31463 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO - BUILDING-ELECTRICAL. PIRMITNO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 31463
BUILDING ADDRESS: - / /ISANITARY NO. APPLICATION SUBMITTAL DATE
IV
D ;4 ME: P1 C]j'�C�_/��^ CO RACT( ACT(; F.: IC NO: -
e�L•C.b%[( Gly— N/C CONTROL to
A HI'IECT GINEER: LIC NO: O E. ❑ -
CONTACT:, PHONE: BUILDING PERMIT INFO
" ' ❑ Consultant Pees Paid by Applicant(InIt1Rp' BLDG ELECT Oil MECH
❑ ❑' ❑
LICENSED CONTRACTORS DECLARATION QTY HLECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCR PTIO '
�QRZ with Sedinn]tNNOof Division Business and Prolexsions Cade,and rylumosais R SID NTIA :
OO in fullforce and IT PERMIT ISSUANCE ��_I_
� - - - ❑SFDWL .❑KITCHEN REMODEL.
FFQ,V License Cl ass Lic.N -
fna{E6{ Dare Contractor APPLIANCES-RESIDENTIAL
Z ❑ADDITION ❑PLUAfBING RF.PIPE
[., t, 9RC1111-1 S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
PANELS
Z O ij I undersmnd my plans shill he used m public mands - ^ MODIFICATION
OZ UP T02WAMPS �.
O ❑INTERIOR ❑CHIMNEY REPAIR
9 0 ul Licensed Professional 2(11ER I AMPS IMPROVEMENT
�d J that I a -BUILDER m DECLARATION OVER IINI(IAMPS,. ❑ TH RI.M DE EPAIR ❑D•h OLITION
C'�W Q I hereby affirm that 1 um emmpt from the Cnmmetor's Licenve Law for the
O L U following urian.(Semiatn 7031.5.Business and Ihofessims Code:Any city or county SIGNS ELECTRICAL OTHER
F O which requires a permil to construct,alter,improve,demolish,or repair any structure
qqqq prior to its issuance,also requimas the applicant for such scomil in File a signed statement SPECIAL CIRCUITIMISC.
yNatheit Llceaedpursuanuo the provisions of,hc Colon rs License Law(Chapter 9
00 (commencing with gealion]INIIB of pivisinn7olThc Business unA Professions Cade)or. r, TEMP.METHR OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION
9 ",N
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penullynf POWER DEVICES ❑TENANT ❑FOOD SERVICE
e } not mom Nan five hundred dollars O5W). - IMPROVEMENT
QQ1,as owner ofthe properly,ormy employees with wages a their sole compensation, SWIMMING POOL ELECTRIC
will Aotlm work,undlbe strticrmis not intended or offered formic(Sec.]044,Business 0 ER
aand Probations Cafe:The Contrecmes License Law costs not apply to an owner of 013TI:IETS-SWITCHES-FIXTURES +
properly who builds or improves thereon,and what does such work himself or through
his own emno
employees,provided that such improvements arc t imended nr offered for NEW RESIDENTIAL ELECfR SQ rL
sale JL however.the buildingor impmvemem is cold within one yearofinmplction,the SQ.IT..FLOOR AREA ,$/SQ.f7
owner-builder will have the burdenofpmving that he did not build or improve for Pur-
- pose owner
wne - !'i A p
❑I.as
rob the pmpeny.am exclusively contracting with licensed commcmrs ns ' TOTAL: FFF r I't
construct the project(Sec.7044,Business and Professions Cade:)The Conlmctor's Li-
ceuse Law does not applyroan owner atfpngmdy who builds niimprom,thereof.air d QTy. PLUMBING PERMIT" -FEE DEC �,{/ 1996
who sucpursuant contracts for h projects with a contractors)licensed pursuano the Contractors
License Law:
❑ 1 um exempt under Sec. ,B&P C for Nis reason PERMIT ISSUANCE (/ -
OwnerDate ALTER-DRAIN& 1`tic -WATHR(HA) L
WORKER'S COMPENSATION DECLARATION BACK FLOWPROTECT.DEVICH
I heaby affrni rmdez penalty of perjury one of Nc following declarations
•❑I have and will maintain a Certificate of Consent to self-insure for Workers Compete DRAINS-FLOOR,ROOF.AREA,GOND. ,STORIES - TYPP,CONSTRUCTION
cation,as provided for by Section 3700 of the Labor Code,fonhe peifnrframe of the - '
work for which this permit it isaucd. FIXTURES-PER TRAP _
I have and will maintain Workers Compensation Lasumnce,as oximmd by Section
3] I ofthe Labor Cale,for the performace ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 DO I'LETS
OCC. .ANN
My Workers Countermand lnmrance eardier and Policy number ore: -
Cartier: Policy No.; GAS-HA.SYSTEM-OVER 4BEG -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRI-WASTE INTERCEPTOR _
T his section need not hccdmplete l if the permit is for one hundreddollars(8100) BUILDING DIVISION FRES
•or lass) sGREASETRAP PLANCHF.CK PEE .. ,
I mrody that in the perfoimanceofthe work for which this permit is issuer,I shall SEWER-SANITARY-STORM EA.2013 FT.
ata employ any person in any manner sat u m become subject ro Ne Workers Cnmpen- ENERGY FEE
Z sation Laws of California.Date
. z0 Applicant WATER IIEATEEWNENT?;LECTR ♦g/p�I GRADING ME
Ir V] NOTICE TO APPLICANT,If.after making this Certificate of Exemption,You should WATER SYS'1'EM/TRFATINO
a5 become subject to the Worker's Compensation peen.ions of the Labor Code,you must _ SOILS FEE
LTJ fanhwid,comply with such pmvisionsnMis perrund, hall be darts revoked. WATER SERVICH - s
U�1rCONSTRIICmLENDING AGENCY - NEW RESIDENTIAL PLMB. SQ.FT ' s PAID
Ihcrehy affirm nh:e there ixncmisnmslmctinn lending agency for performance of Data Rettiprp
1 WrF" perthe work for which this mit is issued(Ser.319].Civ.CJ
Lenders Nome - +' TOTAL:
Lender's Address - - - TOTAL: y
L!' I certify that I have rtad this application and slate that Ne above information is BUILDING FEE
Z! emrim,I agree to comply with all city and county ordinances and slate laws mlaling In QTY. MECHANICAL PERMIT FEF.
G.Z building construction,and hereby authorize rtpssantatives of this city to enter upon the SEISMIC PEE
" above-mentioned pmpeny for invocation purposes i - ,
PERMIT ISSUANCE
(We)agree to save,indemnify and keep handlesnos the City of Cupertiagainst ELECTRIC FEE '
liabilities,judgmrnu.mdomid expenses which may inoty way acemeagainstsmil City ALTER Olt ADD'TO MECIL
- consequence ofte g
hrantingof this permit PLUMBING PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,(0)CFM)
'.
SOU RGfi�GULATIONS ^ MECHANICAL I'EE
AIN HANDLING UNIT(OVER 10.000 CPA) CONSTRUCTION TAX
S' azure of Applicant/Carmuctor Data EXHAUST HOLD(W/DUCT) HOUSING MITIGATION ME
MATERIALS DISCLOSU
' Willthe applicant or boom fooldi ng occupant more or handle hazaNaus material HEATING UNIT(TO I001,000 BTU)
as defined by the Cupertino Municipal Code.Chapam 9.12,and this,Health and Safety
r i Coda,Section 25532(x)? - HEATING UNITIOVER 100.000 BT UI -
❑Yes ❑No
JS
VENTILATION PAN(SINGLE RESID)" - ' PAID
Date Rmeiptp
Will'he applicant orfuture building occupantyAeyuipmcuordeviceswhich BOILRR-COMP(3HP OR I pi HTU)
emit haxmdnus air contaminants as defined by the Bay Arca Air Quality Management TOTAL:
UisincfN
' ❑Yes ON. BOILER._COMP(OVER I00,0113 BTU)
I have read the hazararus materials AIR CONDITIONER ISSUANCE DATE
requirememx under Chapter 6.95 of the Cali- _
forms Heahh&Safety Gale,Sections 255115,25533atW 25534.1 mulamnnt I Nut if the NEW RMIDEAGOAL MECH. SQ.PI'. '
building does nm cunenlly have a,mann,that it is my responsibility to m5fy be occupant
of the requirements which must be met prior to burnme of a Cenifcata of @capon,
Owncriammonudogcm I Date TOTAL: . ISSUED BY:
OFFICE r