31260 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 31260
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
B ILDING ADDRESS f SANITARY NO. APPLICATION SUBMITTAL DATE
Ue - 10 "7,56
N:R:S NAME: PHONE: O RACTOp'S N�I;,: „ � I-li NO:
IT'�ITF // ( T NIC
CONTROL p
CIIIT.CT/ENGI EER: LIC NO: D DRESS: Fns+W ❑
CONTACT: _ PHONE: 1 - BU ILDING PERMIT INFO
Consultant Fees Paid by Applicant(Initial) B� I. CT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEF. ❑ ❑
M O Z I hereby affirm that I am licensed ander provisions of chapter 9(commencing JOB DESCRIPTION
with Section 7")of Division 3 class Business and Professions Cale,and my license is RESIDENTIAL
4100 w PERMITISSUANCii
FF U U in full force and ellen. _ ❑SFDWL ❑KITCHEN REMODEL
F�FUV License Class Com APPLIANCES-RESIDENTIAL DADDITION El PLUMBING RE-PIPE
V)Qd Dom TSDE L
Dm ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
y�yt�L�� 1 undersand my plans shall he used as public words MODIFICATION
�'Z'jj'.V UP TO 200 AMPS []INTERIOR []CHIMNEY REPAIR
rA Licensed Pmlessi...I 201.1000AMPS IMPROVEMENT
04 Sd�'� OWNER-BUILDER DECLARATION OVER IMIAMPS []BATH REMO UREPAIR DRATtODEMOLITION
O a I hereby affirm that 1'am exempt from the Contractor's License Law for the ,
U following worm. 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
rea
47 LL Y,fa which teyuites a permit m constrvet,eller,improve,demolish,ar repair any armours
prion.its issuance.also requires she applicant for such Permit file a signed statement SPECIAL CIRCUITNISC.
that he is licensed pursuanOo the provisions of the Conuactors License Law(Chapter 9
W�C00 Ismmntencing with Section 7")of Division3of the Business and Professions Code)or TEMP.METER OR POLE INST COMMERCIAL:
apx,e q that he is exempt marefmm and the hauls for the alleged exemption.Any violation of []NEW BLDG/ADDITION D DEMOLITION
Wim Section 7(131.5 by any applicant for a'perait subjects the applicant to a civil penulty of POWER DEVICES []TENANT []FOODSERVICE
no
marc than five hundred do]lav(S50d. - IMPROVEMENT
Q ElLm owncrof the property,or my employees with wages as their sole compensation, SWIMMING PLO[.ELECTRIC
will do the work,and the swcmtets nal inteoded or.ffered hostile(Spa.71k4,Business ❑OTHER
and Professions Cale:The Contractors License Law does not apply w an owner of OUTLETS-SWITCHES-FIXTURES
proper,who builds or improves themon,and who does such work himself or through
his own employees,provided that such,bapmvemetns are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. �AJ,
sale.l(however,the building or improvement is sold within one year of completion,the SQ.FT�.OA�B�p0 VSQ,FT,
consar-builder will have Ne burden of proving that he did not Build or improve for pur-
1,as owner of the property,em exclusively connecting with licensed c.mmawss toconst81996
move La the project nota apply
to n Business and Professions bui Code:)The es domain,
o m in, std OCT��r/
whoconesdasnmapplytoan its a cofpmpcny whosedprsds or improves Compnand QTY PLUMBING PERMIT FEF,
who amwcae for such projects with a cnnmuetnr(s)licensed personal to the Cnmrvmnrs
CITY 0r uumf I Hvv
1
. 0 Ise Law. PERMIT ISSIIANC
lute exempt under Sec. ,B&PC ba thio reason
Owner Uma S N'I' A'
ALTER-DRAIN (EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT. .VIC
01 60a It
1 hereby affirm under penalty of pe jury tine of the following declared...: `
I have and will maintain a Certificate of Cement o self-insure,for Worker's Compete DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE NSTRUCTION
sermon,as provided for by Section 37M of the Labor Code,for the performance of the -
work for which this perand is issued. FIXTURES-PER TRAP
1 have and will maintain Workee.Compensation I®umace.as required by Section
37M ofthe Lehr Cade,for theptreatmentce of the work for which this permitN issued.. GAS-EA.SYSTEM-I INC.4 OUTLvae OCC.GROUP APN
My W.rker 1 e r er and Policy number CAS-L+A.SYSTF.M-OVER4(EA)
f
Come'!
om ec ry'`k Policy No.:
/ CERTIFICATE,OF EXEMPTION FROM WORKERS' GREASFIINDIISTRL WASTE IM'HRCEPfOR
COMPENSATION INSURANCE 1 NG VISION FEES
(Thissation need not hecomplcmd ifthe permit is forme hundred dollars($100) GREASP,TRAP
ar less.) PLANC .EE �.
Loy anythatinthe any manmmolthe astobekforme subjch ect
this o permitilocs ed,I shallCompn. SLWFiR-SAN)TARY-STORM EA.200 Pf.
not employ any person in any manner su m m become subject to Ne Workers'C.mpen- F.NERG iE
Z colon Lis ws.f California.Date WATER DEATHS WNENT/F.LF.CTR
Z O Applicant GRADING FEE
Z to NOTICE 9O APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEM/IREATING
a7 become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
� ,.. fmobwilbuomply with such provisim,ordiis .it shall he deemed revoked. WATER SERV ICE
Q Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
L)O (hereby amwahanhem is.constmnion lending agency for the peRnmmnce of Uew ftaeiptp
W ,tel the work for which this permit is itoal(See.3097,Ci v.C.)
1"I lender's Name TOTAL:
U
Lender's Address - TOTAL. BUT UNG PEE
I certify that I have read this application and state that the above information is
IA correct,l agree to comply with m[city and count ordinances and state laws relating to QTY. MECHANICAL PERMTr FEE
V building consuuction,andhereby authorize representatives ofthis city toemerupomthe SEI MEC FEE —
i bove-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify end keep hamdess the City of Cupertino against EI.CIRIC FEE
liabilities,judgments,costs and eapensn which may I.any way acemeagainst said City ALTERORADDTOMECIL
in cone"tance of the granting of this permit. PLUMBI E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITG'O IO."CFM)
SOURC,REGUL TIONS. MECHANICALF
AIR HANDLING UNIT(OVER 10,tIW CFM) CONSTRUCTION TA
Si lir n Applica VConwcier Uotc EXHAUST HOOD(W/DI1Cf) HOUSING MITI ION]IONiE
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicant a,future building aeupam atoreorhmpe hazardous material HEATING UNIT('IO u),0(00 BTU)
a defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 15532(a)? HEATING UNIT(OVER 100,000 BTU)
[3 Yet DN. VENTILATION PANS INGLE RESID) PAID
\ Will the applicant or to[=building occupant use equipment of devices which Doe Raeipt
nit Westrdous air contaminant..,as defined by the Be,A.Air Quality Management BOILER-COMP IJHP ON IW,000 BTU)
TOTAL:
sant? BOILER-COMP(OVER 100,0X0 BTU)
[]Yes DNo
I have .it the hazurdnua mumduls relorments under Chapter 695 of the Culi. AIR CONDITIONER
ISSUANCE DATE
Infiniti Ilanldt&Safety Code,Sections 25511.5,25533 and 25534.1 anderslond taut if the NEW RESIDENTIAL.MHCH. -9Q.FT.
building does not currently have a mount,that itis my responsibility to notify the oecupent
of the requirements which must be met prier w asomme of a Certificate of Occupancy.
Owner or so strewed agent Data TOTAL: ISSUED BY:
OFFICE