31345 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. a.a �'a A
BUILDING DIVISION APPLICATION/PERMIT PLUMBRNG-MECHANICAL , . '3 3 4
BUILDING PROJECT IDF.NTIFICAI']ON
BUILDING ADDRFSSO�1/ '/ I SANITARY NO. APPLICATION SUBMITTAL DATI
OWNER'SN �� / _ PHQ1j ^ A710 COM
{zV1`0.6 � NIC CONTROL M
ENGINEER: *
ADDM 1�fe
13,�067 I n ❑
CONTACT: n PHONE: `JJ (' BUILDING PERMIT INFO
s.N — -M_ 64;� ❑ Consultant Fees Pals'by Applicant(Initial) BLDG - ELE❑CT PLUMB M C
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 ren licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
'Z ith SecamIt100)of Division 3ofthe Busineesand Professions Code.andmylicenuis RESIDENTIAL:
�O w PERMIT ISSUANCE
Iy_ in full force and etteriv /-`� ❑SFDWI. F1 KITCHEN REMODEL
�UZ�j License Cls (/ Lic.MQ APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
�6L Dae Contractor
N�=yt ARCHITECTS UECLAR 1 PANELS - ❑MULTI-UNIT ❑MODIFI STRUCTURAL
MODIFICATION Z O h QZ 1 understand my plans shall be used as public seconds MODIFlCATION
024- UP TO 200 AMPS [I INTERIOR [I CHIMNEY REPAIR
Licensed Professional 201dfNp AMPS IMPROVEMENT
�,.••44� OWNER-BUILDER DECLARATION OVER Itl00AMl'S -
DEATH REMODEUREPAIR [I DEMOLITION
66,,S'W 6 I hereby affirm that I am exempt from the Contractor's License Law for the '
6l�0.0 fallowing reason.(Section 7031.5,Business unit Professions Code:Anyciry or county SIGNS ELECTRICAL HER
4411 ea LL� which requires a permit to construct,alrer,improve,demolish,or repair any structure
prior to its is uetue,alto requircsthe applieam fmrsuch pemtivo film signed cmtemem SPECIAL CIRCUITaHSC.
ythat he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
Qf (commencing with Section]WO)of Division 3 of the Boinces and Professions Csde)m TEMP.METER OR POL ST. COMMERCIAL:
oC that he is exempt therefrom and the basis for the alleged exemption:Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
4• Section 7031.5 by any applicant for o permiuu6jon,s the applicant I..civil penalty of POWER DEVICES
=rn []TENANT ❑FOOD SERVICE
JJ t marc than five hundred dollar y employees
bbd wi Lo the as lkofthe.cal property,(it myyemntended with eredf r their sole 044,8 sines SWIMMING OL ELECTRIC IMPROVEMENT ,t
pW C will dothewmk,eodthehe Con.isnots License otteudfinetsale,,Iy to an,Nosiness ❑OTHER
j and Professions Cod.:The Con the Cars License taw does not apply to an owner of OUTL -SWITCHES-FI%TURPS
6'3^ his o ny who builds or improves thereon,and who dcea such work himself or through t
his own employees.PnrvidW that such improvements arc not intended or offered for NARESIDEbUIALELECTR SQ
sale.If,however,the building or improvement is sold within one year ofcompletion,the SQ.PI'.FLUTNU.
mer-builder will have the burden of proving that he did not build or improve for pur-
pose ofault.).❑I,asownenof the property,um exclusively comructing with licensed Colntractors toTOTA '.w`. Q.konstnat Ne projC,(Sec.7044,Bsiness send Profession.Cade:)The Comrectr's Li- .NOV21c se Law does not apply to an owner of proprny who builds or improves theman.and Q'y. PLUMBING PERMIT E
who contractsfor such projects with a contmemrs)licensed Pursuantto Ne Commucuss 1I'1 )IF VUr
Llcenae Law. . PERMIT ISSUANCE
1 ao exempt under Sec. - ,B&P C for this reason
Owner Dam
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /w✓
I herehy affirm under penalty of perjury one mf the following declaretiam:
❑Ihaveand will maintainaCenificmeofConuntmulf-insure for WorkeraCompen- DRAINS-FLOOR,ROOK AREA,CONTI. STORIES TYPECONSTRUCfION
sedan,as provided for by Section 1700 of the Labor Code,for the performance of the
w rk for which this permit is issued. 'FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
300 of the Labra Cods,f�o/r�the performance ofthe work for which th' pemi
rt is issued. GAS-EA.SYSTEM-I INC.40 LLT$ - OCC.GROUP APN
My Worke/�aR�'J�p�/yry�'y�}F,color/p/'�'�.I�1 tcjIartier and Poli n
Carrier L(�—`=�-LI(� prilicyN .. 150 GAS-EA.SYSTEM-0 X
4(EA) �2
CERTIFICATE OF EXEMPTION FROM WORKERS' j
COMPENSATION INSURANCE I GREASFIINDUS ASTE INTERCEPTOR BUILDING DIVISION FEES
(This semlomoeed not be completed lithe Permit is for one hundreddollon,F$U0) GREASE TR
m less.) PLANCHECK PUT
I certify that in the performance man,work for which this permit is issued,l shall SEWE -SANITARY-STORM PA.200 PT.
not employ any person in soy manner so as to became subject to the Workers'Compen- ENERGY FEE
�.., action Laws of California.Date WATER HEATER WNENT/ELECTR
0 Applicant GRADING FEE
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should WATER SYSTEMOREATING
become subject to the Workers Compensation provisions of the labor Cao you most SOILS FEE
{ail forthwith comply with such provisions or this Permit shall he deemed revoked. WXTIiR SERVICE
G 0
CONS0NLENDING AGFNCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
V Thereby affirm at Ndon,
is is.eonstmainn le Wing agency fm the performance of D ReceiptM
{L
[[[err the work for which this pemtit is issued(Sec.3097,Civ,CJ
Lenders Name TOTAL:
Lenders Address TOTAL: -
,�{rs 1 certify that I have uud this application and smm that the above information is BUILDING FEE
i-1 fan comet.I since to comply with all city and county ordinances and state laws saluting to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby connote representatives ofthis city to enter upon the
SEISMIC FEE
above-mentimrM property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep ha ibleas the City of Caperton against ELECTRIC FEE
liabilities,judgments,cows and expenses which may in any way acerae against said City ALTERORADDTOMECH. PLUMBING FEE
in consepoence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO M."CPM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,01M CFM) CONSTRUCTIONTAX
Signature of ApplicantlContmnor Date EXHAUST FOOD DODUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will to applicant or future building occupatnstorc or handle hazardous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cade,Section 25532(x)1 HEATING UNIT(OVER 100,000 BTU) O)
❑Yes - o PMD 2
VENTILATION FAN(SINGLE RESID) Dae Receiptis
! Will the applicant m fusee building use equipment or devices which BOILER-COMP OHP OR 11X1,000 BTU)
emir hazadnus air constructionsc-defined by by the the B Bey Ares Air Quality Management TOTAL:
District?
❑Yea //RI, U)BOILER-COMP(OVER 100,000 BT. �
Ihave read ra
dee hand us materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER 1 $DANCE.ATF.
fomia Health&Safety Ca ,Sections 25505,25533 and 25534.1 undersmnd that if the NEW RESIDENTIAL MECH. SQ.FT
iafdhcngilrcs a umntly have lase san itmy is � t - -
ofthe a: met, in to issueneemfa Coro
ility t eo
Ow or use noted agents Data TOTAL: O ISSUED BY:
OFFICE