31115 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 31115
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESSSANITARY NO. APPLICATION SUBh11'FI'AL DAPI
6s'1 =2 �l
OW"NV '. PHONE: CONTRACTOR'S NAME: LIC NO.
1 l '.F NIC NIC CONTROLp
QCCK
ARCH]I LCHENGWEER: /t Oe,� 11 q 9 ADDRESS: E]CorrrACF,00 I- � �NS- D' �� Ej Consultant Fees Paid by Applicant(Initial) BLDG BUI ELEEC�PER{PL�7MRNFO
PHONE
LICENSED CONTRACTOR'S DECLARATIONQ9z QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9 orvion clog JOB DESCRIPTION
wo, with Section 7")of Division 3 ofthe Business and Profession.Code,and my license is PERMITISSUANCE RESIDENTIAL:
n
Flpy..i L License
Class and effect, ❑SFOWL [I KITCHEN REMODEL
aVU Date Class Lick APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE
NaaDale cnmmelar
,Doo PANE DECLARATION PANEfS ❑MULTI-UNIT 0STRUCI'ORA[.
7bOz Iunderstand.,,pI.m,ha111ro.,vd.a public records MODIFICATION
O Z4G UPT02MANIPS InEl INTERIOR DCHIMNEY REPAIR
F 4LW Licensed Proasoonal 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER Il1W AMPS ❑BATH REMODEUftEPA1R DDEMOLITION
T%C 1 hereby affirm that I am exempt from the Contractors License Law for the
O following reason.(Section 7031.5,Business and professions Calc:Any city m county SIGNS ELECTRICAL D OTHER
1+13 p which or,m ca.permit to construct,ober,hnprave.den Okla.m repair any structure
C) .sumo its Issuance,vkw regnirea the applicant ho,mh Parma,,,Ncasigned s,memant SPECIAL CIRCUIT/MIS
that he is licensed pursuant)the provisions of The Cotnmemr',License Law(Chaptcr9
W �C, (commencing with Sectioa7000)ol Division 3 of the Busincxs and Vrofesxiot,CWc)m TIiMP.METER OR 'Tjy
COMMERCIAL:
L y o the he is exempt IhcrclYom nnJ the hu.�s for the alleged cxcTnplion.Any violation of ❑NEW BLDG/ADDITION D DEMOLITION
W..y Sedion 90315 by mnynppfcamt lin m pemtll subject,Weap,licanl to a civil penmlly of Powj:R[ll?VI( .NANT ' ❑FOODSHRVI H
not more than five hundred dollars U%I.
FZY IMPROVE
NT
=6D1,as owner afthe property,or my employees with wogesm,heirsole rnmpcns'annn, SWIMMING POOL 'LF,CfR1C
AL2 will Jothe work,andtheshoamesnot imcndcdaroffrri Rn.mle(See.AH4.Business [D OTHER
4 3 m and Pmfcoinn.s Gdc:'I'he Cono-acTnr'x License Law does not apply man owner of OUTLETS
-SWITCf S-PIX'1'URES
pm,cr y who builds or improves,hereon,and who does such work himself or through WS
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL CLECfR SQ Ell
sale.IL however,the building or improvement issold within one yenrofcomplction.'It SQ.FT.FLOOR WAjI $ISQ.n
owner-builder will have the burden of proving that he did not buil
or
improve for par- `+ Oak
pose of sale.). r
I,as owner of the pntpeny,am ejmmghs�
givdy ling IicenuJ contractors to TOTAL:
hnglrvd Ne project IS 9OW.Rus Gide:)The Conaaclors Li- {SLI G U
c ae law Juts trot apply ut an awfpeds or improves dtereon,and QTY.. PLUMBING PE MIT FEE n1n 1 �{
who mmmfls for inch Pmjc Muan,to the ChmmnoNs �1�1eU
License law. PERMIT ISSUANCE (s(Y VY IJUr
�0 1 an exempt r Sec. t-PCvfor Niz mason V11
ALTER-DRAIN Rt VENT-ATER(PA VALUATION
Dae Io red
F. MPENSjur,on DECLARATION BACK FLOW PROTECT.DEVICE
ereby affirm under penally of perjury one of the following dedamtihns:
I&I❑ ae l have and will maintain a Cenlfi< ofCunmm,oself-insure for Workers Campers. DRAINS-FLOOR.ROORAREA,COND. STORIES TYPE CONSTRUCTION
salian,as provided for by Section 3900 of the labor Code,for the safora ance of me
work for which this permit is issued FIXTURES-PER TRAP
D 1 have and will maintain Workers Cam,amaion Imamnce,m required by Section
PW of the Labor Cao,for the parfomence of the wmk for w hich this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insnr nee currier and Policy number am:
Carrier: Policy Na: GAS-EA.SYSTEM OVER 4(EA)
CEKHFICA'rE OF EXEMPTION FROM WORKERS' GREASFl1NDUSTRL WASTE INfF.RCEPfOR
C(IMPIENSNE[ON INSURANC1i BUILDING DIVISION FT:E9
(Thigsaionncednol bocoraveled if the panni,in Throne hundred dollars($100) GREASETRAP
or less.l PLANCHECK FEE r
I cenlfythv,o lleperlirmance of Ihework forwhich thispernot is issued,l shall SEWER-SANITARY-STORM EA.21X1 ff..
not employ any pees,,.in any manner go as I,,hec,,.e subjno to the Worker'Comoro- ENERGY FEE
O Z soba.Laws of Cdil'omla.Duca WAF17R HEATER WIVEM'ITT rC'TR GRADING FEE
0 Applicant
'n2J y NOTICE TO APPLICANT:IL ahc,oHkm,this Ccnifienc of Exemption,ym should WATER SYSTEMII'REA'FINC
re^ haame x.bjca,In the Worker's Compcmntioo previsions of The I,vhor Code,you must SOILS FEE
WTti forthwith comply with suchpmvisionsar,his permit shall he dutmedmvoked. WATER SERVICE
0
az CONSTRUCTIONUENDINGAGENCY NEW RESIDENTIAL.PLMR. SQ. PAID pale RccciplX
L)O l hereby affirm that there is commaction lending agency for,he performance of
U" H the work for which This Tomtit is i...ad(Sec.3W).Civ,C.)
Lenders Name TOTAL:
1 IxndasAddre,s TOTAL; BUILDING FEE r
I renlfy that I have raid This application and stm
ats that the a infarmmn is
,F. rn co,recl.l agree mc�mply with all city and county ordinanc a aws rdalingm QTY, MECHANICAL PERMIT FEE
V z building construction.and Thereby amhrnize repose sof ' city to enter upon the SEISM IC FEE
above-mentioned pmpcny for ins"ttinpu s. PERMIT ISSUANCE
(We)agree m save,m cmnif 'yep hon s the Ciry of o against ELECTRIC FEE
Iiabilities,judgmems,toxo conA swhicb ymany.. rue against said City
ALTER OR AUU TO MF:CH.
inconsequence of the gra 6oflhisa PLUMBING FEE
APPLICANT ON .TANDS WILL. PLY WITH ALL NON-POINT AIR HANDLING UNIT(7010,11011 CFM)
MECHANICAL FEE
SOURCERE ATIONS.
AIR HANDLING UNIT(OVER 10.0010 CFMI CONSTRUCTION TAX
gnamn - pPI' Cn,ii Dale EXHAUST GOOD(W/DUCT) HOUSING MITIGATION FEE
HA]ARDDUS MATERIALS DISCLOSURE
Willtbc applicant or future buildingoccumo
pumxre ,handle harandm,annual HEATING UNIT(TO 100.0W BTU)
as dcfned by the Cupertino Municipal Calc,Chapter 9.L2.and the Health and Safety
Code,Section 25532(0)? HEATING UNIT(OVER 100.00 BTU)
❑Yc 0N VENTILATION FAN(SINGLE RP_SID) PAID
Will thea applicant or future building occupant devices which Data Receipt X
pp gt upon quipmen BOILER-COMP(3HP OR 100.000 B'FU)
t haNnue aireommninnn,s m defined h try Arta uality Management
D, 0axTOTAL:
Lim ❑Yef BOIL[R-CONP(OVIiR 10),000 BTU)
I have reads woodon,unaterial: uirc.,cntn undc hapter 695o the Cali- AIR CON DI'HON F:R ISSUANCE DATE
mania Health afcry Calc.Sectio ..505.15533,inte2r534.I understood that if the NEW ' '1e,,I P HH, SQ.Irl..
buildin• not curzanAy hav• umt, m
thi ' yrcv ansihllym
lTnotify lbe,.,. an
oft egairemems whit tact T a nl uCenillca Toney.
O a d agent Date IGTAL^ ISSUED BY:
OFFICE