31428 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, reRMrr No. ^
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L
BUILDING PROJEC7P IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNC: 'S NAME: PHO E: CONTRA TOH:S NAMII: LIC NO:
)�C F+ 1 CU f U NIC CONTROL#
RC 1 F.CTIENGINEER:. LIC NO: ADDR!SS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECT RIC PERMIT FEF.
1 hereby affmt[tintI and licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
00Z with Section 7000)of Division 3 of the Busiar,,iud rnfensinneCMc,ttnnor li enseis
�DO O PERMIT 1'ISSUANCII RESIDENTIAL'
is Poll farce and elf ! L ❑SFOWL ❑KITCHEN REMODEL
Licenu
mF�a DateCnnmactmr
pAPPLIANCES-RESIDFMTIAL []ADDITION ❑PLUMBING RFPIPE
F 'S UECIRT✓ �
m
❑MULTI-UNIT ❑STRUCTURAL
LF.. I understand my plans shall be used as public mord, PANELS
Z O�,zj P MODIFICATION
02i-- UPT0200 1OAMPS []INTERIOR - [I CHIMNEY REPAIR
F��t�i Licensed Professional 201-IOINIAMPS IMPROVEMENT
LgLq�� � OWNER-BUILDER DECLARATION
3 U 1 herchy affirm Lha I am exempt from the Comract.f,License Law far The OVER?"AMPS EI BATH REMOL�flfjl�PAJIi 0,DEMOLITION
dfollowing reason.(Section]031.5,Basin,,,and Professions Code:Any city or county SIGNS ELECTNICAL OTHER _f/a/(fT�J
Cwhich requires a permit To construct.esker,improve,demolish,or repair any swmum f
prior to its issuance,also requires theapplicom forsuch pemtiuo filed signed statement SPECIAL CIRCUITIMISC.
�tj that he is licensed parsuam mthc provisions ol'the Contractors License Low(Chapter 9 L�
1 (commmen is with SectionID fovision3 ofthe Business andl'miesslonsCMe)Or 'I£MP.METER OR POLE INST.
mat he is exempt therefrom and The basis for the alleged esionno in Any violation of ❑NEW BLDGIADDITION [I DEMOLITION
I Section 7031.5 by any applicant linapernth subjects the appllcanno a civil penalty M TOWEL;DEVICliS
E-Z} m
not oa,had live hundred dollars(S5W1. ❑TIiNANT ❑FOODSERVICE
SQ ❑I,as owner of the progeny,army employees with wages.,their sole compenuttion, SWIMMING POOL ELECTRIC IMPROVEMENT
y$
willde lire work,and the"Income kind dm ime dam offemil for sato(See 9044,Business - ❑OTHER
and Profesaiom Cole:The Contractor's License Law does not apply to an owner of OUTLETS-SWI'TCHPS-FIXTURES
property who builds or improves thereon.and who does such work himself or Through
his own cmpltiyecs,provided that web improve wris are non intended or offered for N17W RESIDENTIAL ELECTR SQ FP
sale.If,however,The building or improvement is sold withinon,year ol'completion,the SQ.FT FLOOR AREA $/SQ.Fp.
owner-builder will have the burden of proving That he did not build or improve for par- AID'
posenf,aleJ.
1,as owner of the pmpeny,um exclusively contracting with licensed contractors to 1nT
ocam uct the project(Sec.TUW,Business and Professions CMeU'Me Contractors Li- (y ����
come Law does no apply toonnwnernf property who builds or Improves mC ercon,and QTY, PLUMBING PERMIT _
who contracts for such projects with a contractor(s)licensed pursuant To the Contractor's
License law.
E] PERMIT ISSUANCE I am exiondunder See ,B&1'C for This reason Uh uti Cp(I INN .
Owner Date ALTER-DRAIN&VENT-WATER(EA) + VALUATION
.
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby union under penalty of perjury one of The fallowing dalmatimn:
El I have and will maintain a Certiftcateof Comm in sel6insure for Workers Condition. DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
s;tion......ided for by Section 3700 of the Labor Code,for The perfi m once of the
ork for which tis permit is issued. FIXTURES-PER TRAP
Iav hand will maintain Nnhcr's Compensation Insurance,os required by Section
hel..bor ode,for me perbtmtance ofthe work for which this permit in issued, GAS-EA.SYSTFM-IINC.40UTLETS OCC.GROUP APN
Ca rier: 'e CT ('go n r t rand Policy nwoh r Tom:
Cartier. rPolicano oho / —�, GAS-13A.SYSTEM-DVIiR 41P.A)
�R,tI lLATE FEXEMPTIONVFROM WORKERS' GftI3ASElINDUSTRL WASTE.INTERCEPTOR
COMPENSATION INSURANCE:
(Dissection need not becompleted ifthe permit is former,hundred dollars HI001 BUILDING DIVISION HERS
or less.) pe- GREASE TRAP PLANCHECK FEE,
Loy any that in The anymroarrnnerance o as t become subjewhich ct
to permit is iocCon,hml SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as m become suhjen to The Wurkers'Cnmpen- ENERGY FEE
O z plLaws o(Califomia.Date
Applicant WATER HEATER WIVENTIELECTR
r� Q APPlGRADING FIAT
fn. NOTICE TO APPLICANT:IL after making This Certificate of Exemption,you should NATER SYSTEMITREATING
F+ become subject to the Worker's Compensation provisions of the 1-abor Code,you must SOILS FEE
Lakl fonhwidn comply winhmtch provisions or This pmool shall bedcemedmorked. WATER SERVICE
0
CONSTRUCTION LENDING AGENB.CY NEW RESIDENTIAL PLMSQ.FT. PAID
Ca)Q k for which thithat there ix.conamction len Jing agency forthe performance mf Date Receipt
p
� F+ Larsu kfor which This permit is iss.W lSec.3U9],Civ.CJ
0 U Lender's Name TOTAL:
Lenders Address ( -
per, 1 certify That 1 have rend this application and state that the chose information is BUILDING FEE
VI comet.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hominy authorize representatives of his city to entcrupmn the SEISMIC FEE
"+ aMve-mentioned progeny for inspection purposes. PERMIT ISSUANCE CT '
(We)agree m save,indemnify and keep laundress The City of Cupcnino against ELERIC FEE
Iiabilities,judgmems.caste and a uses which may in my way accruer,mmisaid City ALTER OR AUf3 TO MECH.
in consequence to grant, I his Pen...1. PLUMBING FEE
APPLIC. DER! N AND WILL COMPLY WITH ALL NO AIR HANDLING UNIT GO 10,011(1 CFM)
SO' "R GLATI MECHANICAL FEE
_ AIR HANDLING UNIT(OVER 111,01X)CFM)—it' TAX
gart of an o tat or Date EXHAUST HOLD(W/DUCT)PHOUSING MITIGATION FEE
HAZARDOU ATHRIALS DISCLOSURE
Will lir pplicam or future vilding uecupamn store or handle heaardous material HEATING UNIT LTO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)! HEATING UNIT(OVER Inforst BTU)
E]ye, I]No VENTILATION PAN(SINGLE RE.SID) PAID
Dae ReccipT#
Will the npplic tri or future a defineddin,by the BT use equipment Quality
Management
which BOILER-COMP CHP OR 100,000 BTU)
mit httzerduus ter conmminants.a defined by the Bey Arca Air Quality Management TOTAL.
L
e ❑No BOILER-COMP(OVER I(q,IX10 BTU)
mad me hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
&Safety Code,Sections 25505,8533 and 25534.1 understand that if the ryEWRIigIDENq'IAI.M1iGB. SQ.FT.mentss act whicy ustbeave a enanhthmiT isua responsibnificato nmifythetncapat mems which must be met pdonu issu.mtce mf a Cenificatc of Qaparmy.horzed.gem Date TOTAL: ISSUED BY:
OFFICE