31142 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PHRAUr NO. 311 al 2
BUILDING DIVISION APPLICATION/1'ERMIT PLUMBING-MECHANICAL - J [�,
BUILDING PR W ECI'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDA'1'I
70 'x,, '0 4
WNIiR'S NAME: PHONE: )NTRAC'POR'S NAME: - . LIC NO:
� NIC CONTROLp
i cUrrECI'/I?NGINHER: LIC NO: A )RE S: ❑
CONTACT: PHONE: l BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MECH
❑. ❑ fr� ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEF:
1 hereby aft that I an licensed under rd Proens of Chapter 9(commencing JOB DESCRIPTION
��o00 with Scereand0)of Dlvision3ofthe Buxiness untlP ofessions Calu,and my li seise
O in PERMIT ISSl1ANCP. RESIDENTIAL
runs a Class
and effect.
aUZ
License Class Lic.N ❑SFDWL ❑KITCHEN REMODEI.
h6LDate - Colttm �• APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
act ARCHIJECTS DECLAATION pANEI S
zcy I uraentapAiyypL assytlfl beaitlic records OMUI:fI-0NIT ❑MODIFI MODIFICATION
/ MOUIFlCATION
OZ— - UP10-10200MPS ❑INTERIOR ❑CHIMNEY REPAIR
Lmcnxd Profcastnnel 201-ItN1UAMPg IMPROVEMENT
ffid,I B mfouraDER DECLARATION
"yqx a x 6 I hereM1y nfGrm that 1 um exempt from the Contr:mtor's License Law for the OVER 000 AMPS ❑BATH REMODEVREPAIR El DEMOLITION
W 3 F following reason.(Section 7031.5,Business and I'mfessinnd Axle:Any city or county MONS ELECTRICAL ❑OTHER
41 M
olio Which reQnires n Permit to constant,alter,improve.demolish,or repair any strction
prionoit,issuance,also requires the applicant for such permino filoasigned nommen[ SPF,CIALCIRCUIT/MISC.
ythat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter Y
(commencing with Section 10001of Division 3 ofthe Business and professions Cale I I TEMP.MEI'ERORPOLEINST COMMERCIAL
6 na that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION
I Section 7031.5 by anyupplomm far.Penni,suhjcds theapplicam eta civil penaltyof POWIiR DEVICES ❑DEMOLITION
not more than Eve hundred dollnrs(SSW). _ _ ❑TENANT ❑FOOD SERVICE
f C
E] 1,m owner ofthe prupeny,or my employees with wages its their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the swcwre is not intended a omamid far sale(See 70,14.Business []OTHER
W^ and Pmfeasion Cade:The Contractors License Law does net apply to 1n owner of OUTLETS-SWITCHES-FIXTURES
4i 3^ property who builds or improves thereon,and who does such work himself or through
his own employees,provided Nut such improvements are not intended or offered for NEW RESIDENTIAL HLECI R
sale.If.however,the building or improvement is sold within ane years(Completion.the SQ,FT.FLOOR AREA SiSQ.Er
• ereM1uilder will have the burden of proving that he did not build or improve for pore
pox of svlw). PAI
❑ I.as owner ofthe pmpeny.am exclusively contracting with licensed contractors to TOTAL: P W I D
wnetam the project(Sec.7044,Business and Profession,Cedc)'fhe Comrector's Li-
m
claw Jnen not apply to owner of progeny who builds orimpmves thereon.and QTY. I'LUMBINC PERMITPGa AI
at�
cense Law
projects with acotnrecmr(sHiesnnd puts uanuo the Contmemsea "IH 7 ,NRF.as_c
Liars eLaw. PERMIT ISSUANCE
1 am exempt under Sec. B an P C for this reason
ALTER-DRAIN&VENT-WATER(EA)
Owner Date ILITI�d
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE.
.�. I hereby affirm under penalty of perjury one of the following declamtions:
❑ [have and will maintain a Certificate of Conxnuo self-insure for Worker's Codifies- DRAINS-FLUOR.ROOF,AREA,COND. STORIES 'fYPE CONSTRUCTION
dation,as provided I'or by Section 3]00 of the Labor Calc,for the performance of the -
work for which this permit is issued. FIXTURF_S-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 ofthe Lalmr Cade,for the perfomance of the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLE9'S OCC.CROUP APN
My Worker's Compensation Issuance Cartier and Policy number are:
Cartier: Policy No.: GAS-M.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRP.ASMNDUSTRL WASTE INTERCEPTOR
(This section need not he completed if the permit is future hundreddnllms E$HXh BUILDING DIVISION PEES
or indeed OR iTRAi' PLANCHI?CK PER
loyalty thainthe any mannro theas
wask for whish this theeadit Wrkes*Com,hall SEWER SANITARY-
nol employ an Person in an m become subject to the Workers'Cam m STORM FA.200 FT.
p y Ape any do ms I pe ENERGY FEE
,� Lawsof Califomiu.Date
0 Afton F:R BEATER W/VI?NT/F.LI:LTR
�!+l.� NOTIC nt GRADING FEE
L.I;FYI NOTICE TOAPPLICANT:the W..kc, Ciaaftermakinglhis Cenificme ne[,bartCmic.y ushouldmii,l WgTER SYSTEM/fRf:ATING
become abject ns the Wnrker:v.kinds r this provision.,of the Labor Cole,you muvt SOILS Pf?E
Lkl t�
forthwith comply with such provisions or this permit shill be deemed revoked. WATER SERVICE
� z CONS'IRUCTION LENDING AGENCY NEW RESIDENTIALPLMB SQ.17. PAID
V 0 l hereby affmt that there iso consuunion lending agency fonhe eformanceuf Date cipt
W H the work for which this permit is issued(Sec.3097.Civ.C.)
0 U Lender's Name 'TOTAL:
Lcndde.Address TOTAL:
a I cenify that I have read this appliernum and state that the ahove infmmation is BUILDING
rt VI wrzccL I agree m comply with all city and county itrdinmms anU atwe laws relining In QTY, MECHANICAL PERMIT PEE
V z building construction,and hembymuthorve repreacntatives ofthis city to enter upon the SEISMIC
'^ above-mentioned progeny for inspection purposes PERMIT ISSUANCE
(We)agree(.save,indan nify and keep bannlcss the City or Capetian ngulnn ELECTRIC PEE
luddlitiss,judgments,costs and expenses which may in any way ancon against said City ALTER ORADDTO MECH.
in consequence of the graining of this N. PLUMBING E
APPLICAN9'UNDERSTANDS ANI RLL COMPLY WITHAL NON
SOURCE REGULATIONSPOINT PIR HANDLING UNIT'TI'0 111,1100 CFM)
MECHA 'AL HE
AIR HANDLING UNIT(OVER 10,1](1()CFM) - CONSTRUCTR TAX
Sigmwre ofAan rat t, E%IIAUST HOOD(W/DUCT') HOUSING MITIGA ON FEE
HAZ DOES MATERIALS DIS SURE
Will the applicant or fours building occupant s ore or handle hazardous material HEAPING ON IT(TO 100,000 BTU)
sa deliria,by the Cupertino Municipal Cala Chapter 9.12,and the Health and Safety
Cale,Second 25532(1)? HEATING UNIT(OVER 100,000 BTU)
❑Yes 71 No VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use Date Receipt p
e pp g p' co At, mor devices BOILER-COMP JHP OR IW,000BTI1
t harardous air wnmmivints as deflnM by the Bay Arens Air Quality Management ( )
l
ot
'TOTAL:
es Fl No BOILER-COMP(OVER I W000 BTU)
e read the hnuNous mammals AIR CONDITIONER
requiretnetas under Chapter 6.95 of the CAi- ISSUANCE DATE
&Safety Cale,Sections 25505,25533 and 25534.I understand[bat if the NEW RESIDENTIAL MECH, SQ,Er.
s not currently have a tenant,that it is my responsibility In notify the occupant
mcnts which most le,ran priorm issuanceofs Cenificmeoftkcil,ocy.thorized agcm Data R TOTAL
SsueD BY.
OFFICE