31300 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPF,RMIT PLUMBING-MECHANICAL. ,
BUILDING PROJECT IDENTIF'ICAT'ION
BUILDING ADDRESS: - SANITARY NO. APPLICA)'ION SUBMI'IT'AL DATE
L
OWNFy;S PHONE: CON CTOR'SNAME: LIC NO: NIC CONTROL or
or
ARCHITECT/ENGINEER: LIC NO: q RHyQ �� - ❑
CONTACD PHONE: % BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG. ELF. PLUMBMEC
❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY 131.ECTRIC PERMIT TEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing B DESCRIPTION
,�„aZ with Section 7001 D^ivision 34mr,Business and P'fesi ns CMereadmy license is
000 in full forrcund cd� '26
/-1 PERMIT ISSUANCE
C/ )WL ❑KITCHEN REMODEL
out Licenx Clos, 1.10.N PIPE
�Z Date Cmntruem APPLIANCES-RESIDENTIAL ADDITION OPLUMBINGRE-
F.Dvr ,(1�/''pO �'ARCHRECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
Z O In Z I moderated my plans shall be used ure
s public cords
OZ^O UPT02t1(1AMPS MODIFICATION❑INTERIOR ❑CHIMNEY REPAIR
�.�. W Licensed Professianel 201.1NX)AMPS
J OWNER-BUILDER DECLARATION - IMPROVEMENT
Q 1 hereby affirm that 1 um exempt from the Comrx<mrs License Law for me OVER Pat AMPS 013ATH REMODEUREPAIR 0 DEMOLITION
k 36 V following reason.(Section 7031.5.Business and Profession,Gale:Any city or county SIGNS ELECTRICAL D OTHER
LL LLO which requires a Permit to consumer,alae improve,demolish,or repair any structure _
{II prior a it,iotmove,alsmrequire,theapplicam for such Permit fileasilm suemment SPECIAL CIRCUITIMISC.
Pr that he in liccnsoilmonant m rho pmvidmoof the Onbacmr',license Law(Chuplu9
00y (commencing with Section 7000)of Division Sof the Busiressund PrmWons Codeine TEMP,MEI'ER OR POLE INST. COMMERCIAL,
d^nthat he is exempt therefrom end the husi,Italian alleged exemptimn.Any violation of
^N Section 703ISb an a licam fora ,subjects thea livernoa civil It f POWER DEVICES EITENA LDG/ADDITION ODEMGLITIGN
Y rr PP pemti ) pp ..try OTENANT 0FOOD SERVICE
ZF. t mora than rive hundreJ dollars(S3 W).
2p ❑Las ownerofmc the anuy,mmyemployecs withwages mosaic
r sole cmmixtnsmion. SWIMMING POOL ELECTRIC OTHER IMPROVEMENT
wtll da toofie work,and the ice Cora Isnot,Lictie ter Law
dJ fm snlappl y to ora'Business ❑OTHER
til and property
who
Code:The Camrecmr's License Law does nm work
owner of OUTLETS-SWITCHES-FIXTURES - !Q
L property who boils,or improves t such i and who does such work dedohimself or for
his own employees,provided that such impnrvertmms are not intended or offeree for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however the buileing or improvement is sold within one yearof eampletion.rhe SQ.FT.FLOOR AREA SISQ.FT.
owner-huilder will have the burden of proving that he did not build or improve for pur-
,nicotinic.) -
❑ 77
I,as owner of the pmpemy,am exclusively contracting with licensed commrmrs to TOTAL: ,
construct the project(Sec.I(H4,Business and Professions Cale)The Contractors Li-
reason Law([ties not apply to an owner of parvisafty who builds 6r improves thromr,and QTY, PLUMBING PERMIT FEE
who contracts for such project,with a commands)licensed pursuant to the Contreclor,
License law' PERMIT ISSUANCE
O l am exempt wider Sec. ,B&P C for this reason -
ALTER-DRAIN&VENT-WATER(EA)
Owner Dam VALUATION
ATI
WORKER'S COMPENSON DECLARATION CK FLOW PROTELT DEVICE PAID
I hereby affirm under penalty Of perjury one of the following declamtlons:
❑Ihave md will maintain Cer,ificamdConsent to self-insure far Workcr'e Compen- URA S-PLOOR,ROOP,ARI'.A,COND' STORIES 'TYPE CONSTRUCTION
sation,as providedfor by Section 37U)of the I.aM r Cale,Ibr the perfonnunce of the d p(
work for which this permit is issued. FIXTUR_ -PER]RAP OCT `^ 199
0 1 have and will maintain Workers Compensation Insurance.as required by Section
3700 afore Lha Code,En the Pon ormanm.fthe work forwhich this permit is issued. GAS-EA.S EM-I INC.40UILE1'S OCC.GROUP qPN
Mr Carrier:
mPe,:)i t e Parer n , ` CITY OF VUr .ii I INU
Carter:�Pollry NmA� CAS-EA.SY9'1'F -OVHR4(EN
CERTIPICCOMPENSATIONII NFRA WORKERS'
COMPENSATION INSURANCE GREASP/INDUSTRL)KASTE INTERCEPTOR
Tlhis section need not be completed if the permit is for one hundred dollars 0100) BUILDING DIVISION FEES
or less.) GREASE.TkAP PLANCHECK FEE
Loy anythatn the tiny amnnecof mr,w,thcwofkfar whichthi,,permit W,kewakI shadatien- SEWER-SANITARY-STOR err 21X1 f'r.
rat employ any person in any manner wV n,m Iwcnme sunect nt the Workers'COmPcn- ENERGY FEE
OZ sation Laws of California Date WATER HEATER WNENT/EI,F.
Z 0 Applicant GRADING FEE
h NOTICE.TO APPLICANT,If,agermaking this Certificate f of Exemption,you should WATER SYSTEMIfREATING
a
becomesubject comply
to the Workers Compensation his provisions of the Labor Cole,you must SOILS PF.E
111
forthwith Comply with such provisions onhi,permit,hull MAeemed revoked WATER SERVICE
�O m CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
I hereby affuthat them is a construction lending agency battle performance of Date Receipt is
LL P the work for which this Permit is ismed(Sec.3097,Ci,C.)
0 U Lender,Name - 'TOTAL:
Lender,Aderm, TOTAL:
I certify that I hove read this applicmion and stere that the above inhmmatimn is BUILDING FEE
V1 concert.l agree to comply with all city and county ordinances and state lawn relating to QTY. MECHANICAL PERMIT FEE
V Z building amseuction,and hereby auNorim mpmsenta,ives of this city m enter upon the SETS MIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE. ,/y�
(We)agree m not.indemnify and keep harmless the City mf Cupertino against •� ELECTRIC FEE
liabilities,judgment,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. f'
in asequence of the granting of this permit PLUMBING FEL'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 10,000 CFM) -
SOURCE REGULATIONS, MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signature of ApplicanUContmctor Dec EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle haeaNOm material HEATING UNIT(TO 100.0n)BTU)
as defined by the Copemino Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532(1)'1 HEATING UNIT(OVER 100,000 BTU)
0 vet 0N
VBNTILA'HON FAN(SINGLE RESID) PAID Date Receipt 0
Will The applicant or Tuan building Occupanby
use equipmentor Marta which BOILER-COMP QHP OR 100,000 BTU)
emitL.,ffic
ttit air conaminant as defined by the Bay Area Air Quality Management
TOTA Ay Afly
s ON. BOILER-COMP(OVER IW.fI(q BTU)
e thehvuNonsryirems under Chapter 6.95 of Orae Culi- AIR CONDITIONER ISS/y&Safety Cale,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.not currently have a mount.that it is my mpamihild,1. ft,theoccupamment which mus,M met prior to issuance ofa Cemificate of Occupancy.
li me4 ogcnt Umc - IY))'AL: ISSUI3D BY:
OFFICE