31482 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OE CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 31482
BUILDINGDIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGNGA : ,/'� O'_„ o' ^ SANITARY NO. APPLICATION SUBMITTAL DAT(
O R'. NAME: _ 1 PHONF: y/ __�\V\` COQ R 'S NAM n LIC NO:
p /J N/C CONTROLp
s,RCHITECT/ENGINEER LIC NO: )p til 1 , — ❑
CONTACT: PHONE: 1 BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MINCH
❑ ❑ ❑ ,g
LICENSED CONTRACTOR'S DECLARATION QTy ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under Provisions of Chapter 9(commencing JOB DESCRIPTION
MaZ with Section 9000)of Division 3 of the Business and Professions Code.and my license is RESIDENTIAL:
Won wt PERMIT ISSUANCE
Fly..
in fail force and of t. ❑SFDWL [I KITCHEN REMODEL
�UU Licen C . LIC.N APPLIANCES-RESIDGNI'IAL ❑ADDITION ❑PLUMBING RFPIPE
Q S Une Conmemnr
ARCHITECTS DeLARA ❑MULTI-UNIT C1 STRUCTURAL
Z p n Z I understand my plans shall he used as public records PANELS
MODIFICATION
O Z4O UPTO 200 AMPS [I INTERIOR C]CHIMNEY REPAIR
t:ea Licensed Professional 201-10PBAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER IIXIOAMI'S El BATH REMODEIJREPAIR ❑DEMOLITION
I hereby affirm that I am exempt Goin the Contractor's License Law for the
yg�O W U following reason.(Section 7031 S,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
(..u.0 of, which«ques ira permit to concoct,alter.improve,demolish,or repair any structure
J pne"o its ismance.also rectums the applicant for such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
r(,{� that he is licensed pursuant to the provisions ofthe Cnmmcmis License Law(Chapter 9
1Sa�y aa'E (commencing with Section 90X)of Division 3ofthe Busincssanl Proessions Code)., TEMP METER OR POLE INST. COMMERCIAL:
6 a o C that he is exempt NereGom end the basis for the alleged camphor.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
N Section 1031.5byanyapplicant fora permit subjecmthe applicant no a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
not more than rive hundred dollam(55W).
F_ZY at HER IMPROVEMENT
P2
< ❑ Las ownerk,the property..nnyemployees d with mothered
as their 044,8 sines SWIMMING IY)OL ELECTRIC
2 R 0 will dolhewons and the he Contractors
to intended orofw doesor of apply to an,Business El at
d'3m andProfessions Code:The Contmereo License Laws«snotapply himself
owner of OUTLETS-SWITCHES-FI%TURES
his own mplbuilds tar improves t such i,and colt.dcea such work himself or erect through f
hal own owevez.the building that such impros sold w u¢not intended or platin.for NEW RESIDIiNTIAL ELECTft SQ
sale.If.M1awevez the building or improvement is sold within one ycmnfcompletion.the SQ.Fri.FLOOR AREA S/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put-
p soot sated. Y`a
TOTAL:
1,as owner of the property,am exclusively contenting with licensed contractors to
concoct the project(Sec.9044,Business and Professions Code:)The Contractoi.s enLi- `.Cs
cse Law does not apply to an owner ofprupcnand y who builds or improves thereon, QTY. PLUMBINGPERMIT FEE ``
who contracts for such projects with o cmtmrtot(a)licensed pursuant to the Contmctots F/1
License Law. PERMIT ISSUANCE
1 am eacmM under Sec. .B&P C fm Nis reamer
Owner Dam �a�/YY((��
ALTER-DRAIN&VENT-WATER(EA) JVja YT10N
Alms Wm under
SClty of,SATION DECLARATION HACK FLOW PROTELT.DEVICE
1 hereby will
under Penalty of perjury one of the following orker'Co
Ibave and will main mina Certificateio37ofConsent toLabor
Code,fumfer Workers Compeer- DRAINS-Fl.00R,ROOF AREA.GOND. STORIES TYPECONSTRUCTION
amino,as provided for by Section 99(X)of the Labm Cnde,for the po,[.rmancu of the
work err which alis pcnnit is issued. FI%TURES-PER TRA('
have and will maintain Worker's Compensation Insurance,as fequired by Section
3 ofthe labor Code.for the scrommance of the work for whichthispermit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
Cern'uor s I �n l cv uniePol cy No.: b!� GAS-EA.SYSTEM OVER 4(EA)
CETIRCATE OF;EXEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION TEES
(This section need not he completed It the permit is foronc hundred dollars($110n) GREASEI'RAP
or less.) PLANCHECK ITH
Iccnify Matin Neperformore.fNework forwhich this panni,issued.lshall SEWER-SANITARY-STURM EA.200 PT.
not employ any person in any manner so as to become subject to the Workers'Compeer- ENERGY FEE
O Z union Laws of California.Date WATER HEATER W/VENT/ELECI'R GRADING FEE
Z Q Applicant
NOTICE TO APPLICANT:If,offer making this Certificate of Exemption,you should WATER SYSTEM EATING SOILS FEE
become subject to the Worker's Compensation provisions of the Labor Code,you mast _
W forthwith comply with such provisions or this permit steal l he deemed revoked. WATER SERVICE
aQ
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V Q I hereby affirm thatthem is a construction lending agency for the Performance of Dam Receipt
r+ the work for which this permit is issued Sec.3097.Civ.C.)
u" F' Iendefs Name TOTAL:
U Lcndce Address TOTAL:
sY+ W BUILDING FEE
scruffy 1scruffy that I have met this implication and.let.mbar the uMwe information is
Z, comets I agree to comply with all city and county ordinances and state laws mluting to QTy, MECHANICAL PERMIT FEE
IJ Z huildingconawcliun.and he¢byauNmiu relrra,manivesof Nis city w imanupon the SEISMIC FEE
F-t above-mentioned property for inspection purposes. PERMIT ISSUANCE •�
(We)agree tat cavo,indemnify and keep harmless the City of Cupertino against ELECfRICFEL'
liabilitiesjudgments,costs and expenses which may in any way accrue against end City ALTERORADDTOMF.CH. PLUMBING FEE
in consequ<ncc of the grunting of this pcmtit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT DO 10,00j)CFM)
MECHANICAL FEE
OUIg1C- EGULATION 1.
1'��h� NR HANDLING UNIT(OVER 10,(Xp CFM) CONSI'RUCTIDN'AX
,vQ/1aullof Appl�icant/Cmuctm' � Do,# EXHAUST HOOD(W/)UCT) HOUSING MITI ON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Neapplicanl or future building occupant store.,handle hazardous mated.] HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and Ne Heald and Safety
Code,Section 25532(a)9 HEATING UNIT(OVER 100,000 BTU)
C]Yes F1 No PAID
VENTILATION FAN SINGLE RfiSID)
Will Ilse applicant or future building accepts use t or devices which Dmc H cilli M
pp g pan Area
Air
BOILER-COMP GHPOR 100,(X10 BTU)
:mit hazardous air contaminates as defined by the Bay Arca Air Quality Management
TOTAL
Disvict4
❑Yes ❑No BOILER-COMP(OVER hill ll(10 BTU)
I have read the hoondnuanomd.lareyuiremems under Chapter 6.95 of the Cali- AIRCONDTHONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505.25533 tad 25534.1 underi that if the N17W RESIDENTIAL MECH. SQ.19'.
Wildingdoes not currently have.moan,that it is my resrymsibilmy to notify the occupant
odds,reeuiremenu which most he met prior to P,m.of.CenificanofOmapawy.
Owner or authorized agent Date I '1'O'TAL: .00 ISSUED BY:
OFFICE