31154 I TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
.F CUPERTINO BUILDING-ELECTRICAL. PERMITNO. a�
.LDING DIVISION APPLICATION/PERMIT PLUhIBING-MECHANICAL J{
BUILDING PROJECT IDENTIFICATION
1154
GILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
OWNER'S NAME: P O E. ONTRACI'OR'S NAME. LIC NO'
L-41 A017
ARCHITECT/ENGINIiER: a LIC NO: pDORESS; 2 V ❑
coNracr: PHONE: BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) 13LDG ELE T PLUMB MECII
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under previsions of chapter 9 terminal JOB DESCRIPTION
HOZ with Section 7000)Of Division 3 ofthe business and Professions Cale,and my liceuscln PL'RMI'1'ISSUANCII RESIDENTIAL'
n full lives and effect. �/`�
aUV License Class Lic.p ❑SFDWL -y,1sLCITCHEN REMODEL
vFi6eW, Date Contractor. APPLIANCES-RF_SIDENTIAL ❑ADDITION /❑P`L'UMBING RE-PIPE
E.Dm ARCHITECTS DECLARA'f10N PANELS ❑MULTI-UNIT ❑STRUCTURAL
Oc! K I understand my plans shall be used as public rehnd.e
:] UP 3D 2(10 AMPS MODIFICATION
(••'W Llcamed 1'mfessmnal ❑INTERIOR 11 CHIMNEY REPAIR
q BUILDER DECLARATION 201-IINXIAMPS
2 j OWNER- IMPROVEMENT
yyx a O,V Q 1 hereby affirm tient I am exempt from the Cmamctor's License Law for the OVER IOW AMPS El BATH REMODEIIREPAIR ❑DEMOLITION
W c. following reason.(Section 7031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL, ❑OTHER
which rc9mims a Fannil it,construct,alter,improve,demolish,or repub any,nmemre
vrn"71 prions its issuance,also rc(loims the applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC.
vWWll} that he is licensed pursuennn the provisions of the Cnntmemrs Licenw law(CM1aptar')
5�p (commencing with Section 7")of Divisinn 3 ofthe Business and Pmfessians Code)m, TEMP.METER OR POLE INST. COMMERCIAL
d e ys that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION
m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
kE..zz} mtnume than five hundred dolloa($sNo. t ❑TENAN'T .❑FOOD SERVICE
C Q
01,as owner of the pm,xarr,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
5522 m will dil work.andlhexwcmre isnot intended oroffeted for ase(Sec.7044.Business OTHER
d3— and Promilions Code:The Conaamoes License Law dies not apply In an owner of OUTLETS-SWITCHES-FIXTURES
progeny who builds or improves thereon,and who does such work himself or through
his own employees,prnvided not such improvements aro nut intended nr offered for NEW RESIDENTIAL.BLECTR SQ Un
sale.IL however,the hm1cin,mmgnivcntem issold within one year of completionthe SQ.FT.FLOOR AREA S/SQ.Fp.
owner-Hilder will have the burden of preving that he did not buil)or improve for pur-
poseof sale.).
El 1,as owner of the pmpeny,am exclusively contracting with licensed contractors to TOTAL: kille
construct the project(Sec.70cU Business and Professions Cade:)The Contractor's Li-
canIc Law does not rIPly to nn owner of property who in fix or improves lhcrecn,:md QTY. PLUMBING PERMIT FEE „1
who contracts for such Projects with o contmemrts)licensed pursuant the Comractoes ^� n
License law. 1 PERMIT ISSUANCE r y
❑1 am exempt under Sec. ,B&P C for this reason ry
49 Ar
Owner Date ALT17R-DRAIN&VENT-WATER CA) VAI.
WORKER'S COMPENSATION DECLARATION J1 f
IT Art
I hereby affirm under penalty Of BACK FLOW PROTECT.DEVICElt/Ar/ v
perjury one of the following dedamtinns: ✓'+q
❑I have and will maintain a Certificate ofConsetn to self-insure for Workers Compel. DRAINS-FLOOR,ROOF.AREA,COND.
sarion,as Provided for by Section 37011 of the labor Code,for One Ni-formance of the STORIES TYPE CONSTR UC ION
work far which this Permit is issued. FIXTURES-PERI RAP
❑1 have and will maintain Worker's CnmperOcinn Insurance,as requbed by Section
3700 of the labor Cale,for the petformunee of the work for which this permit is issued, GAS-Bp.SVSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker Compensation sutance rand licy rYe u
Carie,. PolicyNo: 7 GAS-EA. -OVER4(F.A)
CERTIFICA EOFE MPTION FROMWRKES'
COMPENSATION'INSURANCE GREASIDINDUSTRI.WASTE INTERCEPTOR
(Tris section neeA not he complemd ifloapscmh is for care hundred dollars(SI W) B HVISION[777 HS
or lcssJ GREASE TRAP PLANCIIECK FE
(certify that in the perfornan ofthe work for wh"hthis permit is ixmed.l shall SEWER-SANITARY-STORM F.A.2W FT.
.are, lay any Eason inany manse so net suj the Workers Co BNERGV P'
Oz wrier Laws of Calif iia Uma o WR'I'ER HEATER W/VENT/ELECM
0 Applicant GRADING
N
NOTICE 10 APPLICANT.If,ea afterpenkmgsati this ,ca.. our Cod . should WATER SYSTEMaRRATING
become subject, the Wnrh Im Compensation provisions of the labor rode,you muss SOULS FR.
� Qforthwith comply with such Provisions nr this permit shat l he deemed revoked.
WATER SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL('LMB, SQ.FL PAID
V 0 l hereby affirm that there is a construction lending agency for the Performance of re Receiptk
the work for which this perm issued(See 3Civ.C.)
0 U Lenders Name - �isi007,
C.7 Lender's Address TOTAL TOTAL:
F04 1 certify that I have read this application and state lost the above inforio ation in - BUILDING EF.
Fr Vl correct.Iugreemcmmply withnll ch,und enomytodinanec and slet,lawsmlating to QTY. MECHANICAL PERMIT FEE �+
U building consuuction,and hereby authorize representatives ofthis city In eructation the SEISMIC III .
above-mentioned pimpeny for inspection purposes. PERMITISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiabilities,judgmems.costs and expenses which may in any way accme against said City ALTER OR ADD TO MIiCII.
nconseyuonce of theg tming of this mil. PLUMBING FEE li
APPLI.ANT UNDER TANDS AND WILL CO PLY L N-P INT AIR HANDLING UNIT(TO 10,000 CFM)
SOUR EREGULATIO ;S. MECHANICAL FEE
S AIR HANDLING UNIT(OVER UtON,CFM) CONSTRUCTION TAX
Signa rc"'A'adieansO, mem, Ilam RXI MUST HOOD(W/DUCT)
HAZARDOUS MAHiRIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building Occupant score or handle hazardous material HEATING UNIT(TO I00,010)BTU)
' as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)1 EAEVIR00 BTU)
❑YesNo
REST])) PAIDWill the applicant o f rare building Occupant use equipment or devices which Date R¢am,R
emit hazardous air contain asdefined by the Bay Area Air Quality Management ,000 BTU)District? TOTAL:
❑Yes ❑No ,OW B1'U)Ihave read the hazoNnus materials requirements under Chapter 695 of die Cali-forma Health&Safety Clde,Ser ions 5505,25533 and 25534.1 undmatnnd then ifthe ISSUANCE DATE
building does nm currently have amnan,then it is my responsibility m ratify the arupaidSQ.Ff.
of the rryuimments which must be met prior m issuance of a Cenifiewe of Occupancy.
a Owner or uuthamed agent Date TOTAL_
• ISSUED 1{y:
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