31262 (2) APPLICANTTO'FILL IN INFORMATION.WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL A' PERMITNO
'BUILDING DIVISION APPLICT'ION/PF,RMIT PLUMBING-MECHANICAL - . 31262
II1)II.DIN(1 PRO11:C'r II)F.NTIFICA'riON
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
7 oat- o roN �JI,
OWNER'S F N� BW�+K/l CONTRACIGRS NAME: LIC NO:
N/C CONTROLM
RCHITECT/ GINEER: LIC NO: ADDRISS: - '❑
CONTACT. PHONE - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB MECH
❑ ' ❑ ❑
LICENSEDat I a CONTRACTORS DECLARATION QTY ISLF:CTRIC PERMIT FEE
I hereby err m mal I an,licensed i nes nd Pisians of chapter a(commencing, JOB DESCRIPTION
OW with s«rce it0)of Divisioin3mf the Business ane Professions ClMe.and myliceme is I
F�� in full force and offal. PERMIT ISSUANCE SD - '
til^ FOWL C)KITCHEN REMODEL
<VU Data Class Lic.IsContractor
APPLIANCES-RESIDENTIAL ADDITION C3 PLUMBING RF.-PIPE
of G W� Data - Convenor
ARCHITECTS DECLARATION' ❑MULTI-UNIT ❑STRUCTURAL
'D7 PANELS
Z p w Z 1 understand my plans shall be used as public records MODIFICATION
O Z=- UPTOIUOAMES &0 1 [1 INTERIOR ❑CHIMNEY REPAIR
F-.~III Licensed Professional301-1000AMPS IMPROVEMENT
la:yf� OWNER-BUILDER DECLARATION OVER 100a AMT'S ❑BATH REMODEUREPAIR ❑DEMOLITION
OC Q 1 hereby affirm mat I am exempt from the Contractor's License law for the
K 3 d U following re..(Section 7031.5,Bminess nnA Professions Cede:Any city or countySIGNS IH.IiCfRICAL ❑OTHER q� -
IA a y which requires a permit to mnswm,alter,improve,demolish,or repair any suuctum _ {w
poor o its issuance,also requires me applicantfor such Permit to file a signed statement - SPECIAL CIRCU1T3MISC. - -
} that he is licensed pursuant ro me provisions of the Commao's License law(Chapter 9 -
W{Y�� (commencing with Sermon 7")of Division 3 of the Business and Pmfessiuns Cubit or TEMP.METER OR POLE INST COMMERCIAL:
6 6 e C mat he is exempt therefrom and me basis far me alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X-m Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICPS ` []TENANT ❑FOODSERVICE:
not more man five hundred dollars IS5001.
F Z,Y IMPROVEMENT
=6 0I,as owner of the property,at my employees win wages as their sole compensation, SWIMMING POOL ELECTRIC ,
all . will do me work,and me soucmre is not imendedor offered for sale(See7BW.Business ❑OTHER
W 3 oa and Professions Carle:no Contractors License law docs not apply to an owner of OUTLE TI'S—SWO CHES—FIXTURES
progeny who builJs or improves thereon,and who dress such work Idmsdf or through
his own mpleyous.Provided That such improvements art not intended or or(ered for NEN'RISIUENTIAL F.LECTR
e
wle.lf.however me building or improvement is add wiminone year ofcnmpinion.the SQ.FT.FLUOR AREA SISQ,FT.
ter-builder will have the burden of proving that he did not build or improve for par- r -
pose of sale.).
❑I.aprogeny,a
s owner of the m exclusively commeting win licensed contractors to TOTAL a
contract he project(Sec.7044,6tninexs and Flotations Code:)The Contmemr's Li-
w
cerise Law dues not apply to an owner of property who builds ur improves Mercer. ad QTY. PLUMBING PERMIT FEF,
who contracts for such projects with a comencoodo licensed pursuant to the Contractor's
License Law. - - ' PERMl1'ISSUANCE
I am exempt under Sea ,H&P C for this rcasnn _
Owner, Dare O ALTER—DRAIN&VENT—WATER(EAI VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under Penalty of perjury one of the following declog tions:
OD (hove andwill mainuinaCertificate of Comemmsdl-insurefor Worker's Corripen- DRAINS—FLOOR,ROOF.AREA,COND. STORIES TYPECONSTRUCION
station,u provided for by Section 3700 of the Labor Gdc,for the perommnce of the -
work for which this Permit is Issued. ' F1XI'ORES—PER TRAP
❑ I have and will maintain Workers Compensation Insurance,as required by Section
37M ofthe Labor Cecil,for the performance of the work for which this planar is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS - OCC.GROUP APN
My Workers Compensation lnsumnce carrier:md Policy number arc: -
Carrier: - Policy Nn.; GAS—EA.SYSTEM-OVER4(L'A) -
CERIWICAII!01'EXEMPTION FROM WORKERS' GRIiA5IV]NDUSTRh WASTE INTERCEPTORCOM PENSM ION INSURANCE _ BUILDING DIVISION FEES
r (This section need not be amrplefeduffic permitts forrmc hundred dollar,IS 100) GRIiASE'TRAP
PLANCHE -
ICenifythatintheperformanceoftheworkforwhichthispermiti.v issued,I shall SEWER—SANO'ARV—STORM EA.PINI Fr.
not employ any ,,,an n in any manner sit uses become subject the Workers Compmr ENERGY
,Z :mina laws of Cslifamiit Dom o WATER IMAI HR W/VENT/ELECI'R
z Applicant GRADINVIFEEJr 1aU�Cla lllyl!
NOTICETOAPPLICAN'T:Il;nfmr making Ihix Ccniliamc nl lixcmptinn,You sbouW WATER SYS]F&I1'RENTING. V
H become subject to the Worker's Compensation post sions of the Labor Cock:you must SOILS FEE
Wr�i forthwith comply wi0>snch proskinmur thls,trmil Quail udeenmd revoked. WAI'I2R SLIRVIC17 -
aQ CONSTRUCTION LENDING AGENCY NEWRESIDENTIA1.PLMl3., SQyFT. ,PAID
UQ ,Thereby affirm thatthem sa constructionlendingagency lou the performance of
Dole Receipt
IL
(•" the work for which his permit is iawed(Sec.3097.Co,C.),
Lenders Name TOTAL:
V Lender's Address TOTAL -
�+ - BUILDING FEE
I ceni(y mit 1 halvemad misapplication and stem That the ohne infuriation roll tion is
Fh burrea.Iogreemmmand herebylommidmm�sentatives of and Iafc city
toentr open the
Q'I'Y. MECHANICAL PERMIT FEE
V ,� building nmswcrian,and hereby ourhnrire representatives of this citymemcr upon the SEISMIC PEE
obove-mentimned progeny for inspection purposes. PERMIT ISSUANCE" ELECTRIC FEE -
(We)agree Il,save,indemnify and keep harmless the City of Catarina against i
' liabil'nies,judgments,consand expenses which may in any way acme against said City ALTER OR ADD TO MECH.
PLUMBING FEE
in asequence of the granting of Ibis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON POINT AIR HANDLING UNIT(TO RI,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Si/g'Z/oat of Pp man u me�ior /Date EXHAUST HOOD(R9DUC) HOUSING MITIGATION FEE
IfAZARDOUS MATERIALS DISCLOSURE
Wt the applicant arfurorebuildingoccupant store nr handle harallous mataral HEATING UNIT(TO HM,000 BTU)
as defined by the Catarrhal,Municipal Code.Chapter 9.12,and the Health and Safety
Cade,Scotimn 2531(a)'1 - HEATING UNIT(OVER 100."BTU)
❑Yes 0 N VENTILATION FAN(SINGLE RESID) PAID Dam Receiplit
Will the applicant or faun building«crop..use equipment or devices which BOILER—COA1P(3HP OR Ipp.000 BTU)
emit hassNo us air cmnuminsnts as defined by Ne Bay Am Air Quality Management TOTAL,
District? BOILER—
❑Yes Fl No COP(OVER 100,000OIXI BTU)
I have read the havueme,ma¢rials ryuiremenu under Chapter 6.95 of the Cali- AIR CONDI'I'IONIiR ISSUANCE DATE
poria Health&Safety Code,Sections Z505,25533 cast M534.I Understand mat if me NEW RESIDENTIAL MECH. SQ.PT.
built ingdoes act currently have a tenant.that it is my rGpomsibility to n tify the occupant
of the rquiremems which must be met prim to is..of o Certificate mOcc mance,
Owner uroumodudogcto Data - TOTAL: ISSUED BY:
OFFICE