31533 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. 31533
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
LDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
C Lillis C q end' o l'� 2 IT
NER'S ME: O P NE: CONTRACTOR'S NAME: - LIC NO:
N/C CON'TBOLN
•ARCHITECT/ENGINEER: LIC NO: -Cl ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm drat I am licensed ander provision of chapter 9(commercial JOB DESCRIPTION
CW00 with Seal°n]00ty.fDivision 3 ofthe Business and ProfesminCedexnd my license is RESIDENTIAL,
'
�� in full force and effect. PERMIT ISSUANCE
Fly C1SFDWL D KITCHEN REMODEL
�U License Class Conn - APPLIANCES-RESIDENTIAL DADDITION [D PLUMBING RE-PIPE
Dam C'S DECLARATION ARCHITECT'S UI3CLARATION DMULTIUNIT []STRUCTURAL
Oxf/1� I understand my plans shut]be used as public records
PANELS MODIFICATION
J UPT02WAMPS [IINTERIOR [ICHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT
IIIiiK44 W OWNER-BUILDERDECLARATIONCe Contractor's
OVER 1o00AMPS 0BATH REMOD�AIR CDEMOLRI N I-
pp,, 1 hereby affirm 1 am exempt from the Coons Cacho:
License Lew for the
DE�6U
whichf.iIyw
a permi(Section]construct,
Business impandrove,
ve,demolish,
ormny city or roomy SIGNS ELECTRICAL DDTHER
4411 WO which taryssu a permit re conswn,applicant
improve,de ennit t or repair any structure
saii
prior heissiemncaxlsotequirhe the
provisions
visio so for such Permit Licensrile ae Law(Chapter
SPECIAL CIRCUITIMISC.
16mrmarm,wiit painationt Sectio70he.f Doismorif eBassiContraemrs Licenses,kn Chaptrr9
00 not he
ergwithherefrom and
of basis for oft he Business prion. nyvisCode)of TEMP.METER OR POLE INS COMMERCIAL'
6 not he is exempt therefrom and rhe basis for the alleged exemption.Any it Penalty of O NEW BLDG/ADDITION D DEMOLITION
Section 7031.5 by any epplicmlfor apermil subjects N<applicammucivil penalty of POWER DEVICES CTENprrr DFOOD SERVICE
not more an Nfive hundreJ dollars(5500).
F Z>' IMPROVEMENT
6 D Lmawnerof the proprcular myemploardadmthwagesaathei(See. 0,01. nmdess SWIMMING POOL ELECTRIC
will do the work.endNeswcwreia not intended mrof(ered for sale(See.70,P1.Business []OTHER
end Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURE
�' .. property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL.HLECTR
seleaf,however,The building or improvement is sold within one year of co SQ. .FL A ASQ.Ff.
owncr-builder will have the burden of proving that he did not build or improve for put-
' 01 ik� - DEC . 21996
❑I,m owner of the property,am exclusively contracting with licensed amuanots m TOTAL:
comauw the project(Sec.7094,Business and professions C_.,The Cas Li-
camelawdoesnotapplytoanownerofpropertywhobuildsorimprovesthereon,and QTT. PLUMBING PERMIT FEE MY UF LUNtMIINO
who cmmacts for such projects with a contactors)licensed Pursuant o the Contmctor'a
License Law. PERMITISSUANCE 1
❑Imine tanleu .B&P C for this reawn
Owner Dem1qL ALTER-DRAIN&VENT-WATER(CA) - - /' VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE / ttCO�—
I hereby afford under penalty of perjury one of are following decimations: `O
I have and will maintain aCenificaeofC°nsent to self-insure for Workers Compete DRAINS-FLOOR ROOF,AREA,COND. STORIES TYPECONSTRUCDON
sation,az provided for by Section 37W of the Labor Code.for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
El 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of Ne Labor CoNe,far the performance of the work for which this permit is issued GAS-EA.SYSTEM-]INC.4 OUTLETS OCCGROUP APN
My Workers Compensation Insurance carder and Policy number art:
Cartier Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be completed if the permit is for one hundred dollars(s IW) GREASETRAP
PLANCHECK FEF:
or less.)
I really that in the performance ofthe work for which this permit is issued,l shall SEWER-SAND'ARY-STORM EA.21g)Ff.
not employ any Noun in any manner so as to become subject to the Workers'Compen- ENERGY FEE
o z wties Laws of California.Data WATER HEATER WNENT/ELECIR GRADING FEE
z 0 Applicant
y NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSMM,TREATING
1^^ Racoma subject to the Workers Compensation Provisions of Ne mbar Cale,you must SOILS FEE
QWa/ti forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
�z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL FINE. SQ. T. PAI DataptM
V Q I hereby affirm that is a construction lending agency for the performance of -
t+ Ne work for which this permit is issued(Sec.31197.Civ.C.)
U. Lenders Name - TOTAL:
0 U Lenders Address TOTAL: -
I cenify Nat I have read this application end state Nut Ne above information is BUILDING FEE i+
ycorrect.I agree to comply with all city and county ordinances and state laws altruism QTY, MECHANICAL PERMIT FEE
U b building construction,and hereby authorize repcsenatives of this city to enter upon the SEISMIC FEE V
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabllities,judgmems,costs and expenses which may in any way accrue against said City ALTER OR ADD]'O MECH.
in wnsegaence of Ne granting of Nis pc.I,, 'PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM) `
MECHANICAL FEE
SOURCEREGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signature of Applicio/Cmmmctor Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or huddle mountains material HEATING UNIT(In 100,000 BTU),
as defined by the Cupertino Municipal Code,Chapter 9.12,and)Ac Health and Safety
Code.Section 25532(x)^ HEATING UNIT(OVER 100.000 BTU)
E]yes CNo VENTILATION FAN(SINGLE RESID) PAID
Will the applicant m future building seement use equipmem or devices which Data Receipt 0
mit hazardous air conaminams as defined by the Bay Area Air Quality Management BOILER-COMP(lHP OR IW,0011 BTU) - TOTAL.
District? + BOILER-COMP(OVER]W,000 BTU)
L)Yes ❑No
1 have read the ferocious araturid,rairdiereems under Charter 6.95 of Ne Cali- AIR CONDITIONER - ISSUANCE DATE
forma gHealth does&Safety Code,a is 25505,25537 and 25534.1 understand Nm if the NEW RESIDENTIAL MECH. SQ.FT. /fix
buildingd«anotdwhiccommit,have is I,that it ismy uace of.ibllityc notify Nebroacy
of Ne tequiremena which mustM met prior to issuance o(a Cenificve oflkcupamy.
Owner or authorized agent Data TOTAL ISSUED BY:
t
OFFICE'