31290 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. f� 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAL G
BUILDING:PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
OWNER A E: PHONE: CO RACEOR'S NAME: LICa NO: IO lar
r I ., 13 1�� NIC CONTROL#
4RCHIT.Cf GINEER: LIC NO: ADDRESS: 10,J ❑
CONTACT: PHONE: ff--l1 BUILDING PERMIT INFO
La Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION . QTY ELECTRIC PERMIT FEE
Ii.n70 E.f that Inm licensed
onextprovirferaof Chapter
ci9(commencing JOB DESCRIPTION
X00 with Section ndeffecDivisinn3ofthe Businessentl Prnfeasinm Cale,unJ my license is
�00 � � RESIDENTIAL:
in fol force and effect., PERMIT ISSUANCE:
�W OSFDWL El KITCHEN REMODEL
� 'anti Class Lin.# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F Doe Contracmr
Fah ARCHDECTS DECLARATION PANELS ❑MUI.TI-UNIT OSTRUCTURAL
ZO'tf I understand my plans shall bcused aspublic records - MODIFICATION
CZ - UPT0200AIl ❑INTERIOR FIIMNEY REPAIR
r � Licensed Professional 201-10110AMPS MPROVEMENEM IT'
OWNER-BUILDERDECLARATION OVER I"AMPS ? 11 BATH VEMENTJREPAIR ODEMOLITION
yy I hereby affirm Nat I ani exempt tram the Contractors License Law for the
X 3 a V following reason,fgection](131.5.Business and Profcsaianx Coda Any city or munry I SIGNS ELECTRIC/,- O OTHER R
ttr[11 LL which acquires a permit to construct aper,improve,Jemoliah,or repair any swewre
��vyI�h prior to its hummaealso requires theapplicamfar such permit to filen signedsmmment SPECIAL IT/MISC.
'hut he is licensed pursunnno the positional the Contractor's license Law(Chupter9
tt44❑00 (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.M 0 OLEINST. COMMERCIAL:
a q eC that he is exempt therefrom and the hour for Ne alleged exemption.Any violation of O NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER ICRS OTENANT El FOOD SERVICE
not mate Non five hundred dollars(SSW).
CZ Q O 1.as owner of the Fina ,or my employees with wages as their sole compensation, SWIMMING POOLEI-Eel IMPROVEMENT
CZya' will do the work,snit thesuunurt haat imendedoroRcred fn isnle(Sec.?(Nq Business []OTHER
W, and Professions Code:The,Council License Low dies not apply to no owner of OUTLETS-SWITCHES-FI
4i property who builds or improves thereon,and who does ruch work himself or through
his own employees,provided Nat such improvements ore not intended or offered for NEW RESIDENTIAL ELECTR 56pi. _
wle.IL however,the building or improvement is sold within one year of completion,the .P17FWWREA $/SQ.FT.
caner-builder will have the burden of proving Nat he did not build or improve for par- W C IJ
pose of sale.).
71 h as owner of the property,am exclusively contracting with licensed contractors to TOTAL OC
construct the project(Sec.7044,Business and Profusions Code:)The Coulactor's Li- � •I
cense Law does not apply to an owner of property who,builds or improves thereon,and QTY, PLUMBING PERMIT FEE 199
whucontrects for such prorp)jects with a contractolicesed pursuant to the Central
License1..law.
PERMIT ISSUANCE Uh CUYE1Y11N0
❑1 em evemM under Sm. ,B&P C far reason
Owner Date
ALTER-DRAIN&V ENT-WATEVALUATION
(EA)� '
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
1 hereby nfftrm under penalty of perjury one of the following declurutimen
I have and will maintain a Cenificam of Consent o self-houre for Worker's Compcn- DRAINS-FLOOR,ROOF AREA,COND'
tion, TYPE CO STRUCf10N
ration,as provided for by Section 37M of the labor Code,for the Performance of the
work for which this panidt is issued. FIXTURES-PER TRAP
O 1 have and will prommin Wofker's Compensation Insurance,as required by Section
3000 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS
(1011 GROUT' ANN
My Worker's Compensation Insurance carrier and Policy number are
Cortise policy No.: GAS-EA.SYSTEM-OVER 4(8A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASF/INDUSTRL WASTE INTERCEPTOR %UI NG 9&ISION FEES
(This section pedant hecumplered if the permit is forme hundreddollars(5100) GREASBTRAP
or lust PLANCH
Icenify that in the perfnrmuncenfthe work for which this peanut isissuW,lehall SEWER-SANITARY EA.200 FT.
not employ any person in any manner so ns tp�come subject to the�ytr�e Compen- ENERGY E
,Z roti w,,t/p,, min.Data A// l / —Y f�
ZO icant -"r bi� — WATER HEATER WNENT/ELBCfR GRADING FEE -
NOTICB APPLICART:Eleanor makig this CentreeteZMMfffpf@t-yuurhould WATER SYSTEM/TREATING
become subject to the Workers Crou,sovtion provisions of the Labor Cale.you must SOILS FEE
rry forthwith comply with such provisions or this permit shall he deemed revoked. WAIER SERVICE
Z) zQ
UO CONSTRUCTION LENDING AGENCY NEW RESIDCN'1'IALPLMB. SQ,FL PAID
1 hereby off nn that then isissued
contraction0 lending agency for the perfommnce of Receipt#
❑+yrs the it a for which this permit is iuued(Sec 3097,Civ.CJ
Lenders Name TOTAL:
(11 Lara e's Addresr TOTAL:
I cerify that 1 have reed this application and rmm that Ne vMeve information is - BUILDING FEE
VaJ cured tapper,to totally which city rand county ordinances and slow laws relating to QTY, MECHANICAL PERMIT 17EE
U building conswetinn,and hereby authorise representatives of this city to enter upon the SEISMIC FEES
slave-mentioned property far inspection purposes. PERMIT ISSUANCE
(we).gran to aave,indemnify and keep harmless the City of Cupertha against ELECTRIC FEE
liabilities,judgments,cars and expenses which may in any way social agent said City ALTER ORADDTO MECH.
in consequence of the#rrating of this Permit PLUMBING FEE
APPLIC NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO[0,000 CPM)
S(]U E 'G LATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10."CFM)
CONSTRUCTIONTAX
ig rt Applican Contractor Dam EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the...heantorfuture huildingoccupent store ar handle hurarl meterivl HEATING UNIT(TO 100,000 BTU) -
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532ol HEATING UNIT(OVER 100,000 BTU)
O Yes ONo VENTILATION VAN(SINGLE RESIDE PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt#
and haervives air tontnminants es defined by the Bay Area AirQdeliry Management ROILER-COMPDHPOR 100,000 BTU) 1
hilt d9
OYcs ❑No t BOILER-COMP 11,0( 1 BTU)
t
I have rend the hazardous materials AIR CONDITIONER ISSUANCE DATC
requirements under Chapter unite 6.95 of the Cali-
7building
nia Health&Safety Code.Sections 25505.833]and 23534.I uMersunJ that if the, NEW RESIDENTIAL MECH. SQ.FT.
does no comedy have a[.at.that it is my responsibility ro notify the occupant
the minima ems which must he met prior to issuance ofs Cenifirme of occupancy. SOW
wner or vuffiral agent Did, TOTAL: ISSUED BY: -
OFFICE
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