31197 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 9
BUILDING PROJECT IDENTIFICAA[ON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
l0 IC�'�IEV1�
A I LT NGINEE fcw I _ RNA .IWE
OW NIC R.y ^S?,,6 J
G ib9ADRESSS
❑
1
CONTACT, _ PHONE: ^iT _ BUILDINGPERMrrINPO
O �7/ /�a ❑ Consultant Pres Paid by Applicant(Initial) BLDGELECT PLU ME
LICENSED CONTRACTOR'S DECLARATION I QTY. ELECIRIC PERMIT FI;E
1 hereby alrnm i that 1 an,licensed under powedam s of chapter 9(cC cneh,g JOB DESCRIPTION It
"Z th Secdcat7000)of Division J of the Businessand Profession Code,sad.,license is RESIDENTIA4
DO wt PERMIT ISSUANCE
in,(.Il force and effect.
TUU License Class Lic.M pppl.lANCGs-RESIDIiNT AL ❑ADD TSFDWL ❑PLUMBKITCHING
REMODEL
F Z�4 Dam Contmm,r W"'A l D ❑PLUMBING RE-PIPE
�n ARCIII'I'EC'I'S DECLARATION ❑MULTI-UNIT ]STRUCTURAL
(..'wl PANHhS
ZO�Z Iundersmial nryplansshall beused as public records MODIFICATION
Oz-0 UP TO 200 AMPS ❑I�aR OL(1grl CHIMNEY REPAIR
F F IY Licensed Professional 201.1010AMPS
,•,...I1I
OWNER-BUILDER DECLARATION OVER I0t0 AMPS [�t�r�TO REMOD81./RDEMOLITION
O Q hreaso.(firm that I con exempt s an the Coniones C's License ban for the �I If(IdKr I/(J�'tl"{I Ip(u
31 U following reason]Section"1031 ru Business and improve,
d sio demolish,
Code:Any city or county SIGNS ELECTRICAL
LL which requires a permit re coronet,alcor,]t for such
demolish,nr a pair any smcturt
�
prior to also requires applicant for tach permit..Ncesigned emmmem SPECIAL CIRCUIT/MISC.
NThat he is licensed pursuant to the provisions of the Contractor's License Low(Chopmr9
0700 (commencing Ihwith Sadon700(fol'Divislon9ol'the Business and Profasiens Code)or TEM]..ME'T'ER OR POLE INST,� - COMMERCIAL,
6 M C that he is exempt ercm froand the bvis for the alleged exemption.Any violation of ❑ :W [IBLDG/ADDITION DEMOLITION
iqG Y• Section 7031.5 by any applicant fora pen d,wbjectsthe applicant..a civil penalty of POWER DEVICES tL ANT ❑FOOD SERVICE'
M marc than five hundred dollars y empl IMPROVEMENT
Q ❑ ko its the work,the propanoure is
des wiNwages or their sole
ec.compensation. SWIMMING POOL ELECTRIC
will da the work,and rho he Cone a torsot intended offered do s Can
apply tof an owniness OTHHR,
a,3 and profession Code:The Contractors the r'e License do does not appy to an owner of OUTLE I:S-SWI3'CItES-FIXTURES 2.
h,mpeacyis own who builds or improves thereon.and who does such work himself of through
his own employees,e provided that such improvements are not intends]or offered for NEW RESIDENTIAL EL[CfR SQ F4.
sale.If.however will have
building or proving
issoldhewithin one year
or improve
Ne SQ.FT.FLOOR AREA $ISQ,FT.
pmeerhuildei will hove the burdat orproving that he did not build or impmvc l'ur sur- 2
pore oLsale.). TAC:
❑1,n owner of the pmpeny,am exclusively contracting with licensed conio ctors to
constmet the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Low does not apply to an owner of property who builds or iniprove.,tharcon,and QTY• PLUMBING PERMIT FEE
who convects for such projects with a canunetnr(s)licensed punuont to theCnnwanra
License law. PERMIT ISSUANCE
❑lader Ste., �,B&PC Tyr this Jeasan
ALTER-GRAIN&VENT-WATER(BA)
- VALUATION . .
' MI'ENSATIUN IIECLARA'TION/ or BACK PLOW PROTECT.DEVICE
I hereby ill maintain
ai under penolty of pe jury one of the insum ng declmatinns:
❑]have and will for by.naCeni37M of Conmt..Code.for the Workersce of the
DRAINS-FLOOR.ROOF,AREA.GOND. STORIP TYPE CONSTRUCTION
work(as provided for mit is i,,a 3)00 of the IaMn CWe,for the perfnmmnce of the
work far which this permit is isuui. FIXTURIis-PER TRAP
❑1 have and will ode.fon Wnrkch Compensation w rk for which
h required by Section
My ofibe Worsts CorCWgionNeprnce cancer and Policy
for athispermitisissued. GAS-pA.SYSTEM IINC.40UTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
' Carrier. Policy No.: GAS-EA.SYSTEM-OVER 4(F.A)
CI7RI FICATF,OF EXEMPTION FROM WORKERS'
COMPIisl ATION INSURANCE GREASE/INDUSTRI,WASTE INTERCEPTOR
ITbis sutinnnt hrom
eedno < pleted if the permit is for one hundred dollars($100) BUIL, IN IVISION FEES I
or lest GREASE TRAP PLANCHECK .E
lay any that in the peromriciany
as to bekni which this lie W rker,'ed.leha]I SEWER-SANITARY-STORM EA.200 FT.
not unpiny any person in any manner so asmhunnm subjed..the Wnrkeri Cnmpen- ENERGY F, —�
� Z sation Lawsof California,Date WATER HEATER W/VENT/ELECI'R
Z 0 Applicant GRA
LA NOTICE TO APPLICANT,,If,after making this CcniOcata of Exemption,you should WATER SYSTEM/IREATING
become subject to the Worker's Cantpensattoo provisions of the Labor Code,you most SOILb ,E
W ✓rt fonbwlth anmply with such pon,,innv or Nls pcnn'a shall hedecmcd revnkcd. WATL'R SERVICE
Q
5Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.IT. PAID
V 0 I herebyaf6nn that iso emear aion lendingagency fonts perfirommoeof te. ReceilxM
W — the wait far which this permit is ismad(SCC.3097,Civ.C.)
Q ULeader's Name 'T'O'TAL:
Lender's Address TOTAL:
6 I certify that 1 have read this application and state Not the above information's BUILD] .FEE r
L76 correct.l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEF,
G G building construction,and hereby authorise representatives ofthis city toenter upon the SEISM/ME /a
uMrvc-mentioned property for inspection purposes. PERMIT ISSUANCE.
(We)agree to save,indemnify and keep hour...the Only of Cupertino against ]'Clic RIC FEE
]iahilitics.judgmems.costs and expenses which may in any way areme against said City ALTER OR ADD TO MECH.
in mcqucntt of the grunting of this Permit. PLU BINGFE
APPLICANT IrNDERS'1}(F6STmrl-*4 'LY WITH ALL NON-POINT AIR HANDLING UNIT('I'O 10,000 CPM) ME LAICAL FET:
SOf1RCF.REQ .A'fIONs.
01
AIR HANDLING UNIT(OVER B).W)CFM) CONSTRU N'FAX
gnelureo ,licnnt/Conaactnr aEXHAUST HOOD(W/DUCT) HOUSING MITI 'TION FEE
HA ARD US MATERIALS DISCLOSURE
Will thcuppliaunt or fart building accupunt store or h:mdlc hozutdous materia] HEATING UNIT IT 0110,1100 ID U)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532007 HEATING UNIT(OVER 100,000 BTU)
❑Yn N VENULNI[ON FAN(SINGLE RESID) PAID
nam ceipt 11
Wradmi,ll ua,'notaton forme building by the ay Aeyuipm Quality
Management
eat BOILER-COMP OR 100,000 BTU)
emit hazardous air umtamiandef ed by the Bey Arca Air Quelity Munugemcnt TOTAL:
UinricC
C]Yes BOILER-COMP(OVER UX%0W III U)
I have rad the horsrdaus mnteriuls rc vinnuents under Chapter 6.95 of Ne Cali- AIR CONDITIONER
q p ISSUANCE,DATE
Ionia li &Safety Cod".eSee a25505,2553a
]on 5 I .1 understand that if the NEW RESIDENTIAL MUCH. SQ.PI'.
it
buildingd snot currently havem nsihilitymnotify thecempant
of the nu
h whicmust he to- sena aCenilica¢
Norized ug It ISSUED BY:
OFFICE