31493APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
- BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL:
BUILDING PROJECT IDENTIFICATION
PERMITNO.
31493
HULLOING ADDRESS:
14 no
SANITARY NO,
APPLIC TION SUtlMITTAL DATE
7
O S NAME I
_
COU31 'S NAME: LIC NO:
NIC
❑
CONTROLM
MRCHITECDENGINEER:
LIC NO:
A
DRESS:
CONTACT: PHONE:
❑ Consultant Fees Paid by Applicant (InlHa1).
BUILDING PERMIT INFO
BLDG B PLUMB MEC
❑ ❑
LICENSED CONTRAC'TOR'S MiCLARA'I'[ON
' I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with ScOunt 7I )of Division) o aBusiness and Professions Codgendm license is
full force and eB y
Licen Cas Lica
J Data Cmnaac r, ima-
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
R I -FFD NT—Ili
GSFDWI. ❑KITCHEN REMODEL
.[]ADDITION 0PLUMBING RE -PIPE
El [2 STRUCTURAL
MODIFICATION
❑INTERIOR []CHIMNEY REPAIR
IMPROVEMENT
O BATH REMODEUREPAIR 0DEMOLITION
❑OTHER
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
ARCHITF.CCS DIiCLA ON
I understand my plans shall be mad as public records
PANELS
PANELS -
UPTO 200 AMPS
Licensee Professional
OWNER-BUILDIiRurn the curse i
1 hereby affirm that 1 am eumpt sham the Conmannr s License law em the
J following reason. (Section ]031.5. Business and Rnfeasions Code: Any city or money
poor to its iseanpermit mconstruct,aper.improve,demolis h, ore a sig any .mument
that he sliceuance, also dpursant to ns the
ovisiosofthecant for such Contrarnin)icense aw(ned snt4mes)
License Law sCodecr9
that heislicensed pursuant to provisions of the the
(commencing with Section ]000)ol'Division Jof lite Busioexe and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more man Eve hundred dollan($5W).
❑ I, es owner of the pmpenY, or my employees with wages us their sole mmpensmme,
will do the work, and the stmcmre is not intended or offered forsale(Sce.JfH4, Business
3 and Professions Code: The Contractors License Low does not apply m an owner of
property who builds or improves thereon, and who does such work hinmself or through
his own employees, provided that such improvements are not intended or offend for
sale. If. however. the building or inhprovemet is sold within one year at completion, the
ownerhuilder will have the burden of proving that he did nut build or improve for Four-
pose of sic.).
❑ 1, os owner of the prnpcng vat exclusively comrueWg win IicensW comrucnns m
cmnnmct the protect (Sec. ]044, Hus and Professions Cndc:) The Cnnvannr'x Li-
rensc law does not applymanowner of property who huildsmimpmves thereon.and
who convects for such projects with a contrvctoubd licensed pursuant to the Comrunots
License law.
O lamcxemptunlm Sea. ,B&PCforthnmairm
201-1000AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL GIRGl1IT/MISC. 3
'fHMP. METER OR POLE INST
COMMERCIAL'
0 NEW BLDG/ADDITION 0 DEMOLITION
[]TENANT []FOOD SERVICE
I ROVEMF,NT O/� .f- r•
HER M��1 / (�I a—
�T-TxT—
49
POWER DEVICES
SWIMMING POOL ELECTRIC
OI1TLEf5-SWITCHES- FIXTURES
NEW RFSIDENTIALELECTR SQ PT.
(.�
_
SQ. FT. F100RAREA
$/SQ, FE
'
}
m
TOTAL: l -/J
QT -y. PLUMBING PERMIT FEE
PERMIT ISSUANCE
LATER -DRAIN & VENT- WATER (EA)
Owner Doie
VALUATION
I
WORKER'S COMPENSATION DECLARATION
1 l hereby affirm under penalty ofperjury one of the following declarations:
I have and will Mainmdo a Cenifcub of Consent to self-insnrm for Workers Compen-
moon, us,nvided for by Section 37W of the Labor Cade, for the petm
p lomnce of the
work fur which Nis permit is issued.
1 hove and will maintain Worker's Compensation Insurance, as emitted by Section
3100 of the Lowr Cede,for the Performance of the work for which this permit is issued.
My Wor s o y$� 11 apt and Palicy.ohytha9o,
Cartier: LBM I'1 , , I`y.ne Policy Nn.: // (( ]] O.JkO(
BACK FLOW PROTECT. DEVICE
_
DRAINS- FLOOR, ROOF, AREA, COND.STORIES
'
'TYPE CONST'RUCI'10!
FIXTURES - PER TRAP
GAS -EA. SYSTIW- I INC. 4 OUTLETS
OCG GROUP
APN
GAS-EA.SYSTI:M-OVER4(EA)
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE:
(This seetimmslinte bemnpletW if the permit is boron hundheddollan($10))
or less.j
for which this the ait Wiaiss'Cmam-
Loy anytpersn in my mannce ro the as Become
not employ any parson in any manner so as m become subject m the Workers Compen-
cation laws of California. DateAppl
GRF.ASEIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION ftS
GREASETRAP
PLANCHECK PEE
ENERGY FEE
SEWER -SANITARY -STORM EA. 2W PT.
WATER 11HATER WNENT /ELECTR
GRADING FEE
-
OTICm
NIf.
NOTICE TO APPLICANT.W16, Compensation
is Certificate,of Exemption, you should as,
bemnm subject m the Wmhero Comps or thin arms hal of the Labor Code, you mush
forthwith comply with such provisions or permit shall he Deemed revoked,
CONSTRUCTION LENDING AGENCY
I hercbyaffirm that there is a mmundelam lendingageney for the Pcrfomsunce of
the work for which this permit is issued (Sm. 3097, Ci, C.)
Lender's Name
WATER SYSTEM/TREATING
SOILS PEB
WATER SERVICE.
PAID
Dal eceiptp
NEW RESIDENTIAL PLMII. SQ. PT.
TOTAL:
lenders Address
-
TOTAL:
I verify that 1 have read this application and statement the above information is
comet. I agree m comply with all city and county ordinances and state laws relating to
building coreauuction, and herehy sandstorm, representatives of this city m enter upon the
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any way rectum against said City
in onse9vence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SO
REWG ULATIONAX SI
kPattle, of Applicnm/Cnmmmm
HAZARDOUS MATER&A DISCLOSU ID.14
Will reor handle hazardous
yteCupemnoFuture building e, Chapterand Sidial
u refined io the Cupertino Municipal Gulp, Chapter 9.12, and the flerldm and Safely
Codes Section 25532(e)'!
❑Yes ONo
Will the applicant or fuwre building sMcupam use equipment or Devices which
mil hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes ONo
I have rare the hi mrdous materials-
requimmemx under Chapter 0.95pf the Cali -
fomia Health & Safety Cede, Sections 25505, 25533 and 25574.1 understand mm if the
'Wilding does nal currently have a tenant, a nl it is my responsibility m notify the occupant
of the reyuinmems which must he net Fodor to issuance of a Certificate of Ocemancy.
BUILDING FEE
QTY, MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
z
ELECTRIC FE
ALTER Olt ADD TO MECH.
"
PLUMBING 13
AIR HANDLING UNITGO I0,M) CFM)
MECHNIt EEE
AIR HANDLING I/NIT(OVFR 10.0WCFM)
CONSTRU NTAX
EXHAUST HOOD (W/DUC17
HOUSING MITI G ION PCE
HEATING UNIT p'0100,1]'p BTU) ,
HEATING UNIT (OVER I00,000 BTU)
PAID
VENTILATION FAN (SINGLE RESIDJ
Date Reaipi a
BOILER - COMP (3HP OR Bit BTU)
TOTAL.
BOILER- COM P(OVER 100,000 BTU) ,
AIR CONDITIONER
. ISSUANCE DATE
tlY:
NEW RESIDENTIAL MECH, SQ. PT.
Owner or vumnnxed agate Dam
TOTALkn)C)ISSUED
OFFICE