31245F
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICArIONIPERMIT PLUMBING - MECHANICAL.
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
31245
BUILDINGADDRFSS:
02 ✓7,e . C.�1. 950/ �/-Zf
SANITARY NO.
APPLICATION SUBMITTAL DA'I
�Ot
OW NAME.PI1ONE:
VLIC
COQ 'S NAME: NO:
NIC
❑
CONTROL x
ARCHITECTIENGINEER: LIC NO:
ADDRESS:
am e/
- .0i
CONTACT: �]/y��}y �(� PHONE:
6/-,041 \L eA os
Consultant Fees Paid by Applicant (Initial)ELECT
BUILDING PERMIT INFO
PLUMB MECH
El ID
LICENSED CONTRACTOR'S DECI,ARATION
1 hereby affirm that I an licensed under provision%of Chapter 9 (commencing
with Section](100) of Division 3 ofibe Blames, and Professions Cm,,and my license is
in enYf I-ndef� f —a9 a fo-�s9
Liccto lases Lic.N
J Da¢ ,onaacmr
ARCHITECTS DECLARATION
_ 1 understand my plans shall Na used as public records
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL'
❑SFDWL ❑ KITCHEN REMODEL
[]ADDITION ❑ PLUMBING RE -PIPE
❑MOON -UNIT ❑STRUCTURAL
h DIFICATION
❑INTERIOR CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODELREPAIR 0DEMOLITION
❑ OTHER
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL -
PANELS
UPTO 20u AMPS
Lmrnsed Pmkssiooel
4 OWNER -BUILDER .imptf DECLARATION
E 1 hcrtby affirm Ihm I am ex,mpl from the DECLARATION
License Law for the
following rearvn. (Scatter 7031.5. Business and Prefe..aions Cmc: Any city or cuddly
which requires a permit to construct, alter, improve, dndolleb, or repair any strucdrt
prior to its issuance, alar requires the applicam for. such proud to File a signed statement
„ that he is licensed personal to the provisions of the Contractor's License Law (Chapter 9
(eoonianci ng ..,It Section 7000) of Dohmon 3 of the uminessand Poolvssfom Code) or
d that he is exempt therefrom rand the basis fur the alleged examptlon. Any violmion of
a Section 7031.5 by any applicant for a pemmil subjects the applicant to m civil penally of
not court than five hundred dollars (35001.
4 Les ownerefthepropcny. ormy employees with wages as their sole compensation.
will do the work, and the sduc ere is not intended orulfered for sale (Sec. ]OW, Business
and Professions Code: The Convacm's License Law docs not apply or an owner of
property who builds or improves thereon, and who does such work himself or througM1
his awn employe.. provided that such improvements arc not intended or offered for
ak. IL however. tM1e builJingmimpmvement is sold xithin one year ufcompletion,the
owner -builder will have the burden of proving that he did not build or improve for pur-
pose of salt.).
I, as owner of the pmpeny, am exclusively contracting with licensed commuch rs m
msadct the Project (Sec. 7044, Business and Pmfcssions Code:) The Cundacurs Li-
conese Law ores not apply mar owner rf pmpcny who hullos or improves Ncreun,and
who contracts for such projects with a commcrm(s) licensed pursuant m Ne Contractm v
License Law.
❑ I am cxnnpt under See , li& P C far this reason
201-I0013AMPS
OVER i 11f111AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MI SC.
TEMP. METER OR POLE INS L
COMMERCIAL -
❑ NEW BLDG/ADDrrION ❑ DEMOLITION
[]TENANT C1 FOOD SERVICE
IMPROVEMENT
❑ OTHER
POWER DEVIC[S
SWIMMING POOL ELECTRIC
OUTLET'S -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECfR SQ FT. -27
SQ. FL BOOR AREA
\
5/SQ. Ff.
TOTAL:
QTY. PLUMBING PERMIT FEE
MiRMIT ISSUANCIi
ALTER - DRAIN & VENT- WATER (EA)
Owner Dec
VAI,OOUA'rION
7 O
WORKER'S COMPENSATION DECLARATION
I I hereby affirm under penally of perjury, one nr the following dceldrrm
tla:
Ihaveaod will maintain. Cerrlfirld,4Consant In Self-insdrt for Worker's Compen-
sation, as provided for by Section 37M of the Labor Code, for the performance of the
r which this permit is issued.
wa I have am will maintain Worker's Compensation Insurance, as required by Section
37M ofthe labor Cade, for the padmrance ofthe work for which this permit is issued.
My WmK's Compensation Insurance carrier and Policy �mhetu
Corti^r �^'a 1- Policy IN r''�e//llll'i
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis sstien need dol be completed if the permit is harem, handled dollars 1$ 100)
or levo.)
Loy any theinthe perany mannero theass work on,subjech t to the Votiniss' Commall
nodemploy any Personinany manner so asmhenmrcmbjen to the Worker'Comped-
Fedor laws of Cabman.. rare
Applicant
RACK FLOW PROTECT. DEVICEOH
DRAINS- FLOOR, ROOF, AREA, COND.
TORIES
OCC GROUP
TYPE CONSTRUCIl01
AYN
FIXTURES - PER TRAP
GAS-EA.SYSTEM-I INC.40UTLES
GAS- EA. SYSTIt OVER 4(EA)
GRE&SE1NDUSTRL WASTE. INTERCEPTOR
GREASE'I'RAP
BUILDING DI ON :FS
HECK FEE
SEWER - SANITARY - STORM EA. 2W FT
Y FEE
WATER HEATER W/VENT/ELECTR
ING FEE
NO'I'ICE'1'O APPLICANT If, after making Ihis Cenilicare nl' Exemption, you should
become subject to the Worker's Compeosation pmvlslmu of the Labor Cuda, you must
forthwith comply with such provisions or this Isrmit%hall bo deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work far which this permit is issued (Sec. 3097, Civ. C.)
Lamers Name
WATER SYSI EMAKFATING
FEE
WATER SERVICE
Date Receipda
*ME
NEW RESIDENTIAL PLMB. SQ. FT.
Torn1.:
Lamers Address
I eerily that I have read this application and sorra that the above information is
l agree m comply with all city antl county ordinances and stale laws miaingtu
conswetion, and hereby authorize representatives of this city rt ender upon rhe
prnperry far inspection purposes.
agree m sae, indemnify and keep hearken the City of Cupertino against
costs and expenses which may in any way accede aainst said CitygLTER
onsequence, of the granting of this permit.
UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT
1,sGULATIONS
'�—�' eIG• o2 -9p
ofApplicanuCammcm Date
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or future building occupant store or handle hazardous material
as defined by the Cupci ino Municipal Cade. Chapter 9.12, and Nc Health and Safety
Code, Section 255321a)?
E] Yes ON.
IWill We applicant or (mare building occupant use equipment or devices which
coil hoxamous air cammniionts as defined by the Bay Area Air Quality Management
District?
F1 Yes nNo
1 have real the Intended, materials requirtmcdn under Cbupmr 6,95 of rhe Cali-
fomia Hcalrh & Safety Cook, Sections 25505, 25533 and 25534, understand Thal if the
building
building docs nor currently have a tenant, that it ism 'bili[ mnollf the occupant
of thcrt which most met Ynsof. Y Y pan
quircnenraw prior to issuance ora Cenilie:ne of (kcupancy
TOTAL:
NG FEE Qaother.
QTY MECHANICAL PERMITFEEbuilding
C FEEabove-mntioned
PF,RMIT ISSUANCE(We)
IC FEEliobilkies.jugments.
OR ADD TO MECIi.rn
ING FEEAPPLICANT
AIR HANDLING UNIT(TO 0,000 CFM)SOU
NICALFEE��L'
AIR HANDLING UNI'1'(OVER 10,IXq CFM)
EXHAUST HOOD(WMUC)
RUCTION TAXSigwmre
G MITIGATION FEE
HEATING UNIT ITO 100.000 BTU)
HEATING UNIT (OVER 100.00) BTU)
PAID
Dae Receipt M
VENTILATION CAN (SINGLE RESID)
BOILER - COMP (3HP OR I00.000 BTU)
TA'A (�^
V
BOILER-COMP(OVER (Motif Bru)
AIR CONDITIONER
ISSUANCE, DATE (--�
I / '(/Vyl
l `
ISSUED BY:! ��
NEW kE51DEN1'IAt, MECH. SQ. F1'.
Owner nr amhorircd agent Date
TOTAL:
OFFICE