31448 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILMNG-ELECTRICAL PERMITNO. 31448
BUILDING DIVISION APPLICATION/PF,RMIT PLUMB NG-MECHANICAL
BUILDING PROJECT IDENTIFICATION
B UILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S)?'AMI?: n� P{iONE: SNA LIC NO:
NS s0P 3/2-� CO NIC CONTROLp
ARCH177iCf/P.NGINI?I?q LIC NO: DD ❑
CONTA•/�i PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ETI' PLUMB METH
LICENSED CONTRACTOR'S DECLARATION ,201 ID El 1:1QTY ELECTRIC PERMIT FEEI hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QaZ with Section 7010)of Division 3 ofthe Businessand Professions Cofe,afm license is
0C) y PERMIOISSUANCE RESIDENTIAL,
ly in full forceandc 4 _'f ❑SFOWL [I KITCHEN REMODEL
�U Licenu lass Lic.p APPLIANCES-RESIDENTIAL
Dote Contmcm ❑ADDITION El PLUMBING RERIPE
ARCHITIiCTg DE -� El MULTI-UNIT ❑STRUCTURAL
FPH PANI31.5
ZOr z Iundemm�J my plans shall be useatpuhlicaccords 14V a0I9 MODTION
OZ O UI"ID 2(NIAMPS 0INTERIOR REPAIR
Licensed Profassinnal 201.1000AMPS IMPROVEMENT
OWNHR-BUILDER DECLARATION
I herehy,flim that I um exempt from the Cmit acOVER IIxMIAMPStor's License Law for the ❑BATH R17MOD171JREPAIR ❑DEMOLITION
{i�506U following reosar.(Section 7031.5.Business and Professions Code:Any city or rountySIGNS CLHCfRICAL ❑OTHER
W 3
16 1" which requires a Permit m construct,alter,improve,demolish,nr repair any swewre
(r u'y6 prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
}, that he is license pamuam to the provisions of the Contractors License Law Channel 9
u1Qo (commencing with Section 7")of Division 3 ofthe Business and Professions Code)or TBMP.MBTf:R OR POLE(NST. COMMERCIAL,
a a e Z4 Nm he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION
�
Section 7031.5 by any applicant fora permit subjects theapplieanna.civil .]flat POWER DEVICES y ❑TENANT ❑FOOD SERVICE
FZ;ss no room than five hundred dollenyempl IMPROVEMENT
=0a ❑ Lo the wor.the propeounmemy a muendeswith ermfosthe(Sm.7D4kLB linen, SWIMMING PULL ELECTRIC
W will do thework.andc'no Cum i ernes t Leena aw does act apply to an Business []OTHER
6'3$ and Profession Cnde:The Cantmetors License do does oat apply m 1f owner of OUTLETS-SWITCHES-FIXTURES
his o
property who builds or improves thereoo,and who doessuch work e himself or though
his own employees,the provided that such impnrvOf v are not intended or offered for NEW RESIDENTIAL ELECfR SQ PT.
sale.IL hnwcvec the huildingmimpmvemem i...ld vicariate year of cnmpletian,the SQ.Ff.FLOOR AREA SISQ.PT.
owner-huilder will have the burden of proving that he did not build or improve for par- P A P1
pose of axle.). V
❑ hso;owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.7114,Business and Professions Code:)The Contractor's Li. AUG ��
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE A
12 who contents for such projects withacontraemr(s)licensed punuam lathe Commemr's /� �
.License Law, 1117RMIT ISSUANCE, VI Y
❑I am exemptnnder Sm. B&P C for thisreason LJrl.U/'CTI I ItyV
Owner Date ALTHR-DRAIN&VEN'P-WATER(BA) VALUATION
'
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ,l
I hereby affirm under penalty of Pe jury one of the following declarations: /f0/5z`_0
❑I have and will nodandin a Cenificam of C,nscnuo self-insure for Worker's CamP,n. DRAINS-FLOOR.ROOF.AREA,COND. 'GRINS TYPE CONSTRUCTION
aetinn,ar prove by Ser ion 3700 of the Labor Code,for the performance of the
asozi.re'un t is pernatoo,ned. FIXTURES-PER TRAP
d will maintain Workera Compensation Insurance,as required by Section
3700ofrhe LaMar Cole,for theeppermrmoaarem.fthe work for which this per`rmit is issued. GAS-EA.SYSTEM-1 INCA OUTLETS OCC.GROUP APN
My
ffad Policy
Camicrrk�n/ V'�"-�Policy His: / r GAS-EA.SYSTEM-OVER 4IEA)
CERTIFICATE OP EXEMPTION FROM WORKERS' GRL'ASU'INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE
BUILDING DIVISION FEES
Oris section need not he completed if the permit is for one hundred dollars($100)
or leas) GRC•ASP.TRAP pLANCHECK FEE
I minty that in the Performance ofthe work for which this pnnrdt is issue,Ishall SEWER-SANITARY-STORM ES.200 FT.
not employ any person in any mnerbecomeanso as to become subject m the WmIceri Compen- ENERGY FEE
zZ sn Lows of California.Data WATER HEATER WNENTMLECTR
ati0 Applicant GRADINGFEE
ILLI in NOTICE TO APPLICANT:If,after making this Clookete of Exemption,you should WATER SYSTEMTREATING
abecome subject to the Workers Compensation provisions of the Labor Code,you most SOILS ICE
LkI forthwith comply with such provisions or this permit shall he deemed revoked. WATER S17RVICE
Q
CONSTRUCTION LENDING AGENCY NEW R1351D13NTIAI,PCMB SQ.Fr. PAID
V Q (herehy alDnn thin there isnconstmdion lending agency forthe perfonnonce of Data Receipt
w the work for which this permit is issued(Sec.3097,Civ.C.)
o Lender's Name TOTAL:
{UHJ Lender's Address TOTAL:
I certify that 1 have read this application and state that the above information is BUILDING FEE
Tacounty l agree to comply with all city and unty ordinances and slate laws relming to QTY. MECHANICAL PERMIT FEE
7p
U G building construction,and hereby authorize representatives ofthiscitym anam.pon the SEISMIC PEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree manse.indemnify end keep harmless the City of Cupe ci a against ELECTRIC FEE
Iiahilitud,judgmems,costs and e"snscswit hmay any way aceme against said City gI.TLR OR ADD TO MECH.
inconmgmnce Iyy granting el this parrna PLUMBING FEE
APPLIC ...&STANDS A,1'13 WILL COMPJY WITH ALL NON801NT AIR HANDLING UNIT(TO 10,000 CFM)
SOUR .RP A 'el ,y- MECIIANICAI,FEE
AIR HANDLING UNIT(OVER to."CFM) CONSTRUCTION TAX
Si m of ApplieanfConuac a Ddle EXHAUST HOOD(W/DUCT)
"AZAR )US MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant in future building occupant storemhaele hazardous material HEATING UNIT(TO 100,000 BTU)
es define by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)?! HEATING UNIT(OVER 100,"BTU)
Yes
VENf11.AT10N PAN(SINGLE RP.SID) PAIL)
Will the applicant or futureas building occupant use equipment or devices which Date Receipts
emit us air nmminantsw define eBay Area Air Quality Management MOILER-COMP IMP OR 100.0071 BTU)
District?
id9 cnTOTAL:Yea BOILER-COMP(OVER Up.0 01 BTU)
`Q
d I hove retN rho bnzurdnus ntumriols r t d Chat fi.95 o[Ihe Culb AIR CONDITIONER
ft ,yniremenaton er per ISSUANCE DATE
Turns Health&Sulety Coale,Scdions IIS,25533 nn 255314.1 undem:md drat if the NIiW RESIDENTIAL MECH, SQ.Pr.
Gtiuildingdoes ally hu cotton lis my respn ibility i,notify decoy,m
of the req,' nem v' r M n¢I prim i issmance of de '� cls
Own, aur rimdigcm Doc TOTAL: ISSUED BY:
OFFICE