31319 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 31319
BUILDING PROJECT IDENTIFICATION
ILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
-541i-FA Brelit-L A A- — —
NER'3 AME.: 1 / s rH0 �: �I C 9'RACI'OR'S NAME: LIC NO: N/C ; CONTROL#
.111111111hARCH ECT/ENGINEER: -V IC NO: 1' ADDRESS:
5 ❑
CONTACT: PHONE: BUILDING PERM IT INFO
❑ Consultant Pecs Paid by Applicant(Initial) 'BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby a0)offirm that I am licensed under provisions of Chapter 9 mmomeneing JOB DESCRIPTION
1000 with Section]00f Division 3onhin
e Busess and l'mm,smas C«le,mtdmy license is RESIDENTIAL:
00 in full force wd effect. PIiItMIT ISSUANCE
p41+I�' ❑SFDWL [I KITCHEN REMODEL.
QV((]] an Class oAPPLIANCES-RESIDENTIAL
�
Qa DDam Commerce ❑ADDITION ❑PLUMBING RIiPIPE
Fly ARCHITECT'S DECLARATION PANELS ❑MUI.TI-UNIT ❑STRUCfURAI,
I understand my plana shun he axed as public records MODIFICATION
OZ0 UPP0200AMPS El INTERIOR El CHIMNEY REPAIR
r,4tw Licensed Pmfesxionel 20PH)AAMPS IMPROVEMENT
OPOWNER-BUILDER DECLARATION OVER 1000 AMPS ❑PATH REMODELRtEPAIR ❑DEMOLITION
OP
a I hereby affirm that I am exempt Item the Com.a.r's License Law for the
!i O y U fdlowing reason(Semi.19031.5.Business and Pn fir,jms Cafe:Any city or aurally SIGNS ELECTRICAL. 1:1 OTHER
W E' which requires a permit to construct,alrer,improve,demolish,or repair any structure
^�L0 prior to its issuance,also requires the applicant for such permit to file a,signed smmmrm 'F,CIAL CIRCUI'1'MISC.
f y dust he is licensed Pursuant to Ne provisions of the C.mmcmts License Lew(Chapter
QO (commencing with Section]t1f10)of Division 3o(the Business and Pmfexsions Cafe)or q' METER OR POLE INST. COMMERCIAL:
6 c C that he is exempt therefrom and the husis far the alleged enemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
WSection]031.5 by any applicant far a pcnnit subjects thn
e applicant a civil penalty of flow, sVISPO ❑TENANT ❑FOOD SERVICE
ZN not more than five hundred dollars S500).
�'-a 1, owner of the n',or to res with wages as their sole<om nmtinn. SW MMING ) ELF. C IMPROVEMENT
0 ❑ prone ) yemP Y g P'
'll do the work,and the structure is not intended Oroffered for sale(Sm.0614,Business ❑OTHER
W a m and Professions Cade:The Contractor's License Law does not apply to an owner(if Hit WrI FIXTURES
property who builds or improves thereon,and who docs such work himself or hrough - •,
his own employees,provided that such improvmmer"are not intended or offered for NEW ES "AL ELEC9'R SQ FC
sale.If.however,the building.,improvement iswld withinome yeantfcOmpleoion.the SQ.F.FLOOR AREA SISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur- pw
p se of sale). 6'� A '
Lae owner of the property,am exclusively contracting with licensed contractors tu TOTAL: A—
onxtrvct the proj 1 f m.TtW4,flusinms end Pmfexsinns Code: The Cnmntcmr's Lh —V
cenu La does' yon on ownendpro t dor improv thereon,anJ QTY, PLUMBING PIiRMIT PEE {/{I
who cont eta fo an ce wit corns Beensed pursuenu eCommctor'x v
License PERMIT ISSUANCE '�I T 6 ��v
In ,B&PCfarthisocanm Ut CcJ
Ald'IiR-DRAIN&VLNT-WN'ER(EA) ATION
tun Dam
WORKER'S COMPENSATION DECLARATION BACK now PROTECT.DEVICE
1 hemby atfi,m under penalty of perjury one of the following declarations:
'❑ [have and will maintain a Cenilicme of Consenno self-insure for Wort Compete DRAINS-FLOOR,ROOF,AREA,GOND.
satin,ux provided fat li Section 391111 of the Loh Code,for the STORIES TYPE CONSTRUCTION
provi y performana of the.
work far
have
this paintiitis issued, FIXTURES-PER TRAP -
❑1 have and will AR.fon Worker's Compensation work
for which
a required by Section
Myofthes Compensation
carrier
nierandwork(number athispe,mitis issued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP APN
My Worker's C.mpens:ninn lnsumnce Cartier and Policy number arc:
Carrier: Policy Na.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE 017 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE CHP.ASMNDUSTRL WASTE INTERCEPTOR
(This section need not becompleocd Ban,pcnnit is private a handled dollars(S Into BUILDING DIVISION PEES
or leu.) GREASE TRAP
PLANCIIECK HE
Icertify that in the any, mar nr beasi becoork meobwh jectll hia permit ikesued,lshillwo. -
" not employ any Penna in any menneryn usmbecomoathjecnnthe Workers'Contpem SIiWi?It-SANITARY-3'TONM IIA.2011 Ff. ENERGY PEE
O Z sation Laws of California.Data WATER HEATER W/VENT/ELECTR
Z Applicant - GRADING FEE
ti
y NOTICE TO APPLICANT:If,after making this Cenifcaoe of Exemption,you should WATER SYSTEM/IREATING
rF become subjmtm the Worker's Compensud.n provisions of the LaMn Code,you mon SOILS HE
h fonbwith comply with such Provisima nr thin permit nMtll he deemN revoked.. WA'TERSERVICH
W Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
L)0 k for shch,hi thauhere issued(S .30 len ding agency farthe Perfo,mence of Dero Receipt
wFthe Larnmek forwhich thispcomitisissuW(Sec.3097,Civ.CJ
Lender's Name 'TOTAL:
1.1 Lender's Address TOTAL:
y, Icertify ohm 1 ply read thirty and county
and dime tem Ne above information is BUILDING FEE
to building agamonver Loco,and with aRcityend coumyordlnarresand smtelaws
enter
upon gm QTY MECHANICAL PERMIT FEE
C.7 � building construction,and hereby amhorize repreuntmives of Nis cirymen¢r upon the SEISMIC FEE
above-mentioned prola:my for inspection purposes.
(We)as.to sive,indemnify and keep humbles,the City of Cupagains
enirm t PERMIT ISSUANCE ELECTRIC FEL
Fiabilitics,judgmems,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. - PLUMBING FEF.
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10."CFM) MECHANICAL UP,
REGULATIONS,
AIR HANDLING UNI]'(OVER 10,000 CFM) CONSTRUCTION TAX
Signature ol'App[icanVComtructor Date EXHAUST HOOD OV/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material BEATING ON[*[(TO 100,030 BTU)
as defined by the Cupertino Municip.l Code,Chapter 9.12,and the 11.10,and Solely
Coda Smarts 25532(.)'1 HFA'PING UNIT(OVER 100.000 BTU)
❑Yes [I No VENTILATION RAN(SINGLE RESID) PAID
Date Receipt X
Will the air comnt.rfnmm building occupant zea Air nintdManaanacme,which BOILER-COME OR 1(10.000 BTU)
emit hazardous air cnnmminants as ddinod by the Bay Arca Air Quality Management TOTAL:
District?
E]Yes C]No BOILER-COMP(OVER I00,IN00 BTU)
I have read the haaardous materials tequiremets under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DA
mrni.[health&Safety Gale,Sections 25505,25533 and 25534.1 made...and Nm if the NEW RESIDEN PIAL MECH, SQ.FL
building does omearrendy have a tenant,that it is my responsibility to notify the occupant
of Ne tcquimmenos which most be mel prior to issuance of s Certificate of Ocmpancy.
Owma,m timmizedagent Date T ISSUED BY:
OFFICE