31285 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. w ��x
BUILDING DIVISION APPLICATIONIPIERMIT PLUMBING.MECHANICAL J{ '2 t8J
BUILDING pROJEC'I'IDENTIFICATION
UILDINGADDRISS: SANITARY NO. APPLICATION SUBMITTAL DATI
1967. ef- I d
It 'SNAME: ✓ PATINE: CONTRACTOR'SNAME: LIC NO
411 rp
X O 1 NIC CONTROL p
1�S CHITECf/F:NGINEER: LIC NO: ADDRESS: El
CONTACT: PHONE: BIJILDINO PERMIT INFO
N��=969-3 ya` Consultant Fees Paid by Appllcant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QT'Y ELECTRIC PERMIT FEE ❑
1 hereby amrtu that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
DIgZ with Section 7"))f Division 3 ofthe Business and Professions Code.and my license is RESIDENTIAL:
OO in full force and effect. PERMIT ISSUANCE
=ut License Class Lion - ❑SFDWL ❑KffCHEN REMODF.I.
Dare Contractor APPLIANCES-RESIDENTIAL El ADDITION /�y'�\h UMBING RE-PIPE
a"
ARCHITECTS DECLARATION ❑MULTI-UNIT - I:1S'fRUCfURAL
I-� PANELS
ZOIn'4 I understand my Plans shall be used as public records MODIFICATION
OZ-0 UPTO 200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
P4I"W Licensed Pmfessimnnl OWNER-BUILDER DECLARATION 201-IWOAMPS IMPROVEMENT
�PC Q 1 hereby affirm that 1 am exempt from life Contractor's License Law for the OVER Into AMPS ?4qH REMODEUREPAIR Q DEMOLITION
igi..�55O6U following reason,(Section]0315.Business and Pmfessiom Code:Any cityercoumy SIGNS(ELECTRICAL []OTHER
h++4 O y which awas a permit tu consuuct,aper.improve,demolish,or repair any swcture
prior it)its issuance,also requires the applicant for.mcM1 Permiuo file a signedsmmment SPECIAL CIRCUIT/MISC.
that he is licensed paramnl to the provisions of the Contractor's License Law(Chapter 9
�� (commencing with Section700(pof Division 3olthe Busmunro
essd Pfessions Code)or TEmR Min-IR OR POLE INST. COMMERCIAL'
It. m Na he is exempt IM1erefmm and IM1e hosts for the alleged exemption.Any violation of ElNEW BLDG/ADDITION ElDEM61ATION
—4y Section]031.5 by any applicant far a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
tet more than five hundred dollars(5500). - IMPROVEMENT
Q ❑1,usowner of the property,or my employees with wagesus their sole cnumansation, SWIM M I NO POOL ELECTRIC
will do the work,and the stmemre Isnot Intended or offered mr,tile(SaoAM4,B nimr,, ❑OTHER
W and Professions Coda The Coninumr's License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURPS
a'
property who builds or improves thereon,and who does such work himself or through, — A
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ f4.
sale.II however,the building or improvement uanld willionnc car of can.p16on,the .Q.FT.FLOOR AREA S/SQ.FT.
owner-huilderwill have the burden ofpmving that he did nm build or improve for pur- n A f D .
puce of salcJ. r N
❑1,as owner of the pmpety,am exclusively contracting with licensed commemn m TOTAL'
construct the project(Sec.]044,business and I'mfcgsion,Cori The Comrumar's Li* � �
14 199
come law does not apply to an owner of property
contractswho bolds or improves thereon,and Q'I'Y. PLUMBING PERM IT FEE 9[]6
who contracts for such pmmts Jwith a commemgtt
s)licensed purouno the Convector's
License law. PERMIT ISSUANCE
❑I ant exam tt Sec. ,B&P C for this reason CITY OF (`I PE
Owner Dnte ALTER-DRAIN&VENT-WATER(EA) VU1 VALUATION
RKER'g CO N A'10 DECLARATION BACK FLOW PRO'T'ECT.DEVICE
1 hereby affirm under penally of pe juryenc of the following declarations
❑I have and will maintain a Certificate ofConwm torelf-insum for Workers Ciampi DRAINS-FLOOR,ROOF,AREA,CONT. STORIES TYPHCONSTRUCTION
sation,as provided for by Section 37W of the Lahor Code,for the performance of the - O
work for which this permit is issncd. WXTURES-PER TRAP
❑1 have and will maintain Worker's Compenmtina Insurance,as required by Section
3]OI of IM1e labor Gavle.for the performance of the work fur which this permit
mission. GAS-IEA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number ere:
Cartier: Policy Not GAS-EA.SYSTEM-OVER 4(EA)
CEKTIFICATE 01:(EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASHIINDUSTRI.WASTE IN'TERCEPT'OR
(This unumm naed nm be rompleted how Permit is furore hundred dollars(5100) BUILDING DIVISION FEES
or less) GREASE TRAP PLANCHECK PEE
Loy any that inthe perfonnnnce ero the as
fur subjectch thispermitWrkesued,I shallCompr- SEWER-SANITARY-STORM P.A.2M FT.
not employ any person In any manner sat as la hrennm subject m the Workers Cnmpen- P.NP.ItOY FEE '
Z cannot Laws of California.Date
z2 Applicant WATER I(EATER WNENT/ELECI'R GRADING FEE
) NOTICE TO APPLICANT.IL after making this Certificate of(Exemption,you should WATER SYS'ITIMITREATING
become subject o the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
fmthwhh comply wl0 such provisinns artbls Mrnit shall he deemed revoked; WATER SERVICE
5Z CONSTRUCTION LENDING AGENCY NEW RESIUENTIALI'LMtl. SQ.Ff. PAID
I hal built rte that them isaeomwe.30 lending agency Toone Performance of Date ReceipfX
W tato war,fur which this permit Is issued(Sea.309],Civ.CJ
O U LcmRr',Name TOTAL:
yLenders AJdf,t
Imnify that have read this application and state that the above informadnn is BUILDING FEE
y corrcct.l agrtemarmply with all city and ronnry oreinances nnJ state laws rclmingm QTY MECHANICAL PERMIT FEL? is
U building construction,and hereby authorize representatives of this city to enter upon the SEISM IC FEE 1
above-mentioned pmperty for inspect inn purposes. PERMIT ISSUANCEIi
(We)agree to,ave,indm
enity and keep harmth
less e C ly of Cotonou)annul ELECTRIC FEE
liabilities,judgmentx,costs and expenses which may in anyway eccme against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence ofthe granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('TO 10,000 CPM)
SOURCE REGULATIONS. MECHANICALITH
AIR HANDLING UNIT(OVER TB,non CFM)
I CONSTRUCTION TAX
Sigumure of ApplicrnVComracmr Data EXHAUST HOOD(W/IIUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle ha4mmus nnnerial HEATING UNIT TO,100,010 BTU)
1. as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532m)? HEATING UNIT(OVER 100,006 BTU) �_JaXXuy�
❑Yes '(]No VENTILATION FAN(SINGLE RESIDI PAID _ V
Dote Ree
Will applicantinfurore h efireg by the on Buse aAir Quordeviseswhich BOILER-COMP IMF OR 100.BOI BTU)
emit District? us air contaminants as def neJ by the Bay Area Air Quality Management TO AL:
D'svin?
r7 Yes No BOILER-COMP(OVF:R IOO,ON)BTU)
(have rood the hazardous mmenols rcyulrancns under Chnpmr 6.95 n1'fhc Cali- AIRC(INDITIONF.R ISSUANCE DATE
made Health&Safety Code,Sections 25505,25533 and 25534,1 understand ohm if the NEW RESIDENTIAL MECH. SQ,FT. 41
building does nm currently have a tenant,fast it is my r. rsibiloymnotifythesrcupanf
} of the reyuirefnems which must be ten prior m issuance of o Cedificme of Occupancy. _
j Owner or submitted agent - Rafe TOTAL; ISSUED BY:
Ir I
OFFICE