31129 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI'RICA I. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 31129
BUILDING PROJECT IIIENTIFICA'L'ION
.DING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
1019 Noveial bev pr 3Z'�
V IIR'S NAMF PHONE: CONTRACTOR'S NAME: LIC NO.
M a 1I e."I P io I s s- 7010 NIG CONTROL
ECHITECTIBNGINEIiR: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT ENI°O
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR S DECLARATIONQTY ELECTRIC PERMIT FIRE 1 hereby affirm that 1 am licemxd under provisions of Chapter 9(commencing JOB DESCRIPTION
�aZ with St 7000).1 Division 3oflhc Basineesand Prmno,im,Cod,and myliconnc is - RESIDENTIAL:
WOOI'IiRMIT ISSUANCE
1,_ full force and effect. [DSFDWL ❑KITCH17N REMODEL
C O F License Class Lic.p
Q U APPLIANCES—RESIDENTIAL -]ADDITION ❑PLUMBING RE-PINI:
�i 6 W Dalc Cmalmo r
(_Dm ARCHIE LUES DECLARATION PANI7LS ❑MULTI-UNIT [I STRUCTURAL
Z p i7 Z 1 understand my plans shall he used as public records MODIFICATION
UP TO 20)AMPS
❑INTERIOR ❑CHIMNEY REPAIR
F N,.F.W Licensed Professional 201-1000AMPS IMPROVEMENT
�at: OWNIR-BUILDER DECLARATION OVIIR IgNIAMI'S [I BIG REMODEUREPAIR ❑DEMOLITION
xt I hereby affirm Ihut 1 am exempt from the Contractor's License Law for the
C.p W U following lemon.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECFRICAL ❑OTHER
3 P-y which requires a permit to construct,alter,improve,demolish,or repair any structure `� US
vl"„�O�' priorto itsix,tos ,iiko requilesthe applicant fnnueh penniuo file.d,redusmntonl SPECIAL CIRGDUUMSC.
fly Nal he is licensed pursarm lo on, rookions of the Comracmrs License Low(Chapter 9
WyO� (commencing with Section 7")of Division J ofthe Business and Professions Code)or TEMP.MEfER OR I'OLF.INS COMMERCIAL:
a y m W that be is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION Q DEMOLITION
uX7 y
Section 7031..5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
I mom than live hundred dollars(5513). IMPROVEMENT
~Z6 0I,as owntt of the propcny.or myempinyceswith wages aslheirsolennnpcnmlion, SWIMMINGPOOLELECIRIG
will do the work,and the structure is not intended oroRered for sile,(Sec.]D14,Business
❑OTHER
W mol Pncdoes
rfessiima Code:The Commmr's Licer a Low not apply nI an owner oLETS
f OUT —SWITCHES—FI% IS
s 3 properly who huilds or improves thereon,and who docs such wink hintmll or through
his own employees,provided Nal such improvements an not intended or offered for NEW RESIDENTIAL ELECTR Q FT.
Sala If,however.the building or improvement is sold within one year ofconnpletion,thc SQ,FT.FLOOR AREA &SQ.I'1'.
owner-builder will have the burden of proving that he did not build or improve for put- P A 1
pone oI rale),
Fl 1,to owner of the properly.am exclusively contracting with licensed contractors lo TfITAh. a•
construct the project(See.](IW,Business and Professions Cade:)The Contractor's Li- {]
c se low does not apply to an owner of property who Funds or improves thereon,and QTY M/ID 25 PLUMBING PERMIT FEE A �n
who cammms forsuch pr,,jcctawilh aconaamodsl licensed pursuantmthc Commnors
License Law. PERMIT ISSUANCE l�r ut-
I am exempt under Sec. .H&P C for this reason LVr
cr 7�GIN
DoleZ ALTER—DRAIN&VENT—WATER IEA) TION
n WORKERS COMPENSATION DECLARATION" J BACK FLOW PROTECT.DEVICH
�0I hereby amrm under penalty of perjury one of die following declaalios:
n
I have and will maintain aCerlificate of Conant to mlf-insum for Workers Compen. DRAINS—FLOOR,ROOR AREA.COND. STORIES TYPE CONSTRUCT ION
snlion,as pnrvided Ion by Section 3700 of the Lot, Code,tin the peffnrmnnee of the
work for which this permit is issued FIXTURES—PER TRAP
I have and will maintain Worker's Compensation Issuance,as required by Section
3/00of the Luber Cod,for the performance of the work for which this permit is issued. GAS—FA.SYSTEM-I INCAOUTLETS UCC.GROUP APS
My Wurker'x Compensation Insurance carrier and Policy mmdher arc:
Cartier: Pull,No.: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASFJINUUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FIBS
(Ods,eclionneudnnt be cnmpleedathc mind is furore hundfeddollurs(s Into OREASETRAP
or ImsJ PLANCHF,CK FEE
Iccrifythm in lheperundanccnfthcwork fmahich thN,vounit isissued.LshdI SF-WER—SANITARY—STORM I:A.2W ET.
not employ any person in any manner m as to becomeobject to the Workers Comper- ENERGY FEE
Z shim Laws nl California[)ale WATER HEATER WNENT/ELECTR
ZApp w,m GRADING FFE
NOTICE TO APPLICANT:If,after necking this Certificate of Gemption,you should WATER SYS'YEM/TRBATING
a ? become subject to use Workers Compensation provisions of ust
the Labor Code,you mSOILS PEG
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
V"o CONSTRUCTION LENDING AGENCY NEW RESIUENTIALI'L.Mp. SQ pm PAID Dam Raeiplp
Q I herebyammt thm there isaconswction lendingagency for the perfainanceof
the work for which this Permit is issued(Sec.30D9,Civ.C.) TOTAL'
OU Lendces Naim
Y' W lenders Address ,. 'TOTAL:
4 I certify not 1 have read This application mrd state that the above information is HULLOING FEE
fy" to correct.l agree m comply with all city and county ordinances and slate laws relating m QTY. MECHANICAL PERMIT FEE
U Z haddin, and hereby.ofts to,reprccenmlivex of Nis city,,enterupom the SEISMIC FEE
above-mentioned properly,lot inspection purposesPERMIT ISSUANCE.
(We) neem save, m
indemnify and keep hornless the City of Cupertino against ELECTRIC FEB
liabilities,judgments,costs and expenses which may in any way tame against said City ALTERORADDTOMFCH. PLUMBING ITE
in nseqacncc of the getting of this .it.
APPLICANT UNDERS'LANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNI'I'(TO 10,0(H)CFM) MECHANICAL FUH
SOURCE REGULATION
LS p.p AIR HANDLING UNIT(OVER 10.OBB CFM) CONSTRUCOONTAX
Sign urc of Ap ieanworn Dom 71 FXHAU ST I IOOD(WIDUCI) HOUSING MITIGATION FEE
HA/ARDOUS MATERIALS DISCLOSURE
Will the applicant or futurebuilding«eupanlsme or handle hnrardous material HEATING UNIT TIO IM.HW BTU)
as defncd by the Cupertino Nitimlipal Cade,Chapter 9.12,and the Health and Safety
Code,Sec,I25532(a)1 HEATING UNIT(OVER 100,000 PTU)
❑Yes ❑No VENTILATION FAN(SINGLE RISID) PAID
Date Receipt p
Will the applicant or future building occupant use equipment or devices which
nail 6uemdnus air cmdonbams as dcfncd by the Bay Arco Air Quality Management BOILER—COMP(3HP OR I W.UNI BTU) TOTAL:
District? BOILER—COMP(OVER 100.00u BTU)
❑Ycs [J No
I have lead the hnmrdnus nmmrials mpriremems under Chapter 6.95 of the Cul,- AIR CONDITIONER ISSUANCE DATE
fnorm Health&'Safely Code,Sections 255(15,255V and 25534.1 undcrvland that it the NEW RGSIDEN'I'IAL MECH. SQ,hT.
building dies not currently have tenant,that it is my hesptmsibility,to notify the occupant
ofthe u' unl he map m' nfacreficatc of sopor
zs
wino t ogcia Dme TOTAL: ISSUER BY:
OFFICE