31202 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOr BUILDING-ELECTRICAL - PERMIT NO. /� /�O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL - J L L
4. BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: I
?�9 � � �^ 6lDc✓� r SANITARY NO. ' APPLICATION SUBMITTAL DATE
O NER'SNAME: PHOJE: CO TRAC'`OR'S NA A.LIC NO: `•� • ^ (.
/—.��0, I G✓ (.� �LS(�'635Y NEC
,4 CONTROLM
RCHITECTIEN LIC NO: ADDRESS: - - ❑.
CONTACT. PHONE: BUILDI PE IT INF
❑ Consultant Fees Paid by Applicant(Initial) BLDG. E PLU MECH
❑ ❑'
LICENSED CONTRACTOR'S DECLARATION, QTY. ELECTRIC PERMIT FEE
I hereby affirm mat I am licensed under and
Professions
ofs Code, 9(commencing ,JOB DESCRIPTION
Cz with Section 9000)ofOivision3uf the Business and Prnfcasione Code,and my license is
O in full force and effect. PERMIT ISSUANCE
VZ U� License Class Lic,p WL ❑KITCHEN REMODEL
rnQ Dam _ Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
z C ARCHITECT'S DECLARATION• PANELS
UPT02 OMULTI-UNIT ❑MODIFI MODIFICATION O Z Z` I understand my plans shall be used as Public records MODIFICATION
C UPT0200 AMPS
¢1 Licensed Pr tevsr 1 - El INTERIOR ❑CHIMNEY REPAIR
201-IOOOAMPS� - IMPROVEMENT
OWNER-BUILDERexemptDECLARATION OVER INS)AMPS ❑BATH REMODEUREPAIR 11DEMOI.ITION
I herebyaffirm.. 1 am exempt f the Contractor's t Linens 1 for the
?p5,O4V
following (e cion]omm Bus nes and rProf Code e y m or county ❑OTHER _
which requires' z permit t n.t t Iter.'top demolish. 'pas any structure SIGNS GLECTRICAI. t,
y
Prior to itsissa I requires the applicant fsuch Permit tfile asigned statement SPECIAL CIRCUIT/MISC.
athat he is licensed purc a meProvisions of the Centimeters L (Chapter9
00
(Oncommengwth Section 7")of Division 3 ofdaBusiness add Pro(..iaC.dc)6r TEMP.METER OR POLE INST. COMMERCIALS
a o[ that he is exempt therefrom and the basis for the alleged exemption.Any violation of - ❑N W BLDG/ADDITION [I DEMOLITION
at.fir ln�.
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
not mare man file hundred dollars($51g)). - NANT- ❑FOOD SERVICE
G ❑'1,as owner of the Property.or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC MOVEMENT
will do the work,add the structure is butimendedmalfired for sale(See 701 Business ❑OTHER
and Professions Code:The Cnnvamor'e License law dins not apply to an owner of OUTLETS-SWITCHES-FIXTURES -
Property who builds or improves thereon,and who does such work himself or trough
• his own employees,provided moo such ImprovemerNme,not intended.,offered for NEW RESIDENTIAL ELMTR SQ FT
sale.ILhowever,the builJing.rimprovemem is sold within ane year of completion,rhe - SQ.FT.FLOOR AREA $/SQ.ET.
owner-builder will have the burden of proving that he did act build or improve for parry - ti
pace of sale).
❑h as owner of the property,am exclusively contracting with licensed contractors to - TOTAL:
ome "to project(Sec.7044,Busher,and Profoasions Cede)The Contractor's Li-
censeLaw does mtmd,manowner.f propeny who buildout improves thereon,and QTY, PLUMBING PERMIT FEE
who convects for so leets with,comemoubs)licensed pursuant to the ContracmJs
License Law. PERMIT ISSUANCE
❑I am exempt it ,B&P C fonhis reason -
Owner m
ALTER=DRAIN&VENT-WATER(EA) ML A eO
WOR AS M ENSAT ON DECLARATION BACK FLOW PROTECT.DEVICE
the y,ffinn oder pe ally of perjury Une of me following declarations: - _ r - -
❑Lha ctaidwillerm 71 naCenificare of Cunsenato elf-insure far Workefs Compen DRAINS-FLOOR,ROOF,AREA,COND. STORI "' TYPE CONSTRUCTION
sation,as provided for by Section 37M of the Lubar Code,for performance of the
work for which this permit is issued. FIXTURES'PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OC/]GROUP � Aped
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER4(EA)' c
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
BUDDING UfV610N FEES
(Thissec[ionnecd not becomplemdifine permit is for one hundred d.liva($I W) GREASETRAP
or leas) t - - PIANCHECK FEE
I certify that in the performance of the work for which this permit is issued,Ishan - SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become suhject to the Workers'Compen- ENERGY FEE
zz sation Lews of California.Date
0 Applicant - - WATER HLATER.WNENT/ELECTR GRADING PEE _
NOTICE TO APPLICANT:If,after nations this Certificate of Exemption,you should WATER SY$TEMITREATING
a [^
become subject to the WorkersCompensation provisions of the Labor Code,you moat SOILS FEE
G Earthwit comply with such Provisions.1 this Permit shall b,deemed revoked
WATER SERVICE
� 014
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FP. PAID e
Thereby affirm that them is uconstmc0on lending agency for the pertonnance nP -D Receipt It
the work for which this permit is issued(Sec.3097,Civ.C.)
Lender's NameTOTAL:
Lender's Address TOTAL:
6i I certify that I have read tis application and state tin the above information is - BUILDING FE
Vf comet.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V Z• building construction,and hereby aumorm representatives of this city to enter upon the SEISMIC
above-mentioned property for inspection purposes. PERMIT ISSUANCE
- (We)agree m save.Indemnify and keep harmless the City of Cupenioo eg.fast ELECTRIC P
Iinbili0es,jodgments,coats end expenses which may in any w�y,ccme against said City ALTER ORADD TO MECH. PLUMBING FE
In consequence of the granting of this permit. '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH-ALL NON-POINT AIR HANDLING UNIT 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FE,
_$ AIR HANDLING UNIT(OVER 10,"CFM) CONST RUCTION TAX
Signature of ApplicanVCommcnor. Date _ EXHAUST HOLD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE - - -
Willmeapplicant orfumre building occupant store orhandle hazardousmmen'al HEATING UNIT(TO I100,000 BTU)
us defimM by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(,)7 HEATING UNIT(OVER,100,"BTU) r.
+ ❑YesNo -
VENTILATIONFAN(SINGLERESID) PAID' Date Receipt
Will to appllemn or future building occupant useegmipmemmilevice,,lawh BOILER-CAMP(3HP OR 100,000 BTU)'
mit hazardous air contaminants as defined by the Bay Area Air Quality Management
District? - - - TOTAL:
F]Yes ❑No BOILER-COMP(OVER 100,000 BTU)
I have Saud the hazardous materials requirements under Chapter 6.95 of me Cali- AIR CONDITIONER
9 P ISSUANCE DATE'
forms Health&Safety Cade e a to ms 23505 is my and 25534h understand that d me NEW RESIDENTIAL MECH. SQ.FT q
of
the
wvrtlyhich have a repent mala ismyof a Cilitytonohfytejimay:occupant -
finerequ'rements which must be met pnnrt ' able Certificate of Occupancy.' - •
Owner oraumanzed agent Date' _ - TOTAL: ISSUEOBY:
OFFICE