31528 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. - PERMIT NO
BUILDING DIVISION ' APPLICATION/PERMIT PLUMBING-MECHANICAL' 31528
BUILDING PROJECT IDENTIFICATION
BUILDINOADDRESS: l SANITARY NO, APPLICATION SUBMITTAL DATE
OWNE 'S NAME: ` I PHONE: ` CONTRACTOR'S NA LIC NO:
o /1 SA \r n NIC
CONTROL#
ARCHITECf/ENGINEER: LIC NO: A RISS: - l.-1, CJiVC a ❑
o e Q
CONTACE PHONE: - BUILDING PERMIT INFO
s �a _ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
co u 'S o
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
F WaZ with Section 7000)af Division 3 of the Business and Professions Code,end my license is RESIDENTIAL'
O ho r H it and e(( y - �. PERMIT ISSUANCE —�--- —
�U License lass' L Lic.g 6� ❑SFDWL 11 KITCHEN REMODEL
fy,�Z APPLIANCES-RESIDENTIAL{s..�� Date Contmcta (]ADDITION ❑PLUMBING RE-PIPE
y A CHITECfS DECLARATION DMULTLUNIT ❑STRUCTURAL
'1 understand m lens shell he used ns blit records PANELS
Z O •',j- my Pu - 'ODIFICATION
pZ UP TD 2W AMPS El INTERIOR /�q��sJsIMNEY REPAIR
�,m'.� L¢rnxA Professional 2014000AMPS IMPROVEMENT
9 OWNBR-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
'Su?77 OE I hereby affirm that I am exempt from the Contncmes License Law for the
following ressnrs(Section 7031.5,Business an l Poraisxiens Cale:Any city or county SIGNS ELECTRICAL El OTHER
I'"IL 00. which requires a permit m Construct.alterimprove,
, demolish,or repair any suucture
priorto its issuance,4190 requires the applicant for such Permit to rile a signed statement SPECIAL CIRCWT/MISC.
ypy that he is licensed pursuant to me provisions of me Commons License Law(Chapter 9
00 (commencing with Section](XIO)of Division 3 of the Business and Professions Cale)or TEN R MFIER OR POLE INST. COMMERCIAL:
M p�=of that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
tXY Ry Section 7031.5 by any applicant fora permit subjects the applicam m a civil penalty of POWER DEVICES
not more than five hundred dollars(S500) ❑TENANT ❑FOODSERVICE
Q �I,as owner of the propery,or myemployces wiNwagesutheir sole mmpenaetion, SWIMMING POOL ELECTRIC IMPROVEMENT
C will do the work,and the structure is not intended or offered for sale(Sec. Business - []OTHER
and Professions Code:The Commences Uceme law does not apply to on owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or though
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 year of completion,ene SQ.FT.FLOOR AREA VSQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: 7-6
-onawct the project(Sec.]BM,Business what Pmfeasiona Code)The Comuocmra Li- A
ID
cense Law does not apply to an owner of propmy who builds or improves thereon,and QTY. PLUMBING PERMIT FEE /�� DEC
4
who convects forsuch projects with a contractons)licensed punuanno me Contractors ,S
License Law. PERMIT ISSUANCE Q
C] gs
1 am exempt under Sec. ,B S,P C for this reason V
Is
Owner Ua¢ ALTER-DRAIN&VENT-WATER(EA) /,1�',
WORKER'S COMPENSATION DECLARATION rV V V��pl I ITV
BACK FLOW PROTECT'.DEVICE c/
1 herebyill maintain
ai under penalty to perjury One of the insure for declarations:
❑Ihnve and will mein mina Certificate ofConvatLah oCodevfor the Workers Campcn- DRAINS-pLIX)R,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
section,as provided for mi Seniors 3]W.(,he lahnr C�dc,far the performance of the
work for which tela Permits issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation the w rkfor Insurance,h required by Section
3]Wo(Ne labor Code,for the performance of the work for which this permit islissued, GAS-EA.SYSTEM-1 INC.40IITLETS OCC.GROUP APN
C�Work ssCorppenwtio 'rimy, tette Carrie
Polls, nu 74 Y GAS-EA.SYSTEM-OVER4 EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - ' GRI?ASE/INDUSTRL WASTE INTERCEPTOR
Ohis section need no,M completed if the permit is for one hundred dollars(S 100) BUILDING DIVISION FEES
or less) GREASE MAP PLANCHECK FEE
I cenify mot in the perfomem,14 the woricforwhichthis permit is issued,l shall SEWER-SANITARY-STORM PA.200 FT.
nm employ any person in any manner so as to become kub,lect to the Wakes'Compcm ENERGY FEE
z cation laws of California.Date
7�O Applicant WATER HEATER W/VENT/ELECTR GRADING FEE
G ZI NOTICE TO APPLICANT:If,atter making this Certificate of Exemption,you should WATER SYSTEMITREATING
a ; became subject to the Workers Compensation provisions of the labor Code,you must SOILS FEE
forthwithexmplywith n¢h provisions err Nis permit shell hedeemed revnkal. WAIERSERVICE
Is 0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
0 - Thereby affirm mauhere isx maturation lendingagemcy for the performaneeaf Date R. g
U
U s.. the work for which Nis permit is issued(Sm.3119],Co.C.)
F, LendeYs Name TOTAL:
W lenders Address TOTAL:
LLt I certify that Ihave read this application and state that the above information is BUILDING FEE
Zf7 corner.I agree to comply withell cityand county mdinonccs and stem lav,hrha ng m QTY, MECHANICAL PERMIT PEE
U G building construction,and hereby authorim representatives of this city m enter upon the SEISMIC FEE
above-reemioned property for inspection purposes. PERMIT ISSUANCE.
(We)agree msecvq indemmifymvd keep hannlesx the Cltyof CUPenino against ELECTRIC E
liabilities,judgmenas,costs and expenses which may in any way mcme against said City ALTER OR ADD TO MECH.
in Consequence of the granting of this permit. PLOMBI GME
APPLICANT UNDERST NDS AN ILL COMPLY WITH ALL NON-POINT AIR IJANGLING UNIT I0,(gO CFM)
URCEREOULAED MECHA AI-FEE
Q' C / AIR HANDLING UND'(OVER 10,(X111 CFM) CONSTRUCT TAX
Signaturcnf App licamVContrector " Uute D EXHAUST HOOD(W/DUCD HOUSING MITIG ON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhandle hazardous material HEATING UNIT(10 100,000 B'I'U)
as Claimed by the Catarina Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532on? HEATING UNIT(OVER I W,OW BTU)
❑Yes C]No - VENTILATION FAN(SINGLE RFSID) PAID
Data Receipts
Will the air limanconn or future building occupantuse equipment or devices which BOILER-COMP UNP OR 1W,WD BTU)
emit hazardous sir contaminants as definW by me Boy Area Air Quality Management TOTAL:
Dm ac
'
❑Yes ❑No BOILER-COMP(OVER IW,(Xp BTU)
I have read the h4zndom materials requirements under Chapter 695of the Cali- AIR CONDITIONER ISSUANCE DATE
funds Health A Safety Cade,Sections 25505,25533 and 25534.1 uvdmmnd that if the NEW RESIDENTIAL MECH. SQ.FT.
building don not currently have a meant.that it is my hespansibilitym notify the occupant
of the requirements which must M met prior m issuance of 4 Certificate of occupancy,
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE