31138 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PURMIT NO. II
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. JK 3
BUILDING PROJECT 1IIRNTIMCATION
BUILDINGADDRISS; SANITARY NO. APPLICATION SUBMITTAL GATT
OWYIL'S NAME: HONE:nn CONTRACTOR'S NAME: LIC NO;
• AN !•r 2� vC/�s NIC CONfkOL#
ARC ITDECT/F CNEER: YT nL=C NO� ADDRESS: ❑
CONTACT. �' �V{IOjjfEy 2-Z ,4 � BUILDING PERMIT INFO
Je� Q/ n - � ED Consultant Fees Paid by Applicant(Initial) x ELECT PLUMB MCH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT eEE
1 hm ereby mnrthat I am licensed unde,pool kio o of Chapin,9(commcncmg IF JOB DESCRIPTION
00 with Section7000)of Divielon3 ofthc nosiness and PndcssioncCode.andmyliccreals PERMITISSUANCE RESIDENTIAL'
t 1_ in full force and effect. ❑SFDWL [I KITCHEN REMODEL
aU0 License Class Lie,is APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
I Q L Did Contacmr
Fpm ARCHITECTS DECLARATION PANELS ❑MULTLUNIT ❑STRUCTURAL
z O y z i understand my plans shall be used as public records MODIFICATION
oz-, UP TO 200 AMPS
C1 INTERIOR ❑CHIMNEY REPAIR
F�.F+la1 Liccaved Pndcavia^n1 2111-I WUAM IMPROVEMENT
�Yf; OWNER-BUILDER DECLARATION OVERH AMPS ❑BATH REMODELBEPAIR ❑DEMOUITON
G 0 W Q 1 hereby affirm that I em exempt Bom the Contmnor's License Law for the
DyV following reamer. 7031.5,Besinees and Pmficouns Code:Any city or county SIGN LECfRIC ❑OTHER
3 LL y which requires o permit to construct,alter,improve,demolish,or repair any swore 1 ^
�� pr on t. Iso 9 rc the pylic mf hpe iu fl g daatement SP CL T/ C.
bar he licensed pva a the provision,of,ho Com License L (Chapter9 �8n
� 00 (cam b d Section 7000) fDo,,u J ftheh is sec
and br,o .Cude)or TI: R N LLE INST.
6 6 eC that he pt therefrom d the basis for the alleged exemption.Any visitation of EW L)GIADDI IDN' L TION
X LL Sauan]OJLS by eny applmam fora perms xubjecrs the eppinevol m a civil penalty of If DEVICES 1�
41�y EN lJ ( ❑F ERVICE
F-ZY at more than five hundred dollars($500). 1 OVEM
= (IL
D Q as owner office property.or my employees with wages as their sale compensation. SWIMMING POOL ELECTRIC LOrC�'(l
ElNn
FIldow
theak,ondwnur
these is not intevdedmLiffered frsale(Sec.]DLL Business ❑OTHER
cc 3 and Professions Calc:The Contrac'tor's License Law does not apply at an owner ofIUTLETS-SWI LIES-FIXTURES v
propcny who builds or improves thereon,and who does such walk himsch or through
his own employees,provided that such intro arowins urs net sanded er offered for NIiW R . TIAL.ELECTR S017
sale.If,however.the building or improvement is sold within one yearnfco mane SQ.FT FLOOR AREA S/SQ.PT.
crbuildcr will have the burden of proving that he did not b�piw
il �ImLw,
f
pose of sale.).
❑L if ale). of'he Propeny,am eaclusivdY cont g wito I ITl
consWcl the Project(Sec.]094,Business and essi ms Gis RQQi�,
cense Law docs not apply m on owner o' piny who build: d QTY V IN ERM FEE
who contracts liar such projects wi umhstant a)la,- purwum mo the Comommes
License law. PERMIT 15U
I am exempt under ,B&P C f rrthis reams
Date
Owner
ALTER-DRAIN& 'ATER(EA) VALUATION
i W KER'S COMPENSATION DECLARATION BACK FLOW PROTECT. EVI
1 hcrcny afOmi under penalty of of Coy enc of elf inure for declarations'.
I have and will mainmina Ccniliaulc of Consent it) for Workersireof h- DRAINS-IL(IUR,ROOI'.A F ,GOND. STORIE TYPE CONSTRUCTION
rection,as provided fur Section 77(01 of Ne Lahr Code,for the peAnrmance of the jiij
work have and this pcmann issued. FIXTURES-PF.R TRAP tkp If bo
❑I have and will Cos .
far hat affmker's Compensation Insurance,which required by Smion
3700ciflifir,Wrker Labor Ccde,fonthsurancrmncer athe work(murdrthispermit is issocd. GAS-FA.SYST['sN 11NC.40UTLETS OCC.GROUP AI'
Cu Workers Compensation Insurance carrier and Policy number are:
Comics Policy Na.: GAS-P.A.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUS'I'RI.WASTE INTERCEPTOR
BUILDI GUI VISION W.
(This samisen need nm be completed ifthe permit is foram hundred dollen(5100)
or less.) GREASE TRAP PLANCHECK FEE
I satisfy that in the performance of the work for which this Permit is issual.I shall S17WER-SANITARY-STORM EA.200 FT.
nua employ any mrsa.a any mnn
aer so es m becd ame oddeGi to the Worker'Conan- ENERGY FEE
,Z( cation Lawsof Caliliaram Dale WATER HEATER WIVEM'/ELF.CPR
Q Applicant GRADING FEE
NOTICE TO APPLICANT.If,after making this Cenifcme of Exemption,you should WATER SYSTEMIIREATING
become subject to the Worker's Compensation pm mom,of the labor Calc,you must SOILS IEE
a.. forthwith comply with such provisions onhis permit shell be decmM revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PALO
I R ¢rpt#
L) 0 (hereby off rat that inhere i.voconstn¢tion lending agency fonhe pednrmanceM ate
the work for which this permit I.s issaed(See.3097,Civ.C.)
OF-' Leader',Name TOTAL:
>" � Lender's Address BUILDING FEE
1 certify that I have read this applicadon ail sec,a that the above i
.F. N corset.lagreent comply with all city and coumy ordivnce to lawsre- mg to QTY. MECHANICAL PERMIT F'
C.) Z building constructions and hereby euthonow repres es afthis city to recon the SEISM IC FEE
abov>mentinn<J pmpnny for taped macs. PERMIT ISSUANCIi
We)agree to save,in sera harmless the ser Colonia against ELLCfRIC FEE
liahilida,judgmrus nd expmneswhichmayi way accre against said City ALTER OR ADD TO M ECH.
inconsequence c, coming of this peand PLUMBING FEE
API UNDERSTANDS AN L CO WITH ALL HIGH. "- AIR HANDLING UNITITO 10,00D CF.MI
SO' EREGULATION 9 MECHANICAL sE
3 4, AIR HANDLING UNIT(OVER 110,M) N
,M)CFM) CONSTRUCTI TAX
Signawre of APPlicnnUCommmor Date / / EXHAUST HOOD(W/DUCq HOUSING MI IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant slum orhandle Incumbents mmcrial HEATING UNIT(TO 1100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter LIT 2,end the Health and Safety
Crede.Section 25532(a)? HEATING UNIT(OVER 100.000 BTU))
❑Ycs ❑No PAID
VENTILATION FAN(SINGLE RP.SID) �- Date Rest #
Will the applicam or future building occupant use equipment ar devices which
emit hazardous air conmminants as defined by the Bay Arca Air Quality Mareagcmcm IiOlLlik-COMP(311POR IIXI,IIINI 11,T) T TAL:
Drcmct? BOILER-COMP(OVER 100.000 BTU)
❑Yes ❑No
I have read the hazard wterials napi ams under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DA E
fomia Health&Sufet e,Bensons 8 5577 send 25534.1 undcntand that if the NEW RESIDENt'IAL MECH. SQ.FT.
,mliingdacano fly havmuc ,that it Lv xIn,ibilityf notify the ucculean
of the¢qu' ants which fort eof enihcme mo(xcapm
w. rtircd ager �'vDatc A ISSUEDBY:
OFFICE