commit. alter. improve,
prior to its isaaance, hisn requires the applicant for such permit o file a signed statement
that he is licensed pursuant to the Pntv'izions of the Contractor" License law (Chapter 9
PAID
Yp/—i"�_i13
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST
COMMERCIAL:
Lenders Address
(commencing with Section 7000) of Division 3 of the Business and Professions Cade) or
LL1C00
d d e
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Q'TY. MECHANICAL PERMIT PEE
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p.
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Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
not mom man rive hundred dollars ($5100).
ar owner nl'the property, or my cmplayecs with wages as their sole cotnperoafion,
will clothe work, and the suucturcrsnot intended or offered for sale (Sec. 9014, Business
and Professions Cnde: The Contractor's License law does not apply to an owner of
property who bull], or impones,heruon, and who docs such work himself or through
POWER DEVICES
TENANT ❑ FOOD SERVICE
IMPROVEMENT
0THER
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10,000 CFM)
his own employees, provided that .such improvements are not intended or offered for
safe. IL however, the building or improvement is sold within one year of completion,the
NEW RESIDENTIAL ELECTR SQ FE
HOUSING MITIGATION FEB
SQ. FE FLOOR AREA
$/SQ. FE
HEATING UNIT (OVER 100.000 BTU)
PAID
ownef,builder will have the burden ofproving thathedid not build or improve forpur-
lose of sale.).
1, as owner of the proton& am exclusively contracting with licensed contmetors to
Dae Receipt#
oto p y'
0 A Y
TOTAL:
TOTAL:
construct he project (Sec. 7014. Business and Professions Code.) The Contractor's Li -
se Law Nesnnt apply to a a owner of propcnY who build ./�++tI�Lmproves memnn, trod
FEB 27 RECD
NEW RESIDENTIAL MEOL SQ. PI'.
QTY. PLUMBING PERMIT FEE
who ccnuacts for such minowtx wither cremations) licensed dar(uanuo Ne Contractor's
OFFICE
1 ort oxen ^ �I li & P C fur this reason
k2 oewtpt order Sec. &ofAw V
s- I_
PERMIT ISSUANCE
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ALTER-DRAIN&VENT-WATER (EAI
Owner r .•
VALUATION
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Wforthwith
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WORKER'S COMPENSATION DECLARATION r� —�-�
1 hereby affirm under penalty of perjury ane nl the following dedarmims,
Q lhavmnd will mainmina Certificvm ofConxm mself-insula for Worker's Cnmpen-
sadon, as provided for by Section 3701 of the Labor GMe, for the performance of the
weak for which this permit is ismed,
❑ 1 have and will maintain Workers Compensation Insurance, two required by Section
3700 of the LaMar Code. for the performance ofthe work for which this Permit is issued.
My Worker's Colnpensalion Iasurincc carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Thorr, section nenet be completed if the panni, is for one hundred dollars ($ 101)
or les'.) r,
I certify that in the Performanccofthe work for which this permit is issued. [,hall
hme oto ,, the WnrRon Compcn.
no, cmlrloy any person in nny manner so auoecn
it. Laws of California. Date
Applicant
BACK FLOW PROTECT DEVICE
DRAINS- FLOOR. ROOF, AREA. CONE.
STORIES
TYPECON
FIXTURES - PER TRAP
-
GAS - EA. SYSTEM -I INC. 4 OUTLETS
OCC, GROUP
A
GAS - EA. SYSTEM OVER 4 (EAU
GREASFANDUSTRL WASTE. INTERCEPTOR
BUILDING DIVISION FEES
GRF,ASETRAP
FEE
SEWER - SANITARY - STORM EA. 200 F,
ENI2RGY FIJI
WR'I'ER HEATER WNEILUELEC IR
GRADING FEE
NOTICE TO APPLICAN'1:If, after making this Certificate alExemption. you shooed
become subject to the Worker's Compensation provisions of the labor Code. you muss,
comply withsuch provisions .,,his permit shall bedcemcd revoked.
CONSTkUCI'ION LENDING AGENCY
Thereby affirm that there isaconnrvvion lending agency for the performarvanf
the work for whi,h,his crind is issued (Sec. 3897, Civ. CJ
Limiters; Name
WATER SYS'I EMIT RHATING
WATERSERVICE
SOILS FEE
PAID
NEW RESIDENTIAL PLMB. SQ, FI'.
Date Rueip,p
TOTAL:
U
U
Lenders Address
TOTAL:
BUILDING FEE
i- 0.
I.as
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ll ciapplication and diva the the weave information is
I certify the, 1 have with
buildngconsectiomply herebylrtyand County ordinances and stem lawtrupingm
building constmction. vol hereby authoms representatives of this city to enter utero the
ahov>mendoned property for inspection pmpsawc
(We) agree fn save. look try and keep hvntlevs the CI,y of Cupertino against
liabilities, judgmems, costs and expenses which may in any way accrue against said City
in consequence of the coming of this permit
APPLICANT UND RSTANDS AND WILL COMPLYWI' LL NON -POINT
SOURCE REGUI T NS.
r
Signn, I 57 ApplamtlC dor ,e
IT US MATERIALS DISCLO. ORE
Will the applica ffumm buildingoecupam store or dle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 2553260]
C] yes No
Will the applicant or future building occupant use equipment or devices which
:mit havallom air contaminants as defined by the Bay Area Air Quality Management
C] Yes Fl No -
1 have read the hw:udous materials requirements underChap, .95 of the Cali-
onto Health & Safety Ctde. Sections 25505, 25533 vol 25534.1 do round that if the
buildingdoesamom have w tenant. shut it is myssap nalbility on ify dicuPa
f Nrt h euircmcros�4f us, m,,g�id nisf�yef arie oent
a C�r,i aiof 0`cupffAr
Q'TY. MECHANICAL PERMIT PEE
SEISMIC PEE
PERMIT ISSUANCE
ELECTRIC PEE
ALTERORADDTOMECH.
PLUMBING ITS
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTIONTAX
EXHAUST' HOOD (WIDUCT)
HOUSING MITIGATION FEB
HEATING UNIT ITO 100.00X1 BTU)
HEATING UNIT (OVER 100.000 BTU)
PAID
VENTILATION FAN (SINGLE RESID)
Dae Receipt#
BOILER - COMP (3HP OR IW,(Np BTU)Disvicfl
TOTAL:
UOILER- COMP (OVER 100.000 BTU)
AIR CONDITIONER
ISSUANCE DATE
'gol-
NEW RESIDENTIAL MEOL SQ. PI'.
OFFICE