31162 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY +{
CITY OF CUPERTINO BUILDING-P,LECTRICAI. PERMIT NO. q /N2/'k
BUILDING'DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1 V6
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO, APPLICATION SUBMITTAL DATE
4
In
11UNAMIIONI?: CONTRACTOR'S NAME—' LIC NO: G -7� 0
b N/C CONTROL#
\RCHITECf/ENGINEER: - LIC NO:
ADDRESS
I 21dJ
CONTACT. PHONE� y�_ HUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EL� B MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑
1 hereby affirm that l on licermed under provisions of Chapter 9(mmmcncing JOB DESCRIPTION
O0Z ith Section]f011)ofDivisinn3afthe Business and Rofevxions Cnde,andm license i.v PERMIT ISSUANCE
W= w y RESIDENTIAL:
m full force and e a
QUV License Clan Lic.#_aL-itlt.�#c++-a�=-W!r ❑SPDWL ❑KITCHEN REMODEL
6w W Dmc Contractor APPLIANCES-RP.SIDENTIAI. ❑ADDITION ❑PLUMBINGRE-PIPE
cnih„Drn - ARCHITECPS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZOOZ Iunderstand.,,]..a shall beused aspublic meoNs MODIFICATION
OZ , UPTO200AMPS [I INTERIOR [:1 CHIMNEY REPAIR
i,4 t Licensed Professional 2061010AMPS IMPROVEMENT
�Se OWNER-BUILDER DECLARA'DON OVER 1100 AMPS (3 BATH kEMO IR ❑DEMOLITI
1 herchy affirm that 1 am exempt Iron the Contractor's License Law for the
igSO d U following reason.(Section 7131.3,Business and Professions Code:Any city or county SIGNS f?LECI'RICALf)': ❑OTHER
w
ow which mit m requires a perco eami alcor,improve,demolish,or repair any mbectute
aa prior to its issuance,also requires the applictmtfor such permit file a signed statement
tTt—
yrn.] SPECIAL CIRCUIT/MISC.
aWY that he is licenx4 pursuammthe Provisions of the Comracmen License law(Chapter9 '
W�GC) (commencing with Section Man of Division 3 of the Burnam and Professions Creditor TEMP,METER OR POLE INST. COMMERCIAL:
a q y that he is exempt there(mm and the basis for the alleged exemption Any violation of ❑NEW BLDG/ADDFHON ❑DEMOLITION
P� Wy
Section 7031.5 by may...liama fora permit suhjecbtheopplicam too civil pc natty of POWER DEVICL.S
not mom than five hundred dollars D510), ❑TENANT ❑FOODSERVICE
LO C1I,os owner of the properly,or my employees with wages.,thimble comparisons, SWIMMING POOL ELECT RIC IMPROVEMENT
GGGGLM will do the work,and the.nmcmre is not intendedorOffered for late(Sec.]044,Business ❑OTHER
a and Professions Cale:Tic Complicates License Law does not apply to an owner of. OUTLETS-SWITCHES_PIXTURES
properly who builds or improves lherenn,and who due,such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however,the building or improvement is sold within one yearnCompletion.the SQ.PR FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put- //II
Foss itsnatene TOT �♦q 6
❑ I,as owner of the pmpeny,am exclusively contracting g with licensedThe
Cmtnadon i-
imoveconstU the se es nota(Sec.7Iw4,Business and property
who but Code:)The Gmuuaon.Li-
censeL mens) nretapply to an itha nfpmpeny who licensed
mint to Im Cercon.and QTY, PLUMBING PERMIT FEE
who se Law.for auuh Projects withacnntamor(,)licensed punuannu the Ctmraemds /1 �
License law. PERMIT ISSUANCE
❑ Tum exempt under Sec. ,N&PCfor this rtuon
ALTER—DRAIN&VENT—WATER(EA) T
Owner U.a 'l
WORKER'S COMPENSATION DECLARATION ppCK FLOW PROTECT.DEVICE C v
Ihcmby affirm under penehy of perjury one of are following declarations: L
❑I have Laid will maintain a Certificate ofComent m self-insutc Im Worker's Camper. DRAINS—FLOOR,ROLE AREA,GOND. STORIL•S TYI'f3 CONSTRUCTION
nation,w Provided for by Section 370 of the Labor Code,for the performance of the
work far which this Penna is issues. FIXTURES—PERTRAP
T�'1 base and will maintain Worker's Compensation Inwronce,as required by Section
(f]W of the Labor Code.fonhe performance of the work for which this permit is issued GAS—FA.SYSTEM-IINCAOUTLEI'S OCC.GROUP APN
My Workers Cumpensauo_n hyur ace cuerier.licy Policy nu rare:
Carricc� QR/�_prelicy N¢; D GAS—BA.SYSTF.M-OVER4(EA)
CERTIFICATEOF SNI'IOTION FROM WORKERS'
COMPmpletedift INSURANCE GREASFANDUST is WASTE INTERCEPTOR
BUB.DING DIVISIONiT&S
(This section neat not be completed if the permit is(or one hundred dollars($100)
nr less) GREASE]'RAP �. PLANCHECK FEE
I certify that in the Performance ofthe work for which this permit is mM,lshall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any mantel so as m become subject m the Workcr%Cnmpen- ENERGY FEE
.O 2. section laws of Culifmmi..Date WATER HEATER WNENGELECTR
Q Applicant GRADING FEE
vNOTICE TO APPLICANT:If,utter making this Cenifcate of Exemption,you should WATER SYSIFMITREATING -
abecome subject to the Workers Compensation previsions of the LaMar Code,you most SOILS FEE
forthwith comply with such provisions or Nis Permit shall be deemed revoked. WATER SERVICE
Q
CONSem is ac0NIB?NDINGAGENCY NIiW RESIDENTIAL PLMB. SQ.Ff. PAID
IJQ I foreby whichnis hat permercissued(See.30lcnding agency for the pcdtrmancc of Date Receipt#
Hthe work for which this permit is issued(Sec.709],Civ,CJ
Q U Lendeh Name TOTAL:
harder,Address TOTAL:
y1 certify that 1 have rand this.pplic.trum end nam tint the above lot ..than is BUILDING FEF.
00 coral.l agree ire comply with all city and county rommurces and state law,selling 1. QTY. MECHANICAL PERMIT FEE
U 4 buildingconstruaion,unit hemhyauthmine represemativesof this city memerupon the SEISMIC FEE
above mentioned pmpeny for inspection purryxnea. PERMITISSUANCE(We)agree m.cave,indemnify and keep hornless the City of Cupertino against ELECTRIC FEE
tiabilities,judgments,costa and expenses which may in any way accrue against said City p1.TER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,"CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,010 CFM) CONSTRUCTION TAX
Signature of ApplicantlCatnmarn - Date EXHAUST HOOD(W/DUC) HOUSING MITIGATION E
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant o,future buildimgoccupant store ostandle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupsnino Municipal Code,Chapter 9.12,and the Health and Safety
Crede.Sec0on 25532pq? HEATING UNIT(OVER IW,W BTU)
❑Yea ❑No VENTILATION PAN(SINGLE RESID) PAID
Data Romipt#
Will nhurs air comorinuture building by in,Bay
Are. pmeuality vices which BOILER—COVE(3HP OR IM.000 BTU)
emit hazardous air coni.minanw ns dcfineA by the Huy Areu Air Quality Management TOTAL:
DiaWn?
❑Yes []No aOILER—CUMP(OVF.H IW,gO BTU)
I have revel the hvzmdnus materuds AIR CONDITIONER
requirements under .1Landr6land that
Ceche - ISSUANCE.DATE
forma Health&Safety Cala Sections 25505,25531 and 25534.1.ndersmnd that it the NEW RCSIDFMIAL MECIi. SQ.FT.
building Jces not currently haves named,dial it is my responsibility m naify the wcupam
o(t •requirements which must he con pd�inoisnuuntt ofaC ilianten (kcu
nee2�>�-i
w er nr aohn aed.,a., Date TOTAL: ISSUED BY;
OFFICE