31134 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PEPNIIT PLUMBING-MECHANICAL BUILDING.PROJECT HIRNITIF'ICATION 3.1134
BUILDING ADDRESS: - SANITARY NO. . APPLICATION SUBMITTAL DATE
OWNER'SNA H PHONE: ACTOR'S NAME: LIC NO:
+ 9; NIC CONTROL#
ARCHITECT/ENGINEER: Ys�LIC NO: AFS / ❑
`�
. eL`- l .1/ .n✓ Al
CONTACT, PHONE: - Bl11LDING PERMIT INFO
❑'Consultant Fees Paid by.Applicant(Initial) ,BLDG ELECT ; FLUORMELD
❑ lk ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby afford Not 1 ard licensed under provisions of Chapter 9(commencing JOB DESCRIPTION'
,Oy^Z with Become ID00)M❑ivision3ofthe Business end Professions CrWe,anJm license is
�00 i Y PCRMITISSUANCE RESIDENTIAL:
�Un full force wd of t -//
zr�r,,J) License Clea Lic.M "0TL DSFDWL, (:1 KITCHEN REMODEL
yQL Dme Cnnm¢m APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE'.
p.psn - ARCHITECTS DECLAR TION ❑MULTI-UNIT DSTRUL WRAL
understand UP
Z 1 undersnd my plans all M1c used as public records � PANMODIFICATION
OZ
O - TCM.0200AMPS D[NTERIOR [I CHIMNEY REPAIR
F if' Licensed Professional
0 F OWNER-BUILDER I201-1000AMPS IMPROVEMENT
theCervica C 1 hereM1y afford that 1 i exempt from
the nn ranaorx License Lvw for the OVER 1000AMPS El BATH REMODEIJREPAIR DEMOLITION
O L U following reason.(Section]031.5,Basinas mW Professions Code:Any city or county SIGNS ELECTRICAL ^ D OTHER
W W O I. wh eh q v 1 nm t construct It improve demolish' r I' o y trumutt
prim t ice s..n e 1:..rv,m.th ppl' um for such cranit to fl '6 Jstvtement SPECIAL CIRCUI DMISC
[TpQ•+��}
that he licensedp anti the Provisions of the Contractor I'e 1 (Chapter 9
�
E5 0 (commenting wnh Secuon]OW)of Omtsinn3 of Ne Business and Pndesmons COJe)mr TEMP.METER OR POLE INST. COMMERCIAL:
a L C E Nat he is exempt Nemfrom and the basis for the alleged exemption.Any violation of D NEW BLDG/ADDITION []DEMOLITION
x^' Section]831.5 by any.,plieant for a perdu,subjects the applicant m a civil penalty of POWER DEVICES El
W^y
- TENANT.
❑FOOD SERVICE
amore than eve hundred Dollars SSW) IMPROVEMENT SWIMMING POOL i ECTIC
wall thew nk the teis not
untamed
nm J ff ed :al IS 7I44 Business OTHER,
tied Pr E C ds:1 he Contractors License Law does
rad pply i n owner of OUTLET S-SWIi'CHES-FIXTURES OP
property,who luml6o,i naprome,Hereon and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECIR SQ FE
sale.If.however.the building orimprovement is sold within one year of completion,the — .IT.FLOOR AREA ESQ.P-n
owner-builder will have the burden of proving that he did not build or improve for par- I PAID
pose of sale). -
❑ 1,as owner of the m n am exclusive) contracting with licensed comments to
P . Y g
cerawa thoesnot(Sec.]04QBusinessand Professions Code:)The Contractors 1.1t, Q �A]1aO �Cs
xa Law doesnotapply roan with
a cofpmpvrty whatsedpdr i;npro the Connecond TY, PLUM BING PERMIT FEE ��j
who contracts Low. such projects wird v rontmmnr(s)licensed pumwm m the Connector's
License Law. - I
❑Lam exemptunderSw. ;e&PCfmnPERMIT ISSUANCE I r 41-
nisrensnn uurClilINU
ALTER-DRAIN&VENT-WATER(EA). s VALUATION
Owner Dam -
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby uflimt tinder penalty,of Perjury one of the following declarations: _
'•❑I have and will maintain a Certificateuf Consent meal(-insure for Wakcr's Compete- DRAINS-FLOOR,R_OOH AREA,COND. S'I ORIFS 'TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Cade,for the performance of the
work far which this permit is vnime. - FIXTURES-PCR TR AP
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labs Code.for the Performance of the work for which this permit is issued. GAS-EA.SYSTEM-)INC.4 OUTLETS OCC.CROUP APN
-isty-N'mklnn n�i�yea� Pa'cy nunClunrmi�efd GAS-EA,SYSTEM-OVER 4(EA)
< CHRL'IFICATE OF EXEhf1"HON
- ' FR WORKERS' GREASPINUUg'I'I(,WASTEINTCOMPENSAIIONINSURANCC RCEPTOR. I- ^
'! CThis section need not be completed if thet is for one hundred dollars - BUILDING DIVISION FRES
�rd'rGREASETRAI'
or leis.)' - PLANCHECK FEE
I certify that in the performance millet work for which this emlit is issued.i shall SEWER-SANITARY-STORM EA.200 F`E
nm employ any peruses in any manner m us to become subject m Ne Workers'Compete. ENERGY FEB
Ozsation Laws of California.Date - WATER HEATER W/VENTIF.LECI'R
•�12 Applicant GRADING FEE '
G raj NOTICE TO APPLICANT If,'after making this Certifcam of Exemption,you should WATER me SYSTCMIi'RFA'I'ING
becosubjeerm the Worker's Compensation provisions of the pm...Code,you must SOILS FEE
forthwith comply with such provisions or this permit a hall he JeemeJ rewked WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENT[At.PLMB. SQ.FL' PAID
V k for
thanhem isaso(.See 3 lending agency for the perfotmm�c<nf Dem Raeiptg
ll�0 f^e the work which this permit is issued(Sec.3(19],Civ,CJ
O U Lenders Name _ TOTAL:
lender's Atldrcns 'TOTAL:
a1 certify that 1 hove read Nis application unJ mate Nat the ahnve infmmnnion is t BUILDING 193E
rV7) convert)agree to comply with a 11 city vad cimmy ordinances and state low,mlatingW QTY, MECHANICAL PERMIT FEE -
V F7 building construction,and hereby authorize representatives of this city to enter upon the SEISM IC FEE
above mentioned property for inspection purposes. PERMIT ISSUANCE(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilides,judgmenla.eats and expenses which may in any way accrue against laid City ALT ER OR AILD IV MECH.
I.consPLUMBING IEC
equea of he tgranting of Nis permit
' 'APPLICANT UNDERSTANDSAND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111000 CI'M) MECHANICAL,17CE" art
SOURCE REGULA'T'IONS, J
�j AIR HANDLING UNIT(OVER I0AXI CPM)
CONSTRUCTIONTAX
Signature of ApplicenVComractar: Dat EXHAUST HOOD DIMUCT) - HOUSINGMITIGA TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willbeapplieant or furore building occupant smom handle hazanlnus matenal HEATING UNH(TO 100,000 BTU)
ea defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25.532(u)1 HEATING ON[r(OVER 100.000 BTU) '
❑Yess ❑No PAID .
1 VENTILATION BAN(SINGLE RE.SID), Date Receipt p
Will the applicant or future building rocupam use equipment or devices which BOILER-GDMP(3HPOR100.000BTU)
emit hazardous air anttaminams as defined by the Bay Area Air Quality Management. TOTAL:District'
❑Yee E]No BOILER-COMP(OVER 100,000 BTU)
I have mad the hcarokas materialsmccurnts under Chapter 6,95 of the Cali-. AIR CONDO TONER
re4 P ISSUANCE DATE
fila Health&Safety Code,Sections 255(1.5,25533 and 25534,1 understand that if the w� NEW RESIDENTIAL MUCH. SQ.I7. �
building does not currently have a mutant.that it is my responsibility of amify the occupant '
of Ne requirements which must be met prions issuance of a Certificate of Decupawy. • ,
Owner or authorial agent Dane TOTAL_ ISSUED BY:
OFFICE