31088 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 31088
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
UUIILDING ADDRESS: �+ SANITARY NO. APPLICATIONSUBMITTALSUBMITTAL DATE
sD 1/ /
NER'g AME: PION@ NTNgCTOR:S NAME LIC NO:
e/ NAC RDLp
CIi1TE IIiNCINHIiR: LIC NO: DURESS: ❑ ���JJJ
PHONE: BUILDING PERMIT INFO
`Trp 6 � G0t /'e'—err-p A ❑ CnnSultant Fees Paid by Applicant(Initial) BLI ELECT PLUMB M C
Rte'LICENSED COM'RACrORI:SSDDEWCLAAR�AATION 7 D 7�0 QTY ELECTRIC PERMIT FEE
I herchy a10rm Nm 1 am licemed under pmvisions of Chapter 9 kammencing JOB DESCRIPTION
OCy with 5ectinn]000)of DivisinnJofha Buslnew onA l'mfessions Code,and illy liana is
Z IDA z00 infulifcndeffl. PERMIT ISSUANCENTI
V WL
C1 KITCHEN REMODEL<Umnuass .ic.a
hQ� ate Contractor APPLIANCES-RESIDENTIAL DITION ❑PLUMBING R&PIPE
I„a ARCHITECTS DECLARATION PANELS
MULTI-UNIT (]STRUCTURAL
ZO IunOentenJ my plans shall limed puM1lic recants MODIFICATION
O _o UPTO 200AMPS ❑INTERIOR [I CHIMNEY REPAIR
F�1p"I1i Licensed Pmfessiovl 201.1"AMPS IMPROVEMENT
9Rd OWNER-BUILDERDECLARATIONCLARATaON OVERI(MAMPS /
KK tK 1 hereby affirm that 1 am eumpl from the Contractor's License Law for the ❑HAITI REMODEL/REPAIR (]DEMOLITION
06 U following reason.(Section 7031.5.Business and Professions Calc:Any city or county ❑SIGNS ELECTRICAL OTHE&`
F O F which requires a permit to construct,alter,improve,demolish,or repair any structure P
priorto its issuance,also resptiresthe applicant for such permit o File asigncd statement SPECIAL CIRCUIT/MISC.
vWvW�s} hal he is licensed pursuant to he powis mo,d he Continuum's License Le.(Chapmr 9
IyS�� (commencing witb Section 7")of Division 3 claw Business and Professions Craft or TI?AfP.MRTI?R OR POLE INST.
6 that he is esmu t therefrom and the basis for he aIle ed eaem tine An Inion of DD[[((TT
Section 7031.5 by amyapplicam fmapermit subjects heappli...t m acvll npenahy of POWER DEVICES D A [I DEMOLITION
t more In.,,Ove hundred dollars MIN)).' ❑TENANT '(]FOODSERVICE
F=O I]1,asowner of the propcny,or my employees with wages us their sole asmpensatinn, SWIMMING POOL ELECTkIC V' IMPROVFfv_IFjNEHTjj IO
_$ wdl do he wark,and It. acmm is not intended oroffeud forsals(See.7044,Business ❑OTHIiR D�YY
and Prows,mov Code:no Comencmrs License Low does not apply to an owner of OUTLETS-SWITCHES-EIXTUR
prnp<•ny who Wilds or improves thereon,and who docs such work hinaelf or through
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR
sale.IL however.the building orimpmvemem is sold wihin one year ofcnmpinion,he ASQ,Ff.FLOOR AREA LSQ,ET.
pwner-builder will have he burden of proving that he did not build or improve for pur.
ose of sine.), IVQ
❑1,as owner of he pm,f,am exclusively rnmracting wih licensed contractors u, TOTAL:
construct he project(Sec.7040.Business and Professions Cale:)The Commctors Li-
Cr
ecnu Law dotes not apply wan owner of property who builds or improves thereon,and QTY, PLUMBING PERM FEE
who mourwis Dar such pn!iecrs with a varnmtor(.0 licensed pursuant m the Cannaram's
License Law. ]']IBM])'ISSUANCE
I um exempt under Sec. ,B&P C(nr this reason
-_O r T - - ALTER-DRAIN&VENT-WATER(EA7
woe Date VAIAAi'ION
WORKER'S COMPENSATION DECLARATSv ION BACK FLOW PROTECT,DEVICE ^/'� — _
1 hereby affiant under penally of perjury one of the following dedumtions 9� a
I have and will maintain a Certificate of Comenuo self-insure for Workers Camper. DRAINS-FLOOR,ROOF AREA,CORD. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 370)of the l.aher Code,for he performance of the
work for which his perm r1itlaimed. IT,TURKS-PER TRAP
I have a
go "i \ ;ers Com ensotinn I is uircA ry Sedrun'
3]IXl alt Tial' ran u t e forwhidt his pemtit is issued. GAS-EA.SYSTEM-I INCAOUTIRTS OCC.GROUP APN
My Workeren. ud 'W icy her are:
J Canter, de GAS-EA,SYSTEM-OVUR4WA)
/ R F ATE OFEXEMPTION FROM WORKERS'
00
COMPENSATION INSURANCE I GREASERNDUSTRL WASTE INTERCEPTOR
(This.uctlon need not be completed ifthe permit is for one hundred dollars(a ITN)) BUIL ISION FFES
or leas) GREASE'1'RAP PLANCEECK H
(certify Natio the anyfrmancen an to became
which this permit "mad.I SEWER-SANITARY-STORM RA.200 ET.
oat employ any person n any manner se as m hecmne subjm m the Workers'Compem ENERGY PL•G
z
Applicant
of Cali(omie.Date
�O ppplicanr _ WATER THEATER WNENT/ELECTk GRADING ,
.~N.t NOTICE TO APPLICANT,If,after making this Certificate of Exemption,you should WATER SYSTEM/fR1iATING
a , become
subject to the Workers Compensation pmvisions of the Labor Codyou mus
e, t SOILS FEE
W
forthwith comply with such pmn
visions or permm
it shall he devoted revoked, WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ Fr, PAID
U 0 lhembysi imthonhere is ammurectton lendingsgencyfortheperfornance of — D e Receipt
Br f'+ the work for which this permit is issued(Sec,3097,Civ,C.)
0 Lenders Nome TOTAL:
0.G Lenders Address TOTAL:
I certify that 1 have read tats application and ,are hot he abuse information is BUILDING TE
V) runwer.I vg we m comply with all city and counryomtnanccsandlanelaws Jatngm QTY. MECHANICAL PERMIT FEE
U huildingconsuuction,and hereby authorize representatives ofthis city menterupan the SEISMIC EE
abuse-mentioned property for imperlum purposes. PERMIT ISSUANCE.
(We).grew tee save,indemnify unit keep harmless the City of Cupertino against ELECT k C FEE
liabilities,judgmems,cava end expenses which may irimy wayammeagainnuid City ALTER OR ADD TO MECH
in consequence of the granting of Ni .s permit. PLUMBING FEE
APPLICA %CNDERSTANDI AND WILL.COMPLY WITH ALI,NON-POINT AIR HANDLING UNI'F(TO Ig000 CFM) -
SOURC F,(ULATIONS. �/'I MECH (CAL FEE
`/�F�—'/'/ AIR HANDLING UNIT(OVER Braniff CFM) =—
are
Signe ffillcmNCunOucmr [)ate EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the appticaut or future building occupant store or handle Enormous material HEATING UNIT(TO 100.00)BTU)
as defined by the Cupertino Municipal Code,Chupar 9.12,and the Health and Safety
Cala Section 25532(a1'f IDEATING UNIT(OVER 11)0,0000"TO)
E3 Year, ❑No VENTILATION FAN(SINGLE RE.SID)
Will the applicant nrfuture building occupant use equipment or devices whichemit hazanluun air donmminants as defined by the Bay Arca Air Quality Mutmgement BOILER-COMP(3HP OR 100,000 BTU)
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑Nu
I have read he hazardous mald.1,mq.im cut,under Chapter 695 of the Cali. AIR CONDITIONER ISSUANCE DATE
fomia Health At Safety Code,Sections 25505,25533 and 25534.1 understand Nat if the NEW RESIDENTIAL MECH. SQ,Ff.
building me notcurrently have.tenant,Outo ismy responsibi ���st��
of the requirements which must be met prior to isxuonread. n I[ke y/qg r IIIIIss
Owner or amhmmedi agent Urate TOTAL: ISSUED BY:
OFFICE ,