31193 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTIN'O - BUILDNO-ELECTRICAL PERMIT NO.
BUILDING DIVISION . APPLICATION/PERMIT PLUMBING-MECHANICAL - 319
1
BUILDING PROJECT IDENTIFICATION 1 9
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA
01t2- o Uls'T boa �, Z .
O E B: PHONE: CONTRACTORSNAMEswaaosa LIC NO,,
NEC CONTROL#
RCHITE T/li G NEER: • LIC NO: ADDRESS: ❑ p / ��
" CONTACT: DNI° BUILD•INVG PF.RMITINFO
_O I ❑ Consultant Fees Paid 6y Applicant(Initial) tlL Z� PL MEC
;P6_7W 67 LICENSED CONTRACTORS DECLAIZATI N QTY ELECTRIC PERMIT FEE
1 hereby affirm Nm 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QW
pWp with Section 900()of Division 3mthe Busineasand Professions Code,and my license is ,
FF++ in full force and effect. PERMITISSUANCF.
CZUE License Class - Lic,# - 'OWL ❑KITCHEN REMODEL
C<j<a Date Convector APPLIANCES—RESIDENTIAL. ❑ADDITION ❑PLUMBING RErPIPE
[.Drn ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT El STRUCTURAL
OO P1 a 1 understand my plans shall be used as public records MODIFICATION
rrg:! 'UP'f02W AMPS ❑INTERIOR '' 1-1 CHIMNEY REPAIR
� LO Lremmd Pmfemunel IMPROVEMENT
GGGG 1B�11 201-IMOD AMPS
��,'4j OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH MODE4/I{�PAIR ODEMOLITION
66 1 heieby affirm that I um exempt fmm the Camructor's License Law for the 'Y g O
?65�OyU following reason.(Sedim 7031.5,Business and Professions Cole:Any city mcounty SIGNSELECTRICAL ❑GTHBR
W 1"' which requires a portion to construct,alter,improve.demolish,or repair any structure
Fey Prior to its ismancee,also requires the applicant for such perming file a Mom,statement SPECIAL CIRCUIT/MI
y blummfit he islicensedPursuam dome provisions of theeBusines snd Profense Law(ChaptersCout) 9
d"� (comm is licensed Sectio,to the of visi.o.fthe eBusiness and Pmfes""signs Crxie)or f7/g
W ❑O TF.MI'.MCfER OR POLE INS3'. '
4 ps"n tY tate he is exempt therefrom and Ne basis for subjects
the exemption.Any violation of - DG/ADtaDITION ❑DEMOLITION
tsXl {e actSection hanfive031.5 by hundredidomrs($50for a permit subjats the applicant toacivil Penalty of POWER DEVICES Q �,p ANT t1, '
Z} not mare than five hundred dollars(SSW). I N� [I FOOD SERVICE
❑ 1,as owner of the pmperty,or my employees with wages as their sale compensation, SWIMMING PULL ELECTRIC IMPROVEMENT
will Jo the wink,and the structure is not imended oroBered for sale(Sec 40c4,Business ❑OTHER
end Professions Code:The ContractSr's License Lew does not apply to en owner of OUTLETS—SWITCHES—FIXTURES
properly,who builds or improves daemon,and who does such work himself or through iz
his own employees,provided that such improvements are not intended or offered far NEW RESIDENTIAL ELECTR SQ PC
sale If.however,the building or improvement is sold within one y,crnfCompletion.he SQ.FT.FLOOR AREA $rSQ,FT.
owner-builder will have the burden of proving that he did not build or improve for par- ♦ �1 A,
•of kale^). 6
w er of Ne properly,am exclusively contracting with licensed common to
c nslmet the project(Sec 744,Business and Professions Code:)The Contractor's
cnse Lew does not apply to an owner of property who builds or improves intent,and QTY PLUMBING PERMIT FEE
whence Low,
o,
1 amfnrsuch projectsN a mu
winacmr(s)Iianscdrs
puuan
nn the Cumra<tors
License
❑i exe exam ,B&P C for'hisreason PERMIT ISSUANCE
e ALTIiR—DRAIN&VENT—WA ) wVALUATIONr
n WORKBR'S COa ENSATION DECIA ,TION BACK FLOW PROTECT.DEVICE !1•� 1
9.
I hereby affirm under persalt ofperjuryoneofthe Ilowingdeclamtions:
[have and will meinminu Certi cmenfComemmscl-insmefor Worker's Compen- DRAINS—FLOOR.ROOF,AREA,CONU'
station,as provided for by Section 37W of the Labor Code,for the performance of Ne STORIES TYPE CONSTRUCTION
work for which this Permit is issuad. FIXTURES—PER TRAP
❑1 have and will maintain Workers Compensation Insurance,ax requital by Section
3701 ofthe Labor Code,for the perfommnce of the work fur which this permit is issued. GAS—EA.SYSTEM-I INC,4 OUTLETS' OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - GREASHANDUSTRL WASTE INTERCEPTOR AA I
1LD G DIVISION FEES
(This scctianneeJ not be completed ifthe Intone is fone hundred dollvrx(5l W) GREASE TRAP '
or less.) PLANCH �.
Ioyany that in the Kdommuanymannce rof the work for which this the W is omponl SEWER—SANITARY—STORM EA.2W PC
not employ any person in any manner snmtn become mbjecun the Workers''Compen- ENERGY E
0',Z smion Lawsof C.lifnnea, Dam WATER HEATER WNENT/ELECTR
0 Applicant
GRADING E
y NOTICE TO APP LIC NIT.If.Workers Compensation
this provisions
of the
Laborde,you
WATER SYSTEMBIREATING
a become subject y the Workers Compensation provisions of the Lahr Cale,you must SOILS FF.E
forthwith comply with such provisions or permit shall he deemed revoked, WATER SERVICE
d Q
CONSTRUCTION LENDING NEW RESIDFMIALPLMB. SQ.FC PAID
UO
I for
which
in!Netmere isamnstraction len ding agency for the performance of Data Receipt#
O•+ LeWorkader's
Nrwhich Nis permit is lesuW(Sec.3097,CIv.CJ
U Lender's Name
• � TOTAL:
Lender's Addres T A
0. 1 eenify that 1 have read this application and state that she move information is - BUILDING Iq
_w
I) contact,I agree it)comply with all city and county ordinances andsmte laws relmingm QTY, MECHANICAL PERMIT FEE0
U building construction, representatives
and hereby authorim m of this cityenter upon the SEISMI E
move-mentioned property for inspection purposes. PERMIT ISSUANCE AE 2 3
(We)agree to save,indemnify and keep harmless the City of Cupertino against ER
Is
liabilities,judgments,costs and expemes which may in any way accrue against said City ALTERORADDTOMECIL
in comequcnce of the grant ing of this permit. PLUM FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO IL"CFM)
SOURCEREGU TIONS. MECH ICALFER
_ AIR HANDLING UNIT(OVER 10,000 CPM)
x � CONSTRU TAX
Simone ofApplicmt/Commno Date EXHAUST HOOD IW/DUCTI HOUSING MITIGAT PEE
HAYARDOUSM £RIALS DISCLOSURE.
Will the applicant or future or ing occupant store or ban wormousubmrion HEATING UNIT(TO I WAW BTU)
rA
as defined by the Cupeninto Manic' al Cale,Chapter 9.12,an c Hea1N end Safer
Code,Section 25532(.)? HEATING UM r(OVER 1(0,11(10 BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building Data Receipt N
Pp goecupemu Area
Air Quality
Management
BOILER—COME QHP OR IW,OW BTU)
emit hazardous air contaminants as defined by the flay Area Air Quality Management
nib TOTAL:
District?
❑Yes E]No BOILER—COMP(OVER I01,000 BTU)
I have it the hamNous materials requirements under Chapter 6.95 mf the Cali AIR CONDITIONER ISSUANCE DATE
fomia Reach&'Safety Cale.Sections 25505,25533 and 25534,1 understand that if Nc NEW RESIDENTIAL MECH. SQ.ET.
building does no currently have a anan4 that it is my responsibility to notify in,occupant
of the requirements which must be met prior to issuunee ma Cer ifdcam o(Occupancy.
Owner or manedied agent Dam A
ISSUED BY
OFFICE