31213APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING . ELECTRICAL
PERMITNO
r: BUILDING DIVISION
APPLICATION/PERMI•F.
PLUMBING -MECHANICAL !
❑MULTI -UNIT
- -3,1213
'
MODIFICATION
BUILDING PROJECT IDENTIF'ICRI'ION
❑ CHIMNEY REPAIR
'
BUILDINGADDRESS:�\
❑ BATH REMODFIAREPAIR
Dfi OLITION
DOTTER
SANITARY NO.
APPLICATION SUBMITTAL DATI
-
❑DEMOLITION
IV I✓/CA)piarznf�o
ICA
IMPROVEMENT
'
❑ OTHER
T14 5T. '5A
CONTACT PHONE: -
m ❑ Consultant Fees Paid by Applicant (Initial) '
�RAtJk 1 I ,
LICENSED CONTRACTOR'S DENAR QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 mm license under rmemary of Chapter 9 (commencing
"AOO hb Semon 7000) of Division 3 of the Bus es; IP feaainneCodeatd mylicenve is
F to full force an I off I q O
aF UZ V I items Clvas Lie M 4
yds
he Cam cur-
I„ay, ACCTeDECIAIt TIO +( -
Z - Z I understand my plans,shall hall M used av public rehoNs
OZ— Q
[-t �LL1 Licensed Pmfessianal r
I OWNER -BUILDER DIECma1'ION+
gN 1 herby affirm that l am exempt from the the Contatcasrs License Lew for the
?q5 at U following ancem. (Section 7031.5, Business and Professions Code: Any city or county IX
sR 3 ti y which requires a permit m construct, abs, improve, deninlish, In repair any structure
0-1 mrah, itco,aD ine, me alipficantl h pernot toFile asigned sttenen
that he fi n
n: dpua' t to the IF ehimis.fth. C t Lusatia, Law Chimera
gx
pousidencid,with Section 710c)(hl'Di sit 3 fthe nosiness dfrofessions Cade) or
that he is exempt therefrom and the hasi.v for the alleged exemption. Any violation of
tL�y Smt1on 71131.5 by any applicant for a format xohjcets the aplicant ma chit penallyof
Z0not mme than Five hundred dollars 1$5101).
❑ Lasownerof the pnsperly, structure is employees withwagesustheirsect rompensetion,
will do Prof work, and theireCmisnotintended,[offered for sale (Seco a,Business
and Professions Code: Tho Comoaetreo Laren,, w Luo dsm, net apply es if owner of
�' .. properly who builds or improves thsuch improvements and who rices such work deed or or through
his ohm employeese provided r m inch eatI%oldw arc not intended of or peered for
sale. ILhowever,thes, buildingorI proving
ivsoldwithinone uld or improve
orpt-
er-butWor will hove the holden til proving thw he did nm httllJ or itnpmve for put -
pose of sole.). ii
i, u thea of the pfnperj�704 , H exclusively contracting with licensed Contractors
t. ^
nmwet the project (Sec. 7014, owner of
and Professions Code:) The Gintmnon, and
m Law dimcenmapply r man with
ofpraperly who nuuasmiatpn,vee thereon, a'a QTY,
who comtnwa for such projects with a ennuunods) licensed pursuem m the Commmnr'e
' License Law. '
I oro cscmpt under Sec. , B & P C for this reason
PERMIT ISSUANCE ,
APPLIANCES RESIDFNTIAI,
PANELS - r
TEMP. METER OR POLE INST �
POWER DEVICES /
SWIMMING POOL HLL'CTRIC >
OUTLE ES-SWITCHES,r FIXTURES.
NEW RISIDENTIAL F,LECTR ,.SQFT.
PLUMBING PERMIT
PERMIT ISSUANCE
Owner- Uate
ALTER -DRAIN&VENT-WATER (EA)
_ WORKER'S COMPENSATION DECLARATION BACK ROW PROTECT. DEVICE u't"
I herchy m r. under fealty of perjury one of the following declarations:
..[2.]have and will maintain a Cent licate of Consent o sel f -insure for Worker's Comfery DRAINS- FLOOR, ROOF, AREA, COND,
cation. nv Provided for by Section 9700 .1 the Lobo, Cade, fnr the performance of the'
work for which this permit voided. •. FIXTURES -PERI RAP
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued. GAS - EA. SYSTEM -I INCA OUTLETS
Ce 'er1{ri 1.19 �r°, d Polley nu m er `�(',
O Iley No.: OAS - IEA. SYSTIEMOVER 4(CA)
CERTIFICATE OF 7 PTION FROb itR CERS'
COMPENSATION INSURANCE "'" GREASEIINDUSTRL WASTE INTERCEPTOR
(ThN section need not be mmplead d theocrat, is f ami, hundred dollar, ($10) ,
L or less) ; GREASETRAP
I cerltfythat home perfamorme ofthe work for which this permit is issued. Ishalf, SEWER -SANITARY - STORM f:A. 200 FT.
i
not employ any person in tiny manner so as to become subject m the Workers' Compsn-
Z suntan Law,olCaldron., Date:
00 Applicant 1' WATER 111?A'I'F.R W/VENT/L'IJiCTR -
Z_
y NOTICE TO APPLICANT, If, after making this Certificate of Exemption. you should WATER SYSTEMITREATING
become subject to the Worker's Compensation provisions of the labia Code, you mmol '
fonhwiIli only withsuch prievisioneur tMsptrlmishullhedoemedrevokeL WATER SERVICE
7z - CONSTRUCTION LENDING AGIENCY. NEWRESIDENTIALPLMB. SQ.
U � I hereby affirin thanhene is a construction lending agency fnnhepMommmceaf _
(~-t the work I'c r which this panni(Is issued (Sue. 9097, Civ. C.) "r
0 U Lenders Name .r
lender's Address TOTAL
y1 certify that 1 have read this application and state that the above inform tion I, '
0 corroh 1ngreo to mnnply with all city and county ,Hint AdxtE. me laws reaming QTY. MECHANICAL PERMIT
U building circ, uchms,and hereby authorize rcprcsentatives of this city or color upon the
above-mentioned properly for inspection purfau. PERM IT ISSUANCE '
(We) agree to save, indemnify and keep harmless the City of Ctiper ino against
Ilahilittes,judgment..covisand expenxav which may in any way aconic against said City ALTER Olt ADD 10 MECH.
in consequa¢e of the .mating of this permit
APPLICANT UND STANDS AND WILL COMPLY WITH ALL NON -POINT AIR HANDLING UNIT (TO 10,000 ON)'
SOUR li IONS. a'
^ AIR HANDLING UNIT (OVER 10,000 CPM)
Si of ApplicaatiCantmctor - Dat IEXHAUSTHOOD(W/DUC)
HAZARDOUS MATERIALS DISCLOSURE
.Will the applicant orfutum building occupant more or handle hazardous material HEATING UNIT (TO I001,000 BT3j
uv defined by the Cupertino Municipal Cade. Chapter 912, and the Health and Safety
Code, Seeman 255321v)! HLATING UNIT (OVER 100,010 BTU)
❑Yet. ❑Nt - - VENT] LAT ION PAN( SINGLE RESID)
Will the applicant or future building occupant use equipment or devices which
••� emit hazmm
arlous air comnints as defined by the Bay Area Air Quality Management BOILER -COMP (JHP OR IOII,fNq BTU)
Dntndl
[] Nn BOILER -COMP (OVER 100.000 BTU)
w- O Vea .
I love mad the hazardous mateduls rennirtmcnis under Chapter 6.95 of the Culh' AIR CONUITIDNIEIi .
fomia Health & Safety Code. Sections 25505, 25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ. FT.
building encu nomurently hnvea tonum. that it is my re...... hilhy m oumify ou nseupom
of theregoimmmus which must he met prior In issuance of a Cenlfimm nl'Ociupuncy. .
Owner or au]horized agent Date :TOTAL:
OFFICE todr
N
INFO
Pg4Ip
FEE
RAY -IR
Artin
j- VALUATION
s' :STORIES .II TYPECONSTRUCTION
13UI1. CI VISION FEES
'PLANCHECK PLP
GRADING
SOILS FEE
PAID
' Date Receipt) '
TGTAL:
BUILDING FBI; /•
PEE SEISMICFEE -
ELECTRIC FETE
PLUMBING FETE
MECHANICAL FEE
CONSTRUCTION TAX
� HOUSING MITIGATION FEE
i
PAID I
Dup, Everaa. '
i r n
JOB DESCRIPTION
-RESIDENTIAL:
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
❑MULTI -UNIT
❑ST'RUCTURAI.
'
MODIFICATION
C1 INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODFIAREPAIR
Dfi OLITION
DOTTER
COMMERCIAL:
❑NEWBLDG/ADDITION''
-
❑DEMOLITION
❑T'HNANT
❑ FOOD SERVICE
IMPROVEMENT
'
❑ OTHER
Pg4Ip
FEE
RAY -IR
Artin
j- VALUATION
s' :STORIES .II TYPECONSTRUCTION
13UI1. CI VISION FEES
'PLANCHECK PLP
GRADING
SOILS FEE
PAID
' Date Receipt) '
TGTAL:
BUILDING FBI; /•
PEE SEISMICFEE -
ELECTRIC FETE
PLUMBING FETE
MECHANICAL FEE
CONSTRUCTION TAX
� HOUSING MITIGATION FEE
i
PAID I
Dup, Everaa. '
i r n