31265 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF.CUPERTINO BUILDING.ELECTRICAL. s PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMPING-MECHANICAL 31265
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
QQQ55570 �
O /R'S NAME: • SPH NE:
CONTRACTORS NAME: LIC NO:
NIC CONTROL
. A CHffECT/ENGINEER: LIC NO'. ADDRESS: ❑'.
CONTACT, PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB , MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 son licensed ander provisions of Chapter 9(commencing JOB DESCRIPTION
�wo0 with Section2000)afDivisma 3 ofthe Busims,sand Professions Cale,and my license is
O PERMIT ISSUANCE
I- to full force andeffect. 'FOWL ❑KITCHEN REMODEL
<U{U,,) License Class Contractor
APPLIANCES—RESIDEN IAL ❑ADDITION [I PLUMBING RE-PIPE
rF<a Dao Contractor
�7y ARCHITECT'S DECLARATION PANELS [I MULTI-UNIT ❑STRUCNRAL
Oz
pj Z 1 understand my plans shell be used as public records MODIFICATION'
:.f UP TO 201)AMPS
pI ❑INTERIOR [I CHIMNEY REPAIR
���',� License]Profession.) 201-IOII0AMP5 IMPROVEMENT
Syn OWNBILBUILDER DECLARATION ,OVER It1W AMPS 'D BATH REMODELJREPAIR CIDFMOLT'ION
jj 6 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
�y(06 V following reason.(Section 2031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL D OTHER �• 1
{xi a W i—e which requires a permit to construct,alter,improve,demolish or repair any structure
t�mJ prium its isrusnce,diore,ires the applicant for such pemtinm filen signed s amment SPECIAL CIRCUIT/MISC,
f p.. that he is licensed inommiuo the provisiousofthe Contmcmrr License Law(Chapter 9 �L 's�•���
apo (commencing with Section 7")of0ivision 3 ofthe Business and Profevioa,Cale)or TEMP.METER OR POLE INST. COMMFRCIAI �
6 W m 2' that he is exempt themfmm sad the basis for the staged exemption.Any violation of D NEW BLDG/ADDITION ❑DEMOLITION
iC Y. Section 2031.5 byanyepplicunt for.permitaubjau Neappliconnoa civil penaltyof POWER DEVICES
W^'y ❑TENANT CFOOD SERVICI:
�p., not more Nen five hundred Mllors y coni. - %IMPROVEMENT
xQ ❑I,ss�wner of the progeny.or my employees with wager ar their solecompensation, SWIMMING POOL ELECTRIC
FO wIf do Ne work,end Nermcturc is not inlendWoraf@sed forsule(See 2044,Business OTHER,
and Professions Code:The Carnation's License Law does not apply to an owner of OUTLETS—SWITCHES—IBXTURCS
R' pmism,who hadds or improves mhcreon,and who does such work himself or through
his own employees,provided that such improvements sm not intended or offered for NEW RESIDENTIAL ELECfR SQ Ff.
..In IL ho,somr.the building or improvement is sold within one yearofromporion,the SQ.F'?-* R "Q.Ff.
owner-builder will have the burden of proving that he did nor build or improve for pur-
pasenfa.leJ. TOTAL:
D.I.as owner of the pmparty,arnexclusively contracting with licensed counselors to CT " 91996
construct the project(Sea.2044.Business and Professions Cuk:)The Cmincmrr Li-
cenwLawdoesnotapplytoanownerofpropenywhohuildxorimprovesNereon,and QTY, PLUMBING PERMIT FEE 4 ,
who convects for such projects with a conditions)licensed pursuant in the Commuters �IIY Ur uuren nlvU
License law. / PERMIT ISSUANCE 0 -
❑IamexemptunderSee. ,B&PCfmthisreamn
Owner Date ALTER—DRAIN&VENT—WATER IEA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Comped. DRAINS—FLOOR.ROOF,AREA,GOND.
sa0an.a,provided for by Section 3200of the Labor Codc,for the perfonnunce of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. PIXTURFS—PERTRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3701 mflha Lahr Carla,for performance ofthe work for which this permit is issued. GAS—PA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance courier and Policy number arc:
Carder. Policy No.: GAS—EA.SYSTLM.OVER 4(FA)
CERTIFICATE OF EX EMPTION FROM WORKERS' GREASFJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not he completed if Ne permit is for one hundred dollars($100) OREASETRAP
or less.) PLANCHECK FIEM
I certify Net in the performance ofncc work for which this permit is issued,Ishall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Worken'Catalog= ENERGY FEE
ZZ sumo.Laws of Coition..Dam WATER HEATER WNENT/ELECfR
Applicant GRADING FRE
yNOTICE TO APPLICANT.If,offer making this Certificate of Exemption,you should
WATER SYS'I'EM/1'HEATING
become subject va the Workers Compensation provisions of the Latin Cale,you must SOILS FEE
Da forthwith comply with such Provisionsm this permit an.][the decmed revoked. WATER SERVICE
4 Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
D z One -Receipt M
U Q I hereby affirm that there is issued
lending agency for the performane<nf
w+ the work for which Nix pcnnir is issue)ISec.3042,Civ.C.)
u" F" Lender's theme TOTAL:
L) Lender's Address TOTAL:
IA BUILDING FEE
G correct.1 emee Nat I hove rued Nis application and ante Nat the above information is
to ilding agreemcomply
and with y city and caumymatives oseWcityto state ws enter
ng tothe QTY. MECHANICAL PERMIT FEE
V z building construction,end hereby euthoriu rcprcsematives of this city to enter upon the SEISMIC FEL
wamn-mendoned property for impaction purposes. PERMIT ISSUANCE -
(We)agree to save,indemnify and keep harmless the City of Cupertino against I ELECTRIC FEE
r.• liabilities,judgmems,cost,end expenses which may in any way accomagainsm said City ALTERORADDTOMECH.
in consequence of the granting of this permit. PLUMBING FEE �at
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOUR�1(REGULATIONS. ///��� MECHANICAL FEF,
\ • GU �I� ,,` /" AIR HANDLING UNIT(OVER Iff,0011CFM) CONSTRULTIONTAX
Srgnamreof'pplieanUCa ter Date V EXHAUSI'HOOD(W/DUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant or furore building escalator sloreorhandle hnardous material HEATING UNIT Off Raf01)0 BTU)
as defined by Ne Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532m)? HEATING UNIT(OVER Hittin)BTU)
11 ❑Yes r7 No VENTILATION FAN(SINGLE RESID) PAID
Data Receipt M
Will the applicant or future building woup rnf use ryuipmcnt or Devices which
emit havac ous air contaminants as defined by the Bay Arte Air Quality Mamagemem BOILER—COMP SHP OR 100,000 BTU) TOTAL:
District? BOILER—COMP(OVER I00,M)BTU)
❑Yes No "
I have read the Insulation,materials requimments undm Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.ff.
b gMer not curently haveatenum,that it is my mspnnsdid. ton aify the accupam
' hmus'kf me to is, ofok '
73 ^�7 I (��/ N QG
( uthnn agent t TOTAL: ISSUED BY:
OFFICE