31033 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEWONLY '
CITY OF CUPERTINO BUIL=G-ELECTRICAL PERMIT NO. 31033 0`<a�a�a
3
'BUILDING DIVISION 'APPLICATIONAIERMIT. PLUMBNG-MECIIANICAL JL
BUILDING PROJECT IDEN'I'IFICA'1'[ON
BUILDING ADDR&SS: SANITARY NO. APPLICATION SUBMITTAL DKI
I. 7oev
OWNER'S CUNI'It
PI(yV CONTR CfOk"N F;' l, 1.
�OCI JG NIG (ll.a
ARCHD'ECT/ GINEER: LIC NO: A �/ / ❑
CONTACT: �/ PHONE �� BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG hil,.l{iC,'I' rLUMB
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE a'
I hereby aElmn that 1 am licensed ander provisions of Chapr.r 9(commencing JOB DESCRIPTION
DceZ with Section 7000) lHoo m Sof me llnsinea and 11 leash .Cod, .day hearse is
RESIDENTIAL:
1+1 O p PHRMI'1'ISSUANCE r
F
I— in full farce and of O SFDW, ❑KI'T'CHEN REMODEL
C U F, Licenx ax Lica
6 U APPLIANCES—RESIDENTIAL - ❑ADDITION [I PLUMBING RE-PIPE
rn Q W Date Com..., v447444
17 ARCHITECTS UECLAR 'ION - ❑MULTI-UNIT OS'rRUCTURAL
FSH PANELS
'/+Z I understand my plans shall be used as public records.' MODIFICATION
UP TO 200 AMPS
OZ`=S ❑INTERIOR ❑CHIMNEY REPAIR
f-�2t:u2 Lice rued l'mlessi...I - 201-10100AMPS IMPROVEMENT
w s1E�t OWNER-BUILDER DECLARATION - OVER 1(100 AMPS O BATH REMODEIIBEPAIR ❑DEMOLITION
C C 6 I hereby affirm that 1 am exempt from the Convector's Licenx Law for he
aU following remora(Section 7031.5.Business and Professions Code:Any city or county SIGNS F,I.ECfRICAL ' ❑OTHER
1+13 W y which regains a pclu a n:cmuwel..hers improve,dentolish,or repair any structure
prim n al. y d ppl' .t If 1 pe 'tt fl g dstatement SPECIAL CIRCUIT/MISC.oo that hcsi WP tattbp fedContractors L Lr (Chser9
Ilypp (commencing w N Section 7")of Distsuon3 of Ne Business and Professions CotlOm TEMP.METER OR POLE INST OMM RCIA
a a e C that he iz xamopn therefrom and the basis for Ne alleged exemption,Any violation of ❑NEW BLDG/ADDITION O DEMOLITION
m
Section 21131.5 by any applicant for a permit subjects the applicant civil penalty of POWER DEVICES - OTENANT ❑FOOD SERVICE
not more than live hundred doll..'($511111.
F.
IMPROVEMENT -
❑QI]Lasowner k.and
pestructremyemployees
ntended with wages asan(See.compensation, SWIMMING POOh IiLECTRIC
E Owill Jmhe work.andthe he Contatotimcmled Law
not apply
an Business ❑OTHER
a3 m and Professions Code:The Cammam's License Law dors not apply m lI owner of ONT.EfS—SN'ITCN6S—FIXTURES
property who hailss or improves th Hereon,and who dos:s such work deed-or Ned for
his own however.
the
provided That such.teal Ncmmntn me not intended or af@ra1 for NEW Itli$IDENTIAI.I3LECTR SQ Pr.
sale.If,however.the builAing or nnprovenam is sold within nuc year of uunpininn,lbs SQ.Pf,PLOOR ANFA SISQ,FI�
wncrbuilder will have the burden of proving Juin he did not build or improve for par
you of talc.). - -
EJ h rty,
as owner of the prope ,am exclusively contracting with licensed amrexon m TOTAL:
constiect the pmjWt(Sec.2(94.Business and Pmfcssions Code:)Tic Contractor',Li-
came Law does not apply toanow,net(it property who builds or hnmvvca thereon,and (iffy, PLUMBING PERMIT FEE '
who contracts for such projects with a conlmentax)Iiansed punu.m to the Comranor's
License Law. PERMIT ISSUANCE
❑I am exempt under Seel ,B&PC for this lacer
Owner Date
ALTER—DRAIN&VENT—WATER(EA) VALUATION
•
WORKI3N;S COMPENSATION DECLARATION HACK PLOW PROTECT.DEVICE ��/(A�
1 hereby affirm under Penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Waka''s Compen- DRAINS—FLOOR,ROOF.AREA.COND. STORIES TYPE CONSTRUCT 101
scion,as provided for by Section 3703 of the Labor Code,for the perfarmecc of the
rk for which this permit is issued. 11 FIXTURES—PER TRAP "
L have and will nwinmin Worker's Conupcnssiroa hwamrice,as required by Sellar - :7
J of the .(anM1e perfonnantt of the work forwhuech ni GAS-13A.SYSTIiM.I1NC.40UTLE'FS OCC.GROUP APN
e nm ce
My War C pceumierand Pol'cy GAS—EA.SYSTEM-OVER 4(EA)
Cartier rolicy ..
' .CERTIFICATE OF EXEMPTION FROM WORKERS' CREASIIINDUST'RL WASTE INTERCEPTOR
COMPENSATION INSURANCE ' BUILDING DIVISION FEES
( boa,tiun neodnm be conplelcl3hlhe permit is for one hundred dollars lS In)) GRIiAFE TRAP
or ass.) PLANCHF.CK FEE
I certify and imhe famforroulanflhe work far which his permit is issued.Ishan SEWr:R—SANITARY—STORM EA.2W FT.
not employ any person in any rummur ao.s m e su
becombject to the Worker,'Couples- ENERGY FEE
Z anion Lawsof Calikirma.Date WATER HEATER W/VENTIELECTR
Z2 Applicata w - GRADING PER,
izi NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTEM)TR DITING
I•' become subject the Worker's Compensation f the Labor Cada you must SOILS PTai
provi shelf
forthwith comply with ouch provisions or permit shall ba claimed revoked. WATER SERVICE: .
Q n
5Z CONSTRUCTION1,13NDINCACENCY NEWRESIDEM'IALPI.MB. SQ.In PAID t ReceiptN
U O I herchyaffrm that here is.comlruction lending agency for the Performance of
P Ne work for which this permit is issued(Sec.3092,Civ.C.) (j
C) lenders Name 4 TnL'
Lenders Address TOTAL:
ly 1 vaulty thin 1 have read this application and stale that Ne above informatinn isBUIL NF.ftL[L
V) tortt l agree to xenply with all city and county ordinances and state laws relating bra QTY. MECHANICAL PERMIT FEE
U Z buildingcumuLetion.and hereorirs
byauthreprfil
a%cortivesofinitineration the
SEISMIC PEE fYL!
above mentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmlcrs the City of Ci pcnino against ELECTRIC FEE
liabilities.judgments,costa and expense,which may in anyway acemeagmantsaid City ALTER OR ADD TO MECH.
PLUMBING FEE
mebrance of the grunting cf This'pertnh.
APPLl UNDERSTANDS AND WILLCOMPLY WIT ALL NON-POINT AIR 14ANDLING UNIT(TO IfygI CIM) MECHANICAL FEE ,
S I ATIONS. - -
,V., AIR HANDLING UNIT I(hg10 CFM) CONSTRUCTION TAX I
• Slgn.arc nfppplicxnt(//G(�/nt"rn<�nir ' Data EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE -
HAZARDOUS MAfER1ALSDISCLOSURE
`Mil the applicant or future building oecupam store or handle hazardous material HEATING UNIT(TO 100,000 BT'U) -
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cale.Section 255321a1" HEATING UNIT(OVER 100.0110 BTU)
t CYcsn M'H./A ION FAN(SINGLE RFS1D)' - PAID
� VI3Date Reccipna
Will the applicant or future building acupon use equipment or devices which
BOILER—COMI'(3HP OR
emit saturation,air comaminants as defined by the Bay Area Air Quality Management 100.gp BTU)
` TOTAL:
Distrix^ ;0o - BOILER—COMP(OVER 100,003 BTU) '
❑Yee
\ ret. .AIR CONDITIONHR
I hit'
a salad the hazardaos materials requ ants under Chapter M1.95 of else Culi C ISSUANCEDATE
t fnmia HcaIN& afxy Calc,Secdans 25505,25533 and 25534.1 umlerstand Nat if the NEW RESIDENTIAL MECH. SQ.14.' r. / . 7 7
building Mss curmntlyhavcatenMt.that iti,mMYMS snsibilityn nstify eocespon L C
of he x t be met priore,issuance o(a Ccan ateo' u ivy..
(Inst q Tf7
brnL: '�
t sold agent Dute ISSUD,BY'.
OFFICE