31247 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILmNC.DrvIS1DN APPLICATION/PERMIT PLUMBING-MECHANICAL 31247
BUILDING PROJECT IDENT'IF'ICATION
BUILDIN ADDRESS: SANITARY NO. APPLICATION SUHMITTAL DATI
ip�Fi3 WC)Lr— M, 81�iI,D I.G e-l(�_ CU.PE27 islo I Ck sib-0l
OW CR _ 0r_"9F �s^�9pH(Nli: COM'RACTOR'S NAME: LIC NO
cN S M 4J `L IY NIC CONTROLX
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: P Osff; BUILDING PERMIT INFO
J-ACEYL,u.6E N.PIt* 45)2650 Consultant Fees Paid by Applicant(Initial) BLD eu!CTj PLUMY MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm then,I am ii,nsea under pmehumo of chapter v recommencingJOB DESCRIPTION
Ma'Zwith Section l00f)uf Division 3 ofthe Business and Pmfcssions Cole.and my license is RESIDENTIAL:
FCC in full Indecent effect. PERMITISSUANCE
W� ❑SFDWL ❑KITCHEN REMODEL
aUU License Class LiaN APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
r Z L Data Conwaor
F=q ARCHITECI'S DECLARATION PANELS ❑MULTI-UNIT' ❑STRI1CfURAL
ZpyZ l undersmndmy plar,imall bemedas public records MODIFICATION
CZin UP TO 200 AMPS ❑INFERIOR ❑CHIMNEY REPAIR
1-N:,a1 Licensed Pmfcssimad 201-I000AMPS IMPROVEMENT
�sd OWNER-BUILDER DECLARATION OVER 1000AMPS 11 BATH RF:MOUEUREPAIR El DEMOLITION
C Q 1 hereby affirm that 1 am exempt tram the Conversion,License law for the
KL U following reason.(Section]0315.Business and Professions Code:Any city or caunry SIGNS ELECTRIC ❑OTHER
413 LL which requires a permit to crnstruc6 alter,improve,demolish,or repairany,,tmctam
F�Cwa On to its iss...re, ins requires the applicant lir such permit to rile a signed statement meSPECIAL CIRNITIMIS .
Ra that he is licensed punuam m the provisions of the Contractor's Licem,Luw(Chuper9
D
(commencing wild Suction 9000)of Division 3 of the Business and Professions Code)or TEMR METER OR POLEI
H
a 6 ethat he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑N LDG/ADDITION 0 DEMOLITION
xl� Section 7031.5 byanyapprcam turn or.subjects the appliemo ret civil pe unity of POWER DEVICES •ANT
C3 FOOD SERVICE
I„Z} rot mom than five hundred dollars($500). IMPROVEMENT
_-' ❑ L as owner of the pmpeny,or my employees with wages as theirsule a mpcnsation. SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended ondferai for sale(See.7044.6usinec. ❑OTHER
L 3 an and Professions C de:The Contractors License Law does no,apply,o an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or Improves thcrc+m,nnJ who does sucfive k himself nr thraug
his own employees,provided that such improvements are not intended or offered for NI?W RESIDENTIAL ELECTR SQkr
sale.IL howeverthc huildingnrialaoludent i.csrld within enc Year n(cninplelinm the SQ.FC FLOOR AREA VSQ.FT.
are-builder will have the burden of proving that he did not build or improve for pan,
pose of side.).
❑Lmowner of the pmpedY,am eneWsivdy conuac,ing with liansN comracmrsm T L:
construct the project(Sec.90,14,Business and Professions Cafe:)The Contractor's Li-
«nse Law does not apply to an owner of property who builds or lmpmvcs thereon,and QTY PLUMBING PERMIT FEE
who somans for such pd,v,with a conn cions)licensed punuu ll m,he Conrremr's
License Law. PERMIT ISSUANCE
lamesedfumader Sen. ,B&PCfur thi,maam
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date {{{���``'
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ( O
1 hereby affimt under penalty of perjury one of the following dedar's Ca J go 0
Jon,as and ide[forh,neCion 37te of Consent to Code,samfer Worker's Camped Ov DRAINS-FLOOR.ROOF AREA,CONT). STORIE TYPE CONS'T'RUCTION
smirk,as hick the for by Sermon 3100 of the Labor Code,for the perfommncc of the
work forwhich this loom(is over 1>IX'1'URF,S-PER TRAP
1 have and will ode.bon Worker Compensationwalk
lkforwhich
h required by Section
My Worker's
Co Gxle.fonhsuranc carrier
atd Polis for this permit is issued. GAS-FA.SYSTEM-I INCA OUTLETS OCC.GROUP AI'N
Ca Worker's Cnmpensmion Insurance carrierand Policy number am:
Cartier, policy No.: GAS-PA.SYSTEM-OVER 4(EAJ
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASF/INUUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This metinn decd nm be completed if he pe-,it is f cane hundred dollars is 1007
r le".) CREASE TRAP 1'LANCHECK IZIi
I certify that in the pefformonceof the work tin,which thli permit is iswcd.I shallX
not employ any pawn in any manner so as m become subject to the Workers'Compcn- SIiWER-SANITARY-STORM EA.21X1 p1'. ENERGY FEE vir
�D
0zcodon laws of California.Doc GRADING FEE
WATER HEATER WNEN`IELECTR V
z
2 Applicant
to NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should WATER SYSTEMaRRATING
a ; become subject to the Workers Compensation provisions of the labor Code,you used SOILS FEE
forthwith comply with such provisions or this pndard,hall be deemed revoked. WATER SERVICE
Q
.Uti. zCONhem is anetm'IONLIiNDINGAGENCY NEW RESIDENTIAL I'LMB. SQ.Pf. PAID eccil#
1 hereby elaffirmthanhereis a cominn lending agency lonm
he per[orvnce of p
U- ,he work for which this permit is issued(Sec.3097,Co,C,)
{I. Lenders Name
D TOTAL:
Lekderl Addlenity
d thTo,
1<enify e I have read Nis applicationand nae that the above information i. BUILDING FEE �
FH correct.I agree to comply with all city and moray ordinances and ante laws relating to QTY, MECHANICAL PERMIT FE'
UZ building constmclinn,and herebyauthori/c repre.aenmtives of Nil city to enter upon the SEISMIC FEE f
.hove-mentioned properly far inspection purgon, PERMIT ISSUANCE b 'J
(We)agree m save,indemnify and keep hannlces the City of Cupertino against .ELE TRI PBT, �/
Iivbilitie,j.dgmcros,cost,and expenses which may in anyway accrue against said City ALTER OR ADD TO MECH. O
inaeraga eof the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00)CFM)
ANICAI.FEIi
SOURCE REGULATIONS. ac <10
AIR HANDLING UNIT(OVER 10.000 CFM) QOd,STRUC710N,TAX,.�,
Signoturerf Applicant/Cnnoactor Dare 17XHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MA'I'HRIALS DISCLOSURE
Will the applicant rr future building occupant stare or handle haavNous maledal THA'I'ING UNIT(TO 100,000 B'TO)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Covide.Serthrm 2553200? HEATING UNIT(OVER 101,000 BTIf)
C)Yes ❑No VENTILATION FAN(S INGLE RESID) PAID
�� W,II the applicant or future building Occupant use equipment or devices which Dae Receipt X
nhazardum air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP pf{P OR 100,000 BTU) TOTAL:�0 0644
D,aricIT MOILER-COMP(OVER 101,0(1)BTU)
❑Yes Fl No
I have rend the havrdons materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE,
fomo Heath&Safety Coda.Sections 25505,25533 and 25574.1 undemaal that if the NEWRESIDENTIAL.MECH. SQ.ET.
building docs rot currently have a want.that it is my msponsibiliry to notify the occupant V'\ - / r— Q
of(he requirements which must he met prim to issuance of a Certificate of Occupancy. Q
Owner or nuthnriuJ agent
Date TOTAL ISSUED BY: F
OFFICE