31442 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL 14 ZIT
BUILDING PROJBC'I'IDEMTIFICA'PION
BUILDINGADI)7S g 9 SANITARY NO. APPLICATION SUBMITTAL DATE
//�/ J` —At
Owl ' NA /•--� PHONII: CO "ICAC R'S AMI:: LIC NO:
O Q N/C CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADI S: /' ❑
CONTACI`
PHONE: BUILDI ,PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MRCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby ofBrn that I am Fee ad under pmvidons of Chapter 9(cam eencing JOB DESCRIPTION
yqy]1aZ on Seeno.7 )OTD rision3ofthe Busine rofessions ,andmy lumens s RESIDENTIAL'
F00 in full force a PERMIT ISSUANCE.
aV�j Limnsc Cla Lia.# ❑SF'DWL ❑KITCHEN REMODEL
APPLIANCES-RESIDENTIAL.
��W Dam �y Centmcu []ADDITION El PLUMBING RE-PIPE:
py r/0 ARCIII'IECTSDE ❑MULTI-UNIT El STRUCTURAL
F /yJ PANELS
Z p E2Z 1 unJerstan ny plans shall he need a public records MODIFICATION
OZ—� UPT02fq AMPS [1 INTERIOR ❑CHIMNEYREPAIR
F`31'..W Licensed Professional 201.10011AMPS IMPROVEMENT
W�9don I ma OWNER-BUILDER toDT:Ce CannoON OVER IIXp AMPS ❑BATH REMODEUREPAIR El DEMOLITION
yy C G I hereM1y affum oat I am cxcntpl from nc Conuacmr's License Law firth,
t;tY F following reason.(Section 70315,Business and Professions Code:Any city or county SIGNS ELECTRICAL �O—
/_l
uF LL C H which requires a permit to construct,alter,improve,demolish,or repair any structure L
prior to its iwhince,alse mgmreiffic.#Ikon,for such permitto file.signedatutanent SP17CIAL CIRCUIT/MISC. �-
} thm he is licensed pursuant to the provisions oflhe Contractors License Law(Chapter 9 y/"
' a0 (commencing with Settled 7")of Division nflhe Business and Prafessiona Code)or 'TEMP.MH'DiR OR POLE IN,ST, COMMERCIAL
4 y o K that he is exempt nerefmm and rte basis for nc alleged exemption.Any viol.lfik of ❑NEW BLDG/ADDITION ❑DEMOLITION
uX) Is' Section 1031.5 by any applicant for a permit subjects the applicant to a civil penally of POWERDEVICHS ❑TL'NANT ❑FOOD SERVICE
I-Z i' not more than five hundred dollars(SSW).
0 C] I.as owner of the popery.or my employees with wages as thedselc compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
rya will dotheludised the structure is not i mended or all for sile(See 10,14,Business El OTHER
and Professions Codc:The Contractor's License Low does not apply It,an owner of OUTLETS-SW ITCHES-FIX'I'U RES h�
�' .. properly who builds or improves Ihcreon,and who dlxs such work himself or through
his own cmploycea,provided that such improvements am mol intended or roared for NEW RESIDENTIAL ELIhTfR SQ ITS
sale.If,however the building or improvement is sold linin oocyte,of completion,the \ SQ.IT,FLOOR AREA $/SQ.F.T.
owner-builder will have the human of proving that he did not build or improve for pur-
owns
Point of suleJ. ^
1,us nwnerof the popery,em exclusively comment,with licensed cnnvunnrs to �J
construct the project(Sm.1041,Business and Ponessions Code:)The Contractor's Li-
cense Law does not apply to an owner fpopeny who builds or improves theater.and QTY. PLUMBING PERMIT C O I-FEE
who contracts for such priests with a cuntractor(s)licensed pursuant to the Contractor's -
Licenso haw. PERMIT ISSUANCE y
1 am exempt under Sec. ,B&P C for tis reason
Owner - Dom ALILR-DRAIN&VENT-WAIWor k1s. VALUATION
WORKER'S COMPENSATION DECLARATION HACK FLOW 1414ECK DEVIL
I herehy affiant under penalty of periaryone of the following declurations
❑Ihave and will muim.in eCenifmlf nfConsem to+elf-insure for Worker's Compen- DRAINS-FLOOR,ROOF,ARH OND. 1y)R g TYPECONSTRUCTION
don,as or by Section 31W of the Labor Code,for me performance of the `\s
wor hi chthispennilisissued. FIXTURES TRAP 3'
hove end will maintain Workers Compensation Insurance,as required by Semina Ncv
3100ofnf Labor Qale+forthe peramnanceof rework which thuspermitis isguc GAS-CA,SYS9'HM-I INC.4 OUTLETS OCC.GRp APN
e c d Pnll r "
CericrLq¢YI�Policy Nt sf GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICAT'Or.EXEMPTION FBO WORKHRS'
COMPENSATION INSURANCE GNEASF/INDUSTRL WASTE INTERCEPTORJ
(T his section need not be completed ifthe peons lv fornnc hundred Jall,ars($11X)) UU GDIVISION FEES
or less.) GREASE 5'RAP I'LANCHECK FB
Loy any pari#the mymnaneemn to him Rn subject
so#certirker,' ortmell SEWER-SANITARY-STORM EA.200 FI'.
notch Law any person in any manner m as to became subject m the Workers'Cmnpen- ENERGY FEE
'O ,"� muchLawsof California.Data WATER HEATER WNEN9'/I?LECfR
Z 0 Applicant - ❑NADING FEB '
y NOTICE bj ct to the Work If.rs Cor perking this Cedimcam of ILaverJo d yon should WATER SYS'fI?MITREATING
becomesubject the worker's ist m i, provi.+inns of the hoMr Code,you must SOILS FEE
� ..I
forthwith comply with such pmvisinns or tis pcmtil shall be deemed revoked. WATER SERVICE
Q
U7-. CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMR- 5 �� ,PAID
L D I which
nis permere isaed(Sec.0n tenths.agency fnnhoperfnnn.roof V _"(' Doe' Rmeipt# -
0 ti the work for which this permit is issued(Sec.3097,Civ.CJ n
1-" Lenders Name TOTAL:
{Uil Iende Address �IY)TAL
I : 1
Zl certify that 1 have rad This application and store that the advise hfivformminn is BUILDING FEE 22 od
0 .erect.Lugme meonuply whh all Illy and county orddims.sundstum ententntingm QTy. MECHANICAL PERMIT PEE �"
V Z b.ildingnnswction,roil hemby amhnriu repreeemetives of this citymemer upon rte Ihp11 F1:
abovcmendoned properly for inspemion pugx�ses. PERMIT ISSUANCE
(we)agme to save,indemnify and keep harmless tie City of California against O + DG Ra7T RIC FEE
liabilities,judgments,costs and eaperases which may in any way acme against said City ALTER ORADDTO MECH. pS p!.
eofbegmntingofthispednit. `� a PLUMBING FEE
APPncnAenc U ERS'TAN AND WILL COMPLY WITH ALL NON-POINT u`�
AIR HANDLING UNIT(T010JIIIOCms MECHANICAL FEE
SD ICE :G 'IONS. / p/1
AIR HANDLING UNIT(OVER)0,000CFM) CONSTRUCfIONTAX
am e.fApp1i m/Cm r Dam EXHAUST HOOD(WMUC'I} HOUSING MITIGA'TIDN PEI:
ITA DOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hvmJous material HEATING UNIT(TO I WJB)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilealn and Safety
Code,Section 25532dd? HEATING UNIT(OVER MOW BTU)
M Yes [I No PAID
V ENTIL.ATIONI'AN(SINOLI?RGSIO) Dom Receipt#
Will the air contacant orfurore building occupant
yAequipmentordevices which BOILER-COMP OR 100J)W BTU)
•emit h.rameus air contaminants m defined by the Bay Area Air Quality Managanem TOTAL:
District?
E3 Yea ❑Nn BOILER-COMP(OVER IW,fl00 BTU)
I have mail the h.vardnus materials AIR CONDITIONER
requimme ad under Chapter 695 of the Cali- ISSUANCE DATE
forma Health ffi Safety Code,Sections 25505,25an trod 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
oft se haveat ant,t .myresponsibiliry lr notify rte oecupam
oft re m n:h must td u rissmncc face i on notify
mee
O n uunodeed agentUare TOTAL: ISSUED BY, d!
OFFICE