31370 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT- PLUMBING-MECHANICAL ,
31370
BUILDING PROJECT DENTIFICATION
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
o s3
(folLy Ave . CL* +%No 'CAI gsc>ly �ozag6
OWNER'SNAME: F PHONE: CO ACTOR'S NAME: LIC NO:
e sae -2 (VQ S NIC CONTROL#
\RCHITECGI?NGINEER: I LIC NO: ADDRESS: ❑
CONTACT - PHONE. BUILDING PERMIT INFO
n ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSEDCONTRACTOR derP DECLARATION QTY ELECTRIC PERMIT FEE
Oaz
1 hereby arm that I am licensed under provisions of Chapter v(commencing LOB DESCRIPTION
with Section TII0T.f Division 3nflhe Business wd Professions Cale,anJmylicemseis.
'�x1,�0 PERMIT ISSUANCE RESIDENTIAL:
W r m full force and affect.
�UU License Class Lic.p ❑SFDWL ❑KITCHEN REMODEL
�Zy Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
tt
Z:)v, ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
PANELS y _�Qunderstandray plan hallMused sspublicr ods /// MODIFICATION
'OZ^� s UPT021p AMPS RINSFRIOR C3 CHIMNEY REPAIR
Licensed Professional 201-Iola AMPS PROVEMINT
OWNER-BUILDER DECLARATION ContaON OVER TWO AMPS ❑BATH REMODEI/REPAIR El DEMOLITION
L 6'w Q 1 hcrehy,,(firm on 1 nm exempt Tann the C Professions
Cod :License Low for he
ip5, :6 V following reason.(Section]031.5,Business and Professions Cole:Any city or county, SIGNS ELECTRICAL ❑OTHER
s�a W 1N¢"' which requires a permit m construct,,her,impmve,demolish,or repair any structure�yWy.2 prior to its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUIVMISC.
CYmot he is licensed puna if
nran the pow,am.fthe Contractor's License Law(Chapter 9 ET
a a'� (commencing with Section o0of.f Division 3 of the Business and Professions Coded Or TEMP MER OR POLE INST. COMMFRCIAI-
d Gx Qo a 0. the he is exempt the«from and the basis for the alleged corruption.Any violation of El NEW BLDGADDITION D DEMOLITION
I W�H Section 1031,5 h,ch,applicant fall permit subjects the applicant too civil penalty of POWER DEVICESi ❑TENANT ❑FOOD SERVICE
not more than five hundred dolLaa IS500). IMPROVEMENT
C] SWIMMING of me propcty,nr myemployenwim wegesmtheireole cnmpenvtiod. SWIMMING POOL ELECTRIC ❑OTHER
W will do the work,and the soucture is not intended oroBeted for vide(Sec.1044,Business
W and Professions Code:The Cont,mW,License Law does not apply to an owner of OUTLETS-SWITCHES-FI%TURES
L 3^ property who builds or improves thereon,and who does such work himself or through
his own employe¢,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELEM SQ ET.
salad(,however,the building arimprovetmmis salt within one year of asmplaion,the SQ.FT.PLOORAREA FJSQ.FT.
owincobuilder will have the burden of proving that he did not build or improve for put-
❑M 1,assowne IOTA / P
I,as owner of the iec,70y,asn Imes,add contracting with licensed contractors i- e
constrvd the project(Sec.]044,Business and Professions Calc:)The Convacmr's Li-
sense Law does not apply to an owner of propmy who builds or improves thereon,and QTY. PLUMBING PERMIT E OCT
whocontment fersuch projects with acontvcmgs)licensed pursu,nttu the Contmcmr's {/ �� n
License Lew. PERMIT'ISSUANCE lOAC
Meme oda Sec. ,B&PCfm isle 1m v9(8
ALTER-DRAIN&VENT-WATER(G) p,CK ILUATION
•Owner Datc VV
W.andr,SCadyOf ,j., nDECI RATION BACK FLOW PROTECT.DEVICE INU
I hereby effvm under,penalty of perjury one afth fallowing Jedamli0ns:
❑Ihave end willmainmin uCetifcatu ofComem meal(-insu«for Worker's Compem DRAINS-FLOOR,ROOF,AREA,GOND.
sam ,as provided for by Section 31x1 of the Labor Cale,for me Not....of the 51'011115 TYPE CONSTRUCTION
n
work for which this permit is issued, FIXTURES-PER'TRAP
F1 have and will maintain Worker's Compensation Insurance,as required by Section
311,0 0111,labor Cale,for the performance ofthe work for whichthis permit is issued, GAS-6A.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.: GAS-EA.SYSTCM-OVER'4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRLWASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be complemdlf the .I,is(Drone hundreddollers(SI00) GREASETRAP or less.) PLANCHECK FEE '
I certify that in the Performance ofthe work forwhich this Permit is issued,l shall SEWER-SANITARY-STORM EA,2W FT.
not employ any person in any manner was to become subject m the Workers'Compen. _ ENERGY FEE
(Z. eation Laws of California.Date z WATER HEATER WNENTIELECfR O Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should WATER SYSTEMPEREATING
iI"! become subject to the Worker's Compensation provisions of the labor Cafe,you must SOILS FEE
tff3X1 forthwith comply with such Provisions or this permit shall be deemed revoked. WATER SERVICE
5z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ,FF, PAID
G Q Ihereby of tin that mem is a construction lending agency for the performance of Date RecciptIf
II. F the wont for which this Permit is issued(Sec.3097.Civ,C.)
CLender's Name TOTAL:
WLender's Address TOTAL:
fi1rr p, I certify that 1 have real anis application end swm that the ahwe information is BUILDING WE
f^. In correct.l agree to comply with 01 city and county ordinances and state laws relatingm QTY. MECHANICAL PERMIT FEE
V building conarvclion,end herchy authorize repraxenmtives of this city to emtt upon the SEISMIC FEE
,hove-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(Way agree to save,indemnify and keep hamdess the City of Coperino against
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MUCH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTIONT
Signature of Applicat(Commetor Data UXHAUST HOOD(W/DUCT) HOUSIN TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hazardous material HEATING UNIT GO 100,000 BTI)
as defined by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Safety
Calc,Section 25532(.)7 HEATING UNIT EOVER 100,0110 BTU)
❑Yes , f]No PAID
VENTILATI(IN PAN(SINGLE RESID) Date Receipt#
Will the applicant mfuture building by[be By Aequipmentordeviceswhich BOILER-COMP(311P OR 100,0011 BTU)
cm it hazardom air ammminants ax defined by the Bay Area Am Quality Management TOTAL:
Disvict?
Yes ONO BOILER-COME(OVER 1100,00000 BTU)
❑ .
AIR CONDITIONER
I have read the hazardous must requirements under Chapter 6.95 of the Cali- ISSUANCE DATE
frmis Health&Safety Code.Sections 25505,25533 and 25534,1 understand that if the NEW RESIDENTIAL MECII. SQ.FT.
building does not currently haven taunt,that it is my responsibility to codify the Occupant
of the requirements which must be met poor o balance ance of a Cenilicam of Occupancy
Owner or authorind agent Date TOTAL: ISSUED BY:
OFFICE