31201 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES,USE BALL POINT PEN ONLY '
CITY OF CUPERTINO, ' - BUILDING.ELECTRICAL - PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
s BUILDING PROJECT IDENTIFICATION -BUILDING ADDRESS: • SANITARY NO. APPLICATION SUBMITTAL DATI
�7 l:on c/o1in �- 7^g
OW/NNER'S NAME: - PHONE: CO AOR' AME' 1.ICNO:
(�..Q.✓lfJ l ✓ !r �_ 6;1J N/C CONTROL#
RCHITECTMNG EER. LIC NO: ApORS
CONTACT: �( .PH :—./ �� - BU DING PERMITINFO
❑ ConsWtEnC Fecan
es Paid by Applit(Initial)
2 �y3 '( BLDG- ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ❑ El ❑
QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under Prof talons of Chapter 9(commencing JOB DESCRIPTION
WZO with Section 7000)of Division 3 ofthe Business and Professions Code,and my licenieis" PERMIT ISSUANCE - '
full force and effect.
m - El KITCHEN REMODEL
�UzUU License Class o. APPLIANCES-RESIDENTIAL
SFDWL
y6y Dare Contrn actor El ADDITION El PLUMBING R&PIPE
F,p so ARCHITECTS DECLARATION O MULTI-UNIT ❑STRUCTURAL ;
1 oodetstand my plans shall be used as public recerds PANELS
Z rfi ZL - MODIFICATION'S
OZ'-Q _ UPT02W AMPS
rot: Licensed Professional - ❑INTERIOR ❑CHIMNEY REPAIR
oSSSS OWNER-BUILDER DECLARATION 201-1 WUAMPS ,IMPROVEMENT
< ,Thereby affirm that 1 am exempt from the Comectnr's License Law for the OVER 1000 AMPS El BATH REMODELREPAIR El DEMOLITION
[iy5OtLU following reason(Section 7031.5;Business sad Pmfensiuns Code:Any city or county SIGNS ELECTRICAL
❑OTHER
FO^ which requires a Permit to construct,alter,'improve,demolish,or repair any structure
RIXraJ pni iunit nc aI'o reymres the apphcamf hp It fdee igned swte nt SPE CIALCIRCUIT/MISC.
y
that he t llcensedp am m de,m,i,ions fth a ntmct sL e L (Chapter9 ,
0I
(commencing withSection 7W0)ofD ulna 3 ftheB dP f nCd)nr TEMP.METER OR POLE INST. ' O��"
4{t, C that he's exempt therefrom and the basis t the alleged exemption,Any violation of. - ❑NEW BLDG/ADDITION ❑DEMOLITION
YiC] t� Section 7031.5 by any applicant for a permit subjects the applicarn m a civil penalty of POWER DEVICES QTENANT ❑FOODSERVICE
yyyy N not more than Ova hundred dollars 15500). - IMPROVEMENT •.
O ❑I,asowneloftheproperty,army employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the stratum is not intended m offered forsale(Sec.7044,Business ❑OTHER
m and Professions Code:The Cmitracmrs License Law does net apply to an owner of OUTLETS-SWITCHES-FIXTURES Ie_
property who builds or improves thereon,and who does such work himself or through' N his own employees„provided Wal such improvements are not intended or offered lot NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however,the building or improvement is sold within one yearofemapletion,the SQ.FT.FLOOR AREA r $ISQ.FT.
owner-builder will have the burden of proving that he did mi build or improve for pan •
pose of sale.). -
F-1macD
1,as Owner of the Property,am exclusively contracting with licensed nbmm to TOTAL:
on,vuct the project(Sec.7044,Basin.,and Professions Codep The Conaactor's
cense Law does not apply to an owner of property who builds or improves thereon.and QTY PLUMBING PERMIT FEE
MAY a 6Cbt
` who commas bal,ach oraeat,With amntractm(s)licensed pursuant to the Contractor's
PERMIT ISSUANCE
License Law.- _ '
I]'I am exempt un ,D&PCfor this reason _ .
-..
Owner ALTER-DRAIN&VENT-WAIER(EA) 111bRTTS G I
WORKS O ENSA ON DECpiu
LARATION BACK FLOW PROTECT.DEVICE '�
r
unity ofpequry one ofthe following declarations:
ng declarations:FII have and will maintain a Certificate ofConsenno self-insure for Worker's Camped- fDRAINS-FLOOR,ROOF,AREA GOND.
,alien,as provided for by Section 37W df the Labor Code,births performance of the STOPPIS TYPE CONSTRUCTION
work for which this permit is issued. n) FIXTURES-PER TRAP -
❑I have and will maintain Worker's Compensation Insurance,as required by Section - - -
3706ofthe Labor Code,for the perfannanceof the work for which this permit is issued. - GAS-EA.SYSTEM-1 INC.4 OUTLETS OCCGROUP APN
My Workers Compensation Insurance carrier and Policy number ore:
Carrier: Policy No: GAS-EA.SYSTEM-OVER 4(EA) „
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
man.section ncednar hecompleted lffla mmil is future hundred dollars($IW) GREASETRAP ar less.) PLANCHECK FEE
I certify that in the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-not employ anNixonin an STORM EA.2W FT.
p y y Pers y manner so as ro become subject m rhe Workers'Comped- ENERGY FEE
�. sat ion Laws of California.Date
JO - WATER HEATER WNENT/ELECTR
P'Q Applicant - � - GRADING FEE ..
ti NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM)TREATING
P4
beemsm exanptothe Worker's item,or his provisions of the Labor Code you must SOfLS FEE -
GTa forthwith comply with such provisions or permit shall be deemed revoked. WATER SERVICE; e
Q
CONSTRDCTION LENOINGAGENCY NEW RESIDENTIAL?LMB. SQ.FT. PAID
'V O l hereby affirm that is a construction lending agency for the performance of ReceiptN
N the work for which this permit is issued(Sec.3097.Co,C.) - -
Lender's Name TOTAL:
fYa Lenders Address TOTAL:
I certify that 1 have read this application sad stale that the above information is BUILDING FE d O
ws In comet.I agree to comply withal]city andcoumyordinances and state laws relating to QTY. MECHANICAL PERMIT FEE -
V 7 r7 building construction,and hereby outhouze representatives ofthls city to enter upon the SEISMIC FEE
mexec-mentioned property for inspection purposes. •- PERMIT ISSUANCE ELECTRIC FEE
(We)agree m save,indemnify and keep harmless the City of Cupertino against -
liabilities,judgments,cwtsand'expeasex which may inany viayaccros against said City ALTER OR ADD I'D MECH. PLUMBING FEE
inconsequencemi
of the granting of this pert.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CTO 10.000 CFM? MECHANICAL FEE
SOURCE REGULATIONS,
AIk HANDLING UNIT(OVER 10,001)CFM) CONSTRUCTION.TAX
Signamreof Applicam/Contractor EXHAUST GOOD(W/DUCT). HOUSING MITIGATION FEES
_ HAZARDOUS MATERIALS DISCLOSURE
Will theii,dimnte,furore building occupontewre nr handle hamPoox,material HEATING UNIT(TO 100,00)BTU) -
os defined by the Caperton Municipal Code,Chapter 9.12,and the Health and Safety -
Cods,Section 255320? - HEATING UNIT(OVER I0if0011 BTU) ,
❑Yes ❑No -
VENTILATION FAN(SINGLE RESID) PAID
Date ReceiptN
Will the air licant or futurecontandmans a building by apund the
Area
Air utor devices BOILER-C ME OHP OR 100,”BTU
mit hazardous air conmminants as Defined by the Bay Area Air Quality Management TOTAL:
District? r BOILER-COMP(OVER IW,000BTU) '- I
❑Yes F7 No
I have read the hazardous materials requimmetns under Chapter 6.95 of the Cali. - - AIR CONDITIONER ISSUANCE DATE
t r fomia Heahh&Safety,Code,Sections 25505,25533 and 25534.I understand Fiat if the NEW RESIDENTIAL MECH. SQ.FT. '
building does not comntly have a tenant,that it is my nesponeihility to notify the Occupant 7— q 7 .
of the reqirem
uerits which must be met prior to issuance of a Cenificam of Occupancy. - '
Owner or authorized agent - -Date - TOTAL: ISSUED BY:
OFFICE '