31259 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 31259
BUILDING DIVISION A ICATION/PFRMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: NTSANITARY NO, APPLICATION SUBMITTAL DATI
po iZ b !a
OWN 'S 1{1 E: - CONTRACTOR'S NAME: LIC NO: NIC _ W
(�J( CONIR/O
i
.ARCHITECT/ENGINEER: L ADDRESS: El
CONTACT. ONBUILDING PERMIT INFO
/ j►A \� )4Cansultant Fecs Paid by Applicant(Initial) a. BLD F.L PLUMB _ MECH
LICENSED CONITRACTOItS DECLARAT N QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QRZ with Sectimi7l"Of Division 3ofthc Binmuessand Profensinns CodgandPERMIT ISSUANCE _Smylicense is RESIDENTIAL,
DDENTIAL,
�00
W in full force and effect, T ❑SFDWL O KITCHEN REMODEL
�UU Date 0Class Con APPLIANCES-RFSIDENTIA DADDITION ❑PLUMBING RF-PIPE
�Z�ul Date Contractor
LL
ARCHITECTS URCLlicrec ON [I MULTI-UNIT []STRUCTURAL
y O�Z 1 undersand my plans Miall be used us public records PANELS MODIFICATION
OZ.-aw UPTO 200 AMPS INTERIOR El CHIMNEY REPAIR
r� J Licensed Ponessirnal 2041000AMPS IMPROVEMENT
3 OWNER-BUILDER DECLARATION OVER I(NIIIAMPS [I BATH REMODL'UREPAIR �DEMOLffION
0 M a 1 masa affirm that 11. exempt from Ne Contractors Liana Lew for thf
xSxOyV following reason.(Stttion]OJLS.Businux and Professions Code:Any city or county SIGNS ELECfRICAI. (]OTHER
ar W el,0 E' which rectums a permit to consumer.alter,improve.demolish.or repair any swnure
.primw.hi ...ce,al.requires theepplieam torxuch pertninn file uxigmd almanal SPECIAL CIRCUIT C.
;!{yNat be is licensed pursueala the provisions of the Contructnr s License Luw(041119W..CC (commencing with Section 70(g1)of Divisic.3afthe Business and Professions Cvxm)or TEMP.METERORPOLEINST. COMMERCIAL:.
a c Y Not rte is exempt therefrom and the basis for Me alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4• Section 7031.5 byany applicant for.permit subjects Neapplicanuoa civil penalty of POWER DEVICES
Z> []TENANT ❑FOODSERVICE
L. not more Nan f o,hundred dollars(5500).
C�aO I]1,asownerofthepmpeny,ormyemployees with wages a,their sale compensalion, SWIMMING POOL ELECTRIC IMPROVEMENT
CX will do the work,and the structure isna imendeJorOffered lmsumgre.7014,Business []OTHER
and Professions Code:The Contractor's License Law dues not apply ,,an owner of OUTLETS-SWITCHES-FlXTURES
propeny who build.or improve.thereon,and who does such work himself m through
his own employees,provided tom such improvements are no,immided or ofered for NEW RESIDENTIAL ELECTR SQ IT.
sale.IL however,the building or improvement is sold within one ycarrofcompletion,the SQ. f.FLOOR AREA S/SQ.FT,
owneo-builder will have the burden of proving that he did not build or improve for put- kish TO 16
pose of
❑I,as owner.j the Sec.70,em exclusively convecting with licensed capaat tars m
construes des not (Slytoan BusinessitProfusions Code)The Commcton, nd ��sg
nuLaw dmanmah Projects
with
aofpmpcny whored pursanpmvw Commences
License
QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contractors)licensed pursuant to the Commcmrs
License Lawe.er PERMIT ISSUANCE
G tont exempt under Sec. fm,B&YCNis mson
a
Owner Date ALTER-DRAIN&VENT-WATER(EG VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE 2 sis �
I hereby affirm under penalty of perjury one of the fallowing declamtirns:
• Muse and will maintain a Certificate of Consent o self-insure for Workers Compen- DRAINS-FLOOR,ROOR,AREA,GOND. STORIES 'TYPE CONSTRUCTION
section,as provided for by Section 37M of Ie bLadu Code,for the performance of the
work for which this permit in issued. FIXTURES-PER TRAP DEC 11
0 1 have and will maintain Wmkcrs Compensation Insurance,m required Similarby Sian
MOB
37M.fNe Labor Com.her the pcommusnceof the work far which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Camiev Policy No: GAS-EA.SYSTEM-OVER 4PEA) CITY Or UUYt `IINO
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRE- SE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
Obis sedinn need nm be completed if the Mrmit isfm oro hundrtddollars(f 100) GREASETRAP
i nr laud - PLANCHECK FEE LUC!Arg
I certify that in the performance of Ne work for which this pemat is issued.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workers Compete ENERGY FEE
OZ cairn Laws of California.Date WATER IIEATER WIVENMELECIR
z O Applicant GRADING FEE
y NOTICE TO APPLICANT':IL after making this Cerificate of Exemption,ya.should WATER SY$TEM/TREATING
abevomesubject to the Worker.Compensation provisions of the Labor Code,you must SOILS HE
LiI forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
'a q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.fT. PAID
.7 z
U. O I hereby eRrm that here is a construction, ding agency for the performance of 'Dant Receipte
the work for which Nis permit is issued(Sec.YN7.J(N7,Civ.C.)
U.
(✓ LenJeh Name TOTAL: '
W Lender's Addressro
L:
P. 1 cenify that I have read this application and state that the above information is BUILDING FEE
rcorrect.l agree to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
7A O
V rZ building convection,and hereby moth int representatives of this city to enter upon the SEISMIC FEF,
abose.rom tinned property for inspection purpaus. PERMIT ISSUANCE
(We)agree to save,indemnify and keep Visionless Ne City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in anyway acerae against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER Iff"CFM) CONSTRUCTION TAX
Signature ofA,licanJConmcuu Data EXHAUST HOOD(W/DUC i HOUSING MITIGATION HE
HAZARDOUS MATERIALS DISCLOSURE
Will lie applicant or into=building occupant stere or handle h.uishow material HEATING UNIT(TO 100.00)BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
E]Yes GNo VENTILATION PANS INGLE RESID) PAID
Will the applicant or future building occupant use equipment mdevices which Data Receipt N
mu hazardous air emnaminaus as defined by the Bay Arca Air Quality Management BOILER-COMP(3HPOR 100,fgp RTU) TOTAL:
Dtslna? BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No
I have read Ne hazardous materials reoptirement under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE If
fomia Health&Safety C de.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building docs not curetnly have.Vernon,that it is my responsibility to notify Ne occupant
of the requirements which must he met pdm to issuance of.Certificate of Occupancy.
Owner or autbrdzul agent Data ISSUED BY:
OFFICE