31210 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO. 31210 � ^L � O
J{
13UILDINGADDRESS'.
e
jo I ti �N �so�l Av.
SANITARY NO.
APPLICATION SUBMITTAL DATE
o
1' 'S AMh: ✓in'1 PHO
5Jl _
TR
CONACTOR'S NAME LIC NO:
NIC
CONTROL
HITLCT/ENGINEER: LIC NO
ADDRESS
ONTACT: PHONE:
•
- E:1BUILDING
Consultant Fees Paid by Applicant (Initial)
PF,RMIT INFO
L ELECT L MEED
❑
LICHNSEDCONTRACTOR'S DECLARATION
1 hereby affmn mat 1 am licensed under provisions of Chapmr 9 (commencing
zwith Sar10)of Divisien3onhe Rosiness and Professions Code. and my license is
in full forcceeand di'ca
U License ClassLie,k
W Date Controcmr
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑KITCHEN REMODEL
❑ADDITION LUMBING RF -PIPE
❑ MULTI -ON] T TRUCTURAL '
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
HREMODELIREPAIR ❑DEMOLITION
OTHER
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
y ARCHITECTS DECLARATION
Z Iundersand in, plar,uall M used as puhlicrecnrdc
Q
PANELS
UPTO20oAMPS
W Licured Professional
OWNER -BUILDER DECLARATION
Q 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
U following reason. (Section 7031.5. Business and Professions Cele: Any city or county
ywhich requires a permit m cooamn, altar, unprove. Jmuulish. or repair any .structure
prior to its issuance. also reyvire. the applicant for such Permit o file a signedstatemem
That he is licensed pursuanno the proviome cifthe Commmors License Low (Chapmf9
O (commmdng with Section 7000).f Division 3afthe Busincasvnd Prnfnanns Cde)or
C that he In exempt Nerefcan and the basic for the alleged exemption. Any violation of—
Section
Section?031.5 by any applicant for a mnnitsubjects Ne applicant to a civil penalty of
oat moa Nan five hundred dollars ($500).
C1, as owner of the ocr,orm Ioces with wages as their sole enol tion,
Q❑ du P c Yetin y g pens.
e will do the work. and Nc strucmais not intended or offered for sale (Sec.76W, Business❑OTHER
ce and Professions Cole: The ContrLicense law does not apply to mi owner of
actor's
property who bui oto or improves thcrnnl, and who Jou such work himself or through
his own employees, provided that such improvements we not intended or offered for
sale. If, however. the building or improvement is sold within one year of completion, the
owner -builder will have the hamen of proving hat he did not huild or improve for pur-
h as i the p of the pec. 734 , Business ns and contracting Cod licensed nmaamnrs i.
❑01,vas,ow)with
amxwa the project (Sec. 7344, and rroren;mx eode:Yrne cmmmemrn l.o-
cause Law does our apply to air owner of Iampaity who builds or iniproves thereon, and
who convects for such prvjeas with a commarmrfs) licensed pursuant m Ne Contractors
License Lit,
FA l and mnpl under Sec. , B & PC for this reason
201-1000AMPS
QyEµ I(M)BAMfS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
COMMERCIAL'
BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑FOODSIERVICE
IMPROVEMENT
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - PEG URF,S
NEW RESIDENTIAL ELECTS SQ FT.
SQ. FT.1 O A F,
MAY e 8 RECO
CITY UI- wrEH l'INU
YSQ. FT
�
QTY. PLUMBING PERMIT FEE
PERMITISSUANCE
ALTER -DRAIN&VENT-WATER(EA)
Owner Dae
VALUATION
t^y
VV
WORKF..R'SCOMPBNSATIONDECI,ARA'1'ION
1 hereby affirm under Penalty of perjury one of the following declarations:
I have and will maintain a Certificate ofCommml toself-innule for Workers Compete
t ns provided rim by Smtinn 391X1 of Nc Lahnr Calc, for the perfornwncc of the
work for which this formal is issued.
1 have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Cmnleneation Insurance carrier and Policy number arc:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSSI ION INSURANCE
(Trisection need not M1e completed ifthe permit is for one hundeaddvllars(S1 W)
or less.)
1 coolly the, In the pedormanccal'Iha cork for wbidh ohn permit -r iswash Lshall
not employ any person in any manner so as to become subjecuo the WorkmYCompcm
7 scion taws of Califomih Date
D Applicant
BACKITLOWPROTEC'T.DEVLCE
DRAINS- FLOOR, ROOF, AR EA, CONE.
STO
OCC. GROUP
TYPP, CONSTRUCTION
APN
TS:FIXI ORES - PER TRAP
GAS - FA. SYSTEM- I INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASOINDUS'I RI. WASTE IN TRCEPI'OR
BUILDING DIVISION FEES
GREASE TRAP
PLANCHECK FEE
SF,WEN-SANITARY-S'fORM F.A. I'I'.
ENERGY PER
WATER HEATER WNENT/ELECTR
GRADING FEE
NOTICE TO APPLICANT: 11, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation Provisions of the labor Code, you must
fnnhwith comply with such provisions nobs Permit snxll be decnmJ revoked.
CONSTRUCTION LENDING AGENCY
Ihemby affirm that hcm isaconstruction lending agency for the performance of
-t Ihewnrk for which lhix permit is issued (Sec. 3099, Civ. CJ
r'sName
�Lawk
LenderAddress AJd
y� 1 certify thin have read this npplleation nnJ stnm ILnt the aMwe inlimnuviun In
/] comma. l agree to comply with all cityand county ordinances and state laws relarm,to
buildingcoromuctim,anit hembyaalhim,cm,reso mives Uflhiscitym enter apo. Ne
.Mice-entioned property for inspection purpose
ms.
(We) agree e, save, indemnify and keep harmless the Cay of Cupertino against
liabilities,judgments. costs and salivates which mayinany way acerae ageinclaaid City
consequen¢ of the granting of thin permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOUR EREC. �GULATION
�7A/11�e�{�/ �/
/
WATER SYSTEWfREATING
Sol" FEE
WATER SERVICE?
PAID
Dam Rceiplp
NEW RESIDENTIAL PLMB. SQ. FT.
-
TOTAL:
I
IIUILDLN
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
1'F.NMI'I' ISSUANCE
ELECTRIC FEE
PLUM BING FE. `
ALTER OR ADD TO SUCH.
AIR HANDLING UNIT (TO 10,00OCFM)
MECHANICAl. FEE
AIR HANDLING UNIT (OVER IILgq CFM)
CONS '1'RUCTION TAX
Signature of Applican/Conuacmr Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingoccup.nt stem or handle howdnun material
as defined by Ne Cupertino Municipal Cole. Chapter 9,12, and that Health and Safety
Cedq Section 25532bul
❑Yes No
Will the applicant or future building occupant use equipment or devices which
tit haurdous air <nnmminanls as defined by the Bay Arm Air Quality Management
Ina'TOTAL:
0Yex ON.
I bulamad the hnardoo mntadals regnirencithundor, Chapter 6,95 (,fine Cal'
lirmia Health & Safety Code. Sections 25wn it P 533 mJ 25534. I ufit,nJ that itthc
building doesnot,as hist' have Own it is myre of. bilirymnotify Nooecupant
of lbs rcquirtme iw wM1ieh moa M1emet rior to iswnne•afo CenifcttnlO,,up nay.
EXHAUST HOOD(WMUC)
HOUSING MITIGATION FEE
HEAT) NO UNIT 00100.000 BTU)
HEATING UNIT (OVER 110,000 BTU)
PAID
Dae Receipt
VENTILATION CAN (SINGLE RESIDE
BOILER - COMP (3HP OR 100,000 BTU)
'
BOILER -COMP (OVER 1 00.0110 BTU)
AIRCONDITIONER
ISSUANCE DATE
ISSUED BY
NEW R[SLDENTIAL MECH. SQ. FT.
Owner or auNonud agent Dam
TOTAL
OFFICE