31371APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. ELECTRICAL. / PERMITNO. 31371
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MEC1IANICAL t�
Fs1111.DING PNOd ECT' IDEhT[FICA'1'ION'
BUILDINGADDRESS: w SANITARY NO. APPLICATION SUISMUT'AI. LLAT
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❑ Consultant Feces Paid by Applicant (Initial)
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I Latah (firm that 1 am licensed under s Lsonf Cha ler 9lcommencin
y a Provisions n p g
with$ection](Mp)of Division Jhf the Business and Professions Code, and my license is
in full force and effect.
License Class Lic.N
Date Connector
QTY. ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL.
TS
ARCHITECTS DECLARATION
�I I understand my plans shall be used as panic orchids
PANELS
U P TO 2S) AM PS
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OWNER -BUILDER DECLARATION
a I hereby vfrom Lha I am enelnpl from the Contmchn's License Law for the
following feusnn. (Section 7031 5, Business and Professions Cude: Any city nr county
201-1000AMPS
OVER 10011I AMPS
SIGNS EI.I[CfRICA],
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which rcyuircs a permit m consaua, aIle, Impnwe, demolish, or repair any ,.Gore
prior1a in issuance. also requires the applicant for such permit o file a signed statement
that ha is licensed pursuant the prus;sions of the Contractor's License Law (Chapter 9
(commencing with Section 7000)hf Division 3 of l he Business and Professions Code)hr
that he is v,mgt therefrom and the breis for the alleged exemption. Any violation of
Steed 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mLm than five hundred dollars ($5110).
nwncs nl"thc prh,ry.hrmymhpIo,rm with wagcsoxlheir snlccompcnsation,
w 111 do the work, and the structure is not intended or offered for sale (Sec.
SPECIALCIRCUIT/MISC.
TEM P. M ITER OR POLE
POWER DEVICES
SWIMMING POOL Lh,lw KI' I
13 m
end Postessiom Cale: The Conaeem's License law does nut apply ro an owner of
property who builds or improves themon, and who dues such work himself or through
his own employees, provided that such anpmventents are not intruded or offered fur
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL. ELECTR SQ�
sale. If, how<ver, the builJing or impmvenent is old within nne ycmof completion, the
owaenbuilder will have the burden of proving the he did not build or impn),c for pun
pone of sale].
EI 1, Its owher of the property, um e,elusi rely convecting wil It licensed cumramors to
TOTAL:
mswn the project (Sec. 7044, Business and Profession C(me:) The Contractor's L,
cense taw dues not apply In as owner of property who builds m improves themon, and
QTY PLUMBING PERMIT
who contracts for such pmjees with a contraction') licensed por avm to the Common's
Pl:RMI'I' ISSUANCE
License Law.
nder Sec. . B & P C limhis rc"
ALTER- DRAIN & VENT- WATER (EA)
s
Owner >ac
WDRKRR'S COMPIiNSATION DE .ARN'ION
HACK FLOW PROT'EC'T. DEVICE
[hereby affirm under penalty of perjury on e o efollowingdcclaretimo:
I Use ad will remail no Ccnificate ofConxat self -insure for Worker's Compen-
DRAINS- FLOOR. ROOF. AREA, GOND,
sailor, as provided for by Seeinn 37(X) of the LI r Gide, for the performance of the
work for which this permit is issued.
FIXTURES - PER TRAP
Fl 1 have and will maintain Worker's C'oniNnsation Insurance, as required by Section
3700o1fNe Later Code. for the performance of the work for which tris permit is issued.
-
GAS- EA. SYSTEM I INC. 4 OUTLETS
My Workeh Compensation Inomnce carer and Policy number sm:
Cartier: Policy Ne-
GAS - EA. SYSTEM -OVER 4 (17A)
GREASUINDUSTRL WASTE IM'ERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
(This sectionnced net he completed ifthe phim, is future hundred dollars ($10m)
or le"'.)
SEWER - SANITARY - STORM Ii .200FT.
I certify thus in the performance oflhe work lir which this Permit is issued, I Shull
not employ any person in any manner so as to become subject to the Wicker: Compere
WATER HEATER WNENT/ELECI'R
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scion laws of California. Dec
Applicant
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NOTICE TO AI'I'LICAM': IL u0er making this Ccnificare of Exemption, you should
become subject m the Worker's Compensation provisions of the labor Come, you mum
forthwith comply with such pmvisionx or this Perron shall be deemed revoked.
CONS '1'RUCTION LENDING AGENCY
1hemby affirm that them is a construction lending agency for the Performance of
the work for which this permit is issued (Sec. 3197, Civ. C.)
Under's Name
WATER SYSTEMRREATING
WATER SERVICE
NEW RESIDENTIAL PLNIB. $Q. F4.
TOTAL
Lenders AJdrns
cenify that I have read this application and state that me above information is
cone. l agree it) comply with all city and county ordinances and + tam laws miming,,
building chnetmetihn, and hemb,amhurim representatives hl' this city to enter upon the
QTY. MECHANICAL PERMIT
PERMIT ISSUANCE
abovcmcntioncd property for inspection purposes.
Ove) agree to save, indemnify and keep harmless me City of Cupertino against
liabilities. judgments, costs and expenses which may in any way acerae against said City
ALTER OR ADD TO M ECH.
in consequence of the gmnling of this permit.
AIR IIA SOLING ON IT (70 10.000 CFM)
APPLICANT UNDERSTANDS AND WILL COMPLY W13'H ALL NOF -POINT'
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER WARM CF,N)
Simmurc of Applwanl/Curnscmr Date
EXHAUST GOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applican[or furore building occupant more or handle hm:Whus maerial
HEATING ON IT DO 100.030 BTU)
as defined by the Cupen'mn Municipal Code, Chapmr 9.12, and the Health and Safay
Calc, Sectio 25552(a)7
HEATING UNIT (OVER 100.010 BTU)
VENTILATION FAN (SINGLE RESIU)
E] Yet ❑No
4t
Will the applicant hr future building ueeupinn use equlphent or devices which
h ,ardour air conmiumams as defined by the [lay Amo Alf Quality Management
BOILER -COMP (3FIPOR Ift0fl( 1H U)
BOILER- COMP (OVER 100,000 BTU)
District?
E] Yes Fl No
AIR CONDITIONER
reyuirep
[have read the hmallous mnlvriak is under Cho ter h.95 of the Cnlh
NEW RESIDENTIAL LEECH. SQ. FT.
5amia Health & Safety Cao, Sections 25505, 255]133and 25534. 1 understand that if the
not currently have a Nato is my
(lien aCe'dy mm notify the hccupam
met p ceof
of the rcquiremenlx which nmm he mm prim m ixsunnce of o Cenilimve of (kvvpuncy
of chin
TOTAL
Owner or authorized agent hale
OFFICE
FEE
❑ ❑ ❑
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
❑ PLUMBING RE -PIPE
❑MULTI -UNIT
❑STRUCTURAL.
MODIFICATION
❑INTERIOR
❑ CHIMNEY RI7PAIR
IMPROVEMENT
0BATH RBMODEL/RF.PAIR ❑DEMOLITION
❑ OTHER
COMMERCIAL:
rEW BLDG/ADDITION CDINOLITION
TENANT - ❑ FOOD SERVICE%
❑OTHER W V�V
SQ. F1'. FLOOR AREA
1
FEE
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAN
Date Receipts
BUILDING FEF,
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FTE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date ltmmpl#
TOTAL:
BY:
ISSUANCE DATE
$/SQ. FT.