31021 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-IlMiC'IRICAL - PERMIT NO. 31021
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BUILDING DIVISION APPLICATION/PERMIT PLUMB NC-MECIIANICAL J
BIIILIIING 1'Nfy,IRCI'111N:N'I'IFIf:A'1'ION
BUILDINGADDRIitiS: SANITARY NO. APPLICATION SUBMITTAL DATE
()SSS U 'iib
OWNS PHONE: C ACOR'SNAME: LIC NO:
4RCHITF.Cf/ENGINEI!N: LIC NO: A SS:
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees PpiU 6y Applicant(Initial) BLDG ELECT PL "BIG
sw
LICENSED CONTRACTOR'S DECLARATION TY ELECTRIC PERMIT FEE ❑ `C{f/•
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
D0Z with Section 7")of Division 3 ofthe Business and Profusions Cole,and my license is
WOO b PERMIT ISSUANCE RESIDENTIAL:
=W r in Poll force and of t. 0 7 G
a V V Licen Class LIC,p Y 66 ( ❑SFDWL [I KITCHEN REMODEL,
II Zw 0. D `�—LT/—'1`I Contractor APPLIANCES—NLSIDENTIAL ❑ADDITION [I PLUMBING RE PIPE
F 7 ARCHITECTS DECLARATION PANELS ElMULT-UNIT ❑STRUCTURAL.
Z O I undentanJ my plans shall M1e used 7i puM1lic rtcords MODIFICATION
O Z..-" UP TO 200 AMPS
Ff I Licensed Professional - - [I INTERIOR C1 CHIMNEY REPAIR
201-IOW AMPY IMPROVEMENT
OWNER-BUILDER LER lar he Cc ATION OVER 1000 AMPS
a a 1 hereby affirm the 1 ton exempt tram the Cssions License city
o far the ❑BATH REMODF EPAIR DF:MOL_ ITjQN
�y(O y U following reesnn.(Section 711)1 5,Business and Professions Code:Any city or county SIGNS F:1.1!CTRICAL [I OTHER a�' (syr-
4i which requires n permit to Gums the alter,rt or,a,demolish, file
repair any swcturt
�� priarmits lsmance,also rctpnires the nPPlienn lint ouch penninn filensigned statement SPECIAL CIRCUIT/MISC.
y that limnsed Curet....70th)pm visions of dm Gameness ad Professions
)or
�d�0 (commencingwith Section 7100)nf0ivisiun7nfthe puniness mad Professions Code)or TEMP.MR'I'HR ON POLE(NST. COMMERCIAL:
LL y o C' that he is exempt thercTmm mtd 7hc hasis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
'rtrSection 7031.5 byany applicant Tm iu penult subjects the applicant to.a civil penalty of POWER DEVICES
rat Section ❑FOOD SERVICE
no
more than Bvc hundred dollars tS510).
50 L,cs owmerofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the absence is not intended or offered for rule(Sec.7044,Business El OTHER
14 and Professions Code:The Connector's License Law does not apply to an owner of Oil TLETS—SWITCHES—FIXTUR iS
property who builds or imposes thereon,and who does such work himself or through
his own employees,provided that such imp rcemena ure not intended or offered for NEW RESIDENTIAL.ELEMR
sale.IL however,the building or improvement is sold within one year ofcompletion,the SQ.FT.FaT.00a�ykR� SISQ.IT.
owner-builder will have the burden of pausing that he did not build or improve for put- //fib A
pnsea tede.). X,
S/
❑1,as owner of the properly,am exclusively contracting with licensed contractors to TOTAL: 041pn
construct the pmject(Sec.7144,business and Professions Calc:)The Commences Li- 4 b 4
cense Law docs not apply to an owner of property who builds or improves themop.and QTY, PLUMBING PERMIT /s /)
who contracts for such projects with u amtracum(q licensed pursuant to FEE the Contractors CpYurC�
License law. PERMIT ISSUANCE LUr�
E]Iamevemptunler Sec. ,B&PCfimdu, eason Ml�ti
Owner Date ALTER—DRAIN&VENT—WATER TA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby offinn under pcmhy of perjury one of the following declarations:
❑I have and will maintain a Certificate ofConeen to self-! arra for Workers Comport- DRAINS—FLO(R,ROOF AREA,CON). n STORIES TYPECONSTRUC ION
sation,as provided for by Section 3700 of the Labor Cade,for the performance of the
work for which this permit!s issued. FIXTURES—PER TRAP
E3 I have and will maintain Workers Compensation Insurance,as required by Section
37M office Labor Code,for the perfonttanreof the work for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS '
OCC.GROUP APN
M Cnmpegy n Insurance carrier Policy
Policy nWn� a
Hier( Q�I^e/� Policy Nu.: ((YLIx'j301;L GAS—EA.SYSIGM.OVER4DIA) ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE IN]'ERCKM GR
BUILDING DIVISION FEES
(Thissection need nm hecompleted illhe ser-mit is foronclmodreddollars(SIW) GREASP.TRAIT
or loss.) PLANCHECK FEE
I certify that in the CoCaro anccofthe work far which this permit is issued,Idell SF.WER—SANITARY—STORM P.A.200 IT,
mtempl)y any person in any manner so as to hecoonsoloccuo the Workao'Compem - ENERGY FEE
,Z. action Lessor California.Date
�Q Applicant WATER IIFATER W/VEN PHLEC'I'R GRADING FEE
In NOTICE TO APPLICANT If,rhrr ,making this Cenilicure of Exemption,you should WATER SYSTEM/TREATING
abecame subject to the Worker's Compensation pno,ocian of the Labor Calc,you must SOILS ME
{✓aforthwith comply with such provisions 0r this permit shall he deemed revoked. WATER SE RV ICE
O Q .
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PALO
8Ihereby ichouth.loti isoedgoo.construction 0lending agency fonhe performance of Date Rccciptp
W. F the work fur which this pcnnit is issued(Sec.3097,Civ.C.)
Q
ULenders Name TOTAL:
r
till fender's Address TOTAL:
1r1 certify the 1 have read this application and sero the the above information is BUILDING FEE
Fly corteet.lagree to comply withal)city and county rich nancesandstmelawsmlatingm QTY. MECHANICAL PERMIT FEE
C.7 Z building construction,and hereby connote representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)ag.to save.indemnify and keep harmlcvs the City of CLpenirm against ELECTRIC
liabilities,judgments,ants and expenses which may in any way oroee against said City ALTER OR ADD TO MECIL
toc)nu9wret,of the gmvtit,ofthis pc.it. PLUMBIN E
APPLICANT UNDERSTANDS AND WILL C MPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0011 CFM) MECHAN
SOUR fall NS.
_y_Gy AIR HANDLING UNIT(OVER 10,0g0CPM) CONSTRUCTIONT X
Signa arc of ApplicanUComrecmr Date
EXHAUST HOOD(W/DUCfI HOUSING MITIG ION FEE
MATERIALS DISCLOSURE
Will the applicant or future building occupant sem or handle harnrdous material HEATING UNIT(TO 1 Clown 11'put
as defined by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety
Cale.Section 2553210)? HEATING UNIT(OVER I W,00D BTU)
❑Yes 0N VENTILATION FAN(SINGLE RESID) PAID
D Rec p
Will the applicant orti future building by the
use ea Air Qu or devices Which
emit hazardous air conmminems ns define)by the Bey Area Air Quality Management BOILER—COMP(JHP OR 100,000 BTU)
District? TOTAL:
�yes IMI No BOILER—COMP(OVER 1011,0010 BTU)
I have read the hvnrdars materials rauimmcros under Chapter 6.95 of the Cali. AIRCONDGIONER
1 p ISSUANCE DATE
fomia Health&Safety Code,Sections 255115,25 , and 25534.I understand that if the NEW RESIDENTIAL.MBCA. SQ.IR,
buildingil nate ntly have u tectum,the i '. ny responsihil try to notify the occupant
of th Tom a hichnmst hmct Crit ssuuneenfit ConiOcntenfOccu nncy. Vw /VS
4 �
Owner nr thurixd agent Dam TOTAL: ISSUCD BY:
OFFICE