31286 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE RTINO BUILDING.ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING.MECHANICAI. 31286
BUILDING PROJECT IDFxEHFICATION
BUILDINGADORISS: SANITARY NO. APPLICATION SUBMITTAL DATE
0 3 V5, �� (z17
O E :S P NET CONT OR'SME'. LIC NO:
NIC CONTROL.#
RCHITECTIENGINEER: LIC NO: ADDRESS: El
CONTACT: PHONE: BUII,DI PER MIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EI.EC)' PLUMB MECH
LICENSED CONI'RACI'OR'S DECLARATION QTY. ELECTRIC PERMIT FEE fCp--'�1 ❑ ❑
1 hereby affirm that 1 am licensed ander proesions m chapter 9(commencing JOB DESCRIPTION
WOOQWz with Section700(bai DIvldon 3ofmc Buslncssnnd Pron,slo.,Cnde,und ary,licen.eu RESIDENTIAL:
WOO p 1'IERMI'1ISSUANCE '
F1_ in full force and effect. C SFDWL C KITCHEN REMODEL
aUU Licenx Class Lic'N APPLIANCIES-RIESIDIENTIAL ❑ADDITION C PLUMBING R&PIPF,
In<d Da¢ Common
Fprol ARCHITECT'S DECLARATION PANfi1S CMULTLUNIT El STRUCTURAL
Z p y Z 1 uodrs
etamd ns my plashall be usd as public record MODIFICATION
p Z..-a UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
�to IT-W Licensed Ymfasional 2111-1(1(NIAMPS IMPROVEMENT
OWNER-BUILDIER DECLARATION
a C C 6 1 hereby affirm that I am exempt from the Contia"ci License law for me OVER lIXM1AMP5 El BATH REMODEIIREPAIR (]DEMOLITION
LLa U following mason.(Swtinn 703 1-1,Business and Pmfir,o.nx Calc:Any city or county SIGNS ELECTRICAL C OTHER
lO yQ which Imports a permit m conxwet,etre,improve,demolish,or repair any structure
yW ..1 primto it,issuance,dsn...mer,thppli
eucte,limmch permit m tole a sigm
ncti,mcent SPECIAL CIRCUITIMISC.
fCon that he is licensed pursuant to the provisions ofthe Contractors Liceve Low(Chapter 9
W OO (commencing with Section M00)of Division 3ofthe fla,m,s and Prol'v,00a,Code)nr 'I EVER METER OR POISJUNST. COMMERCIAL:
L c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION C DEMOLITION
4• Section 7031.5 by any applicant for a pcnnit subjects the applicant Ica civil penalty of POWER DEYE
'
—pa CTIENANT CfOOD SERVICE
t more than fisc hundred dollars(SSW)' P4PROVEMF�S"'.asst
�_< I] I,as owner of the pmpeny.or my employees with wages as their.wde corEmaiation, SWIMMING PIX RC q)A�li
a� will do the work,and the sanumrt is not intended aroRereJ mrsale(Sec.7044,Business )'THEE �tIL y��1
ult R and Pmfesions Cala The Contractor's Liemse Law does not apply to an owner of OUT1,6I'S-SW CHES-P%
6 3 property who builds or improves thereon,and who does such work hineself or through
his own employees,provided nonsuch improvements arc not intended or vi'md far NEW RESIDIENTIAL IE1,
sale.If,however,the building or improvement is sold within one year ofc.mpletion.the SV.PI'.ILO AAA! $ISQ,IT.
owncobuilder will have the burden of proving that he did not build or Improve for pur-
p.ee of Tube). [[
❑1.as owner of the progeny am exclusively contracting with Iicenwd eontraetoes to JAN 2 4 �IIIITEC U
consumer the project(Sec.7044.Business and Professions Caleg The Cmuracmrs Li.
cense law due,am apply in muswmer of property who builds or improves thereon,and QTY PLUMBING PERMIT FETE
who convects for.uch project,with a cmaraaogx)licensed puts......the Cnmrvcmrs CII I Ur kiur&i I If 10
License law. 11I7RMI T ISSUANCE
C l am exempt under See. ,B&P C for this reawn
Owner Dam ALTER-DRAIN&VENT-WAI'ER(HA) VALUATION
WORKER'S COMPENSATION DECLARA'IlON BACK PLOW PROTECT.DEVICE O O��g '
1 hereby affirm en
under Finally of perjury one of the following declarations: V�VV
❑ Ihet.and will moremaiaCerliliemeaf C...car wself-in sure far W.rkers C.open. DRAINS-FLOOR,BOOP.AREA.COND. STORKS 'TYPE CONSTRUCT ION
Nation,as provided far by Section 3700of the Labor Calc,for the performance of the
work for which this p.it is ismed. FIXTURES-PER TRAP
Fl 1 have and will maintain Worker's Compensmion Insurance,as required by Section
3700ofthe Lather Code,far the panamance.fthe work for which this permit is issued. GAS-G.SYSTEM-I INC.4 OUTLETS OCC.GROUP MIN
My Worker'.Compensation Insumace carrier and Policy number are:
Cartier: Policy No.: GAS-EA.SYS'ITEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FgifiS
fihissectinn need not be completed iftha permit is for one hundred Jnllan IS not GREASETRAP or less.) PLANCHIiCK PF.F.
Ioyany p:ninthc pnynexaer ofth1 work for Ndjecthispermitlsissmed,Lsl,aO SF.WIER-SANITARY-S'I DRM EA.20014.
nm employ any peaon in any manrtcr so us m become suhjunn the Worker2 Compen. ENERGY PEE
Oz smion lawsof Calilbmia.Dwe WA1 FR HEATER W/VEM7ELEC7R G
Applicant RADING FEE
.N. NOTICETO APPLICANT:IL alter making This Cenlficntc of Exemption,you should WATER SYSTEM/BEATING
I•' become s.bjectio the Workers Comper-t on provisions of he labor Code,you most SOILS ITE
forthwith comply with such provisions or This pcnnit shall he deemed revoked. WATER SERVICE
0.
CONS'IRUCTI(IN LLNDING AOIENCY NEW RESIDENTIAL PLh1 B. SQ.PE PAID
`7 z Iherebyathnn thanhere is ac.nswaion lending agency for the perlomsance of Date Reccim#
LL L7 the work for whichthis Permit is ootd(See 3097,Civ.C.)
U 1<ulke,Name TOTAL:
Q lender's AJdmx, TOTAL:
1 certify that 1 have read this application and cam tbar he above information is Bl111DING ITE
Val
central.l.,me ,,ntmply will,all c ityand cvmutyordimnce,undsme law,relmingnt QTY. MECHANICAI,PERMIT FEE O
fJ Z building construction,and hereby aumorizereprommativesefthis city memer upon the SEISMIC FETE
ra aMwomentinnd property for impcctin I pulp ux11' PERSON I'ISSUANCE
(We)egme to save,indemnify and keep harmless the City of Cupertino again ELECTRIC FIFE
liabilitics,judgmens,costsuml expenses which may in any way accrue against aid City ALTER OR ADD TO MECH.
in omequence of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITTIO 10.0 0CPM)
SOURCE.REGULATIONS. MI-CHANICAL PEE
AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUCTION'TAX
Sigrmtam of ApplicanUContfacmr Data EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or l'more building uaeupanlstorc or handle lmmrdoms nm¢rial H17ATING ON IT(TO IIXLfKKI BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Seenion 255320)". 1 HEATING ON IT(OVER 100,000 BTU)
❑Yes 0 N PAID
VRNCILATION FAN(SINGLE RESID) prole Remiplk
Will the applicant or future building occupant use equipment or devices which
•mit M1aardoYa air contaminants as defined by the Day Arco Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) IOTA],
Disuict7 DOILER-COMP(OVER 100.000 BTU)
❑Yes ❑No /L _
I have read the Immdws mammals requirements under Chapter695of the Cdi- AIR CONDITIONER ISSCJANCE DATE
Ibmia Health&Safety Calc,Sections 25505,25533 and 25534.1 understand that Ethic NEW RESIDENTIAL MECIL SQ.IF
buildmi,loea nsn comently have a conal.Nat it is my.,,,n,ih,liry to ratify ata aNxtrem
of the requirements which must he met prion to issuance of a Cenlficam of Occupancy. ::�:l
Owner or authorimd agent Date TOTAL: ISSUED BY:
OFFICE