31250 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-'USE SALL POINT PEN ONLY =
CITY OF CUPERTINO I I I BUILDING-ELECTRICAL - PERMITNO. I� /� O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL - J L
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: 109'1/ SANITARY NO. APPLICXUONSUBMITTALDATE
V
OWN g.'Gii1MB: /� PHONE: CONTRACTOR'S NAME: LIC NO:
N/C CONTROL#
'ARCHITECT/ENGINEER: LIC NO'. ADDRESS: - "
CONTACT. - PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUM MECH
I LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
.,I hereby affirm that 1 am licensed under provisions of Chapter 9(camuctcing J DESCRIPTION
QWC with Section?B00)af Division 3 ofrbe Business and Pmfe%sime CAd,and my license is / ,
�. in Poll force and effect.' PERMIT ISSUANCE e.7 RESIDENTIAL-'
License Class Lic.0 ❑SFDWL CHEN REMODEL .
� ul Dam _ Contractor APPLIANCES-RESIDENTIAL
❑
y44m - ARCHITECT'S DECLARATION ADDITION ' "❑PLUMBIURAL PIPE
X O R p I understand my plans shall be used as public records PANELS 11 MULTI-UNIT / ❑STRUCTURAL
O'y:J _ .MODIFICATION
UP T0200AMPS El El CHIMNEY REPAIR
<�< t� Lensed Prnfessonal- IMPROVEMENT
o!�
201-10MAMPS
OWNER-BUILDER DECLARATION
I hereby affirm that IO0.0 1 exempt from the Contrnetrs
aLicense Low fur the OVER]"AMPSMPS ❑ ❑
BATH REMODEVREPAIR DEMOITI
LON.followingreason.(Section 70315. and ve,fdemols Code:Any city structure
1:1 OT h.FF which requires erepair... � SIC SELECT f. ,
O ye q permit r0 conswch alcor,improve,demolish,or statement
y.] hat
slts cense pursuant e,also toteres theapplicantfor such Contrarmiuofile aicense aw(statement SPE CC IT/MI
that M1a is licensed pumuannotbeprovisious of the Contractor's Licence Law(Chapter
sss 00
that
he
achouh Seefter.1andth basis
far th theagaid cssavd Pmfcny i affirm of TEMP.M R P TCOMMERCIAL' r
that he is exempt rberefrom and the basis for the alleged exemption.Any it Finally
of ❑NEW BLDG/ADDITION [-I DEMOLITION
-
WX {y Section]031.5 by any opplicamfor(S300mit subjects the applicant to acivil penalty of POWER DEVICES
y nor more than five hundred dollar($5x0). []TENANT ❑FOOD SERVICE
Q ❑L.a.wurmlthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT t•
will dome work,and the struemre is nor imended or offered for sale(Sec.7044,Business []OTHER
,r 3 and Professions Code:The Cantmemr's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES V'f p A 0
property who builds or improves thereon,and who does such work himself Or through � 13
his own employees;provided that such improvementsare not imendeJ or otfercd fur NEW RESIDENTIAL ELECTR SQ Fr.. 4/0
sale.If,however,the building or improvement is sold within one yea(af completion,the - SQ.IT.FLOOR ApA�IyRpEyA ,�(SQ.FT.
owner-builder will have the burden of proving that be did not build car improve for par- - YVeWY �I � 57R
poarx'sale.) (BII (I �.•I Wf
❑I,as owner of the property,am exclusively contracting with licensed contractors to. TOTAL: .. ,
consumer The projeut(Sec 7TaPL Business and Professions Code)The Cmar edn,Li- s. CITY OF UUPE TINO
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE 'CITY'V 11-LL I
who contracts for such projects with a Fortmeloos)licensed pursuant to the Contractor's
License Law. - v PERMIT ISSUANCE
1 am exempt and Sec , - s.
t . -
❑ P � .R&PCfor this reason -
ALTER-DRAIN&VENT-WATER(EA) t fO
net Uam VALUATION -
•WORKER'SCOMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
y a
p l herebffirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- - DRAINS-FLOOR,ROOF,AREA,COND.
salter,as provided for by Section 3700 of the Labor Cade,for the performance of the •STORIES TYPE CONSTUCTION
work for which this permit is issued. I -FIXTURES-PER TRAP Al/g
❑1 have and will maintain Workers Compensation Insurance,as required by Section
37W oflhe Labor Code,for me performance of the work for which this permit is issued, GAS-EA.SYSTEM-IINC.4OUTLETS 000.GROUP APN
My Workers Compensation Insurance cornier and Policy number a re: '
Cartier: Policy No.: GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
(This section need notbewmplemd lithe permit is Tanana huvdreddmllars($100) BUILDING DIVISION FEES
or less.) GREASETRAP PLANCHECK FEE
I certify mm in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any curt so as m become subject m the Workera'Compen- ENERGY FEE
,z cation Laws of Calilerm..Data
WATER HEATER W)VENT/ELECfR GRADING FEE
Z Applicant � � ,
ti NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMOREATING
F, become subject m the Worker's Coundm niea provisions of the Labor Code,you most SOILS FEE -
fWr+ forthwith comply withsuch provisions or this permit shall be deemed revoked. WATER SERVICE
� z CONSTRUCIONLENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
I hereby affirm that there is a coreuuchoo lending agency for the performance of Dem Receipt#
V. P the work for which this permit is issued(Sec.3097,Civ.C.)
Q Lander's Name _
LenderTOTAL:s Address TOTAL:
Fa I certify That I have read this application and state ihat the abase information is BUILDING FEE
V1 correct,I agree to comply with all city and county ordinances and state laws relating to QTy. MECHANICAL PERMIT PEE tr
V building construction,and hereby aummdzereprosentshoes of this city,t0 enter upon the _ SEISMIC FEE #7�
abovtmentioved property for Inspection purposes.
PERMITISSUANCB
(We)gme to save,indemnifyexpenses
and keep harmless the City of Cupertino s against ELECTRIC PEE Q
I.Ouressi judgmentsecosts
ntingand ofthis which may in any way acerae against said City MEU
ALTERORADDTOMECH. - Z 2--1 .j.GA
I.consequence of the granting of this permit. PLUMBING FEE 7 fro
APPLICANT UNDE STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,1100 CFM) 7O
SOURCE 'IONS. www MECHANICAL FEE
CIX1
/6� AIR HANDLING (OVER 10,000CFM) CONSTRUCTION TAX
Signature of ApphcanpContralmar Y Date EXHAUST HOOD(W/DUCE) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store Or handle hazardous marginal HEATING UNIT EPO I notion BTU) ,
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety _
Cede,Salton 25532m)? HEATING UNIT(OVER E)l BTU) -
❑Yes No VENTILATION FAN(SINGLE RESID) PAID �jyJ'`,-' �`, �
'Will moccupant a applicant or future building cuquip
pant use'e mens or devices which "I Rlderpli
BOILER-COMP OR 100,000 BIV
emit Districts
ous air contaminants as defined by the Bay Area Air Quality Management ( ) - -
Disuict? TOTAL .yO
❑Yee E]No s BOILER-COMP(OVER 100,000BTU)
i
1 have read the hazardous thermals 5,25 can under Chapter and rsta of the if the
AIR CONDITIONER ISSUANCE DATE
fnmin Health&Safety Civle,e a to a 25505,25or an 5534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT.
buildingdce yhave ate t,}}}hhhmit m nsihilirym notify the occupant -
of 1enG list ret. eofaCertif oaf Ooou
Qwrm— hanzeaa ert , —�� /LM7 0
8 Date TOTAL: ' ISSUED BY:
OFFICE