31458 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO BUILDING-ELECTRICAI. PERMIT No. 31458
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BUILDING DIVISION APPLICATION/PF.RMI PLUMBING-MECHANICAL, Jd.IL4 SVS
IIUILDINC RO, ,CT IDENTIFICATION
J5WILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
1094 VIA �50¢w1-o I l 141
NER'S NAME: QP ONE: 1)NTRACTOR:SNAME: LTC
.aNO:
-ti "rO omen 7 S ISI fi � ILS ZGVs�VL NIC CONTROL#
RCHITECURNGINEER: LIC NO: RESS: ❑ /VyrV/syl ll/iir_[/
10 rJ>0
CONTACP. PHONE: BUILDING PERMIT(NPO
❑
UL IJ - o7D Consultant Fees Paid by Applicant(initial) BLDG ELEGT PLUMB MECH
LICENSM CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Bast 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�R with Section 7")of Division 3 ofthe Businessind Professions Cedemal.my license is - RESIDENTIAL:
in full force and fee - PERMIT ISSUANCG
�Up License`tis Lick ❑SFOWL [I KITCHEN REMODEL
�� Date Comrvcmr APPLIANCES-RMIDF IT, ❑ADDITION ❑PLUMBING RE-PIPE
[[--., ARCHITECTS DECLARATION ❑MULTIUNIT C3 STRUCTURAL
y8or, my p PANP.IS
::JJ 1 understand m I shall be used ns public mcnN.a MODIFICATION
UPT0200 AMPS
❑INI'CRIOR El CHIMNEY REPAIR'
F� Lmemed Protessional 201.1000AMPS IMPROVEMENT
yS1 OWNF.Rexemptfom the Committees
OVER IUp AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
0.' I hereby affirm tent I em exempt from the Commcmts Licenx law for The
3:01U
d following reason.(Section 7031.5.Business and Professions Cade:Any city or county SIGNS ELECITICAL ❑OTHER
which requires n permit to construct.ulmr,imp rovq demolish,or repair any swentre
to priorI.its iss...ce,alao requires the applicant fmsuch permit m filen signed statement SPECIAL CIRCUIT/MLSC.
N teas he is licensed pursuant.the provisions of the Contractors License Law(Chapter 9
GOA (commencing with Section 70001 of Division 3 of the Business and Rofessiom Cade)ar TEMP.MID'ER OR PoLC INST. OMC MERCCIAId
6 p� CL
That he is exempt therefrom and The basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION [--]DEMOLITION
4X1 h Section7lAl.Sbyanyapplie.ntforapertnitwbjectslheapplicammacivilpenalyof POWER DEVICES ❑TENANT [1 FOOD SERVICE
not more than live hundred dollars($500). IMPROVEMENT
r❑.qQ
C]1,as owner of the property,or my employees with wages as their sole compensation. SWIMMING POOL P.LE 1
willdo the work,and the structure is not mu mled oroffered for We(Sec.7044.Business ❑OTHER
and Professions Code:The Connector's License law does not apply to on owner of OUTI.LTS-SWITCHES
4i 3
property who builds or improves thereon,and who does such work himself or through
his own c.tployees,provided that such improvements aro not intended or offered for NEW RESIDENTIAL RLLCTR FT.
sale.If,however the building or improvement is sold within one yearof completion.th4SQ.FT.FTr' R RJA® $/SQ.FT.
tuner-builder will have The burden of proving that he did not build or improve far par.
pose of sale.).
❑1,u owner of the property,am exclusively contracting with licensed contractors to L. FEB REC
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li- n
cense Law does not apply to an owner of property who builds or improves thereon,mel QTY. PLUMBING PERMIT FEE �'� (�
who contracts for such projects with a contortions)licensed pursuant to the Contractor's i tI;""'WINO t,'
Ur mc Law. PERMIT ISSUANCE V Il I�NO
❑Iameumptunder gee. ,B&PCferthisreasn
ALTER-DRAIN&V ENT-WATER BA)
Owner Da¢ - VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 2 ��
skied win
pain a enaltyof perjuryoneofthefnlbwing dwlvati Co / O OOd
❑leave anJwilltmimnineCerafmatenf Conxnuo self-insure for Worker's Compen- DRAINS-FLOOR,ROTOR AREA.COND. STORIES TYPE CONSTRUCTION
.do.,as provided for by Sort.37M alone Labor Code,fm the perfnm ance of the
work for which this permit is ecund. FIXTURES-PER TRAP
1I have and will mainlnin Worker's Compensation Insurance,as require:by Section
31300afthe labor Code,for the performance of the work for which this permit is issued. GAS-PA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
Carrier:Car
My Work- x):nm nasion lInsurancePolicy No:W carrier and Policy InSlIbO95 GAS-EA.SYSTEM-OVER 4IEA)
CERTIFIC OFSATIONINFROM WORKERS'
COMPENSATIONINSURANCE GREASPJINDUSTRI,WASTE INTERCEPTOR BUII.DI V ION FR3S
(Thiseectlon need oat he camplueJ if thepermit is for onehmdrW Aollars(flIX) GREASETRAP or less) PLANCHECK fE
I employ
any that im in any cour n r of s tohe orkbac me which this PerThe W is issued,'Cinap allr. a e'•V
notempl.y any person in any manners vsmbecorne subject to the Workers'Competr. SEWER-SANITARY-STORM EA.200 FT. ENERGY FCC 60
Z an..Laws.(California Dom
�� Applicant WATER HEATER WIVfiNT/ELECTR GRADING FEE
rjl NOTICE TO APPLICANT.If,after ranking this Certificate of Exemption,you should WATER SYSTEM/fBEATING
1N' become subject to the Worker's Compenastion provisium of the labor Cale,you must SOILS FEC
Cs fonewith comply with such provisions or This permit shall be deemad revoked. WATER SERVICE
ec Q
CONSTRULTIONLItNDINGAGCNCY NEW RHSIDENTIAI,1'LMB. SQ.PI'. PAID
1J Ifhereby whichaffirm Box pc utL issued(S construction lending agency for the performance.f Date Receipt
O I'•, Ne work for which this pemdt is issued(gee.309],Civ.CJ
Landers theme a TOTAL:
1541 Lenders Address TOTAL:
Cy 1 certify that I have mad KtIppikemion and state that the shave information is BUILDING FEE. �
Vy rmoca.l ogres mcomply with 4611 city and county odimmcex and stem lewa reletingm QTY. MECHANICAL PERMIT FEE
- V K building construction,and hereby authorize representatives of This city to enter upon the SEISMIC is
M -mcn
avedaned property for inspection purposes.
emharmless
1 PERMIT ISSUANCE.
(We)agree to save,indemnify and keep arm
p hless the City of Cupertino against ` ELECTR
liabilities judgments,costs and expenses which my to any way acme against said City ALTER OR ADDTO MECH. PLUMBI
n consequence of the granting of this permit.
AP ANINDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQ000 CFM)
U Cb E, t,,14TIO' MECHANICAL FE w
UI AIR HANDLING UNIT LOVER IO,"CFM)
lll... VV WW L J CONSTRUCTION 'AX
Sigp toren ,Iic.rVCmIowton Date EXHAUST HOOD(W/DUCT) IHOUSING MITIG TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT CTO IOO,OW BTU)
as defined by the Cupertinn Municipal Code,Chapter 9.12,and the Hulot and Safety
Code,Section 25532(0)'/ (No HEATING UNIT(OVER 100,001)BTU)
❑ [
Yes 7 VENTILATION FAN(SINGLE RESID) PAID
Date Receipt,
Wishes applicant itcontaminants
defing by the al IT.,ems Air
ent or ulity evices Management
BOILER-COMP(LHP OR IW,WO BTU)
at incursions air mnmminanms u defined by the Bay Arta Air Quality Muugement TAL:
D's nT
❑Yes Eeo BOILER-COMP(OVER IW,IgO BILI)
I have read the hmeNnus materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
9 P I$SgANCE DATE
forma Health a Safety Cade.e.Se
ctions I.out i,25533 vW 2553J.1 understand that.pate NEW RESIDENTIAL.MECH. SQ.PT.
bei nn urrenny haves tenant,that it is myresp.nsibiliry to ramify theacupmt
of a(aqui s tubi rm I ten prion.issuance of.Cenifm m f cu cy.
�� —
Own rem izedagcar Date TOTAL: ISSUED BY:
OFFICE