31549 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. .�
BUILDING DIVISION APPIACATION/PERMIT PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: I SANITARY NO. APPLICATION SUBMITTAL DATE
� .QWNER'S NAME: PHONE: CONTRA N. NALIC NO:
1Z - ME: /,-r— CONTROL
ARC ITECT/ENGINEER: LIC NO: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ j ❑
LICENSED CONTRACTOR'S DP.CIARAT ION QTY ELECTRIC PERMIT FEE
I funds, licensed y affirm that 1 mincensed under provisions of Chapter 9(transmuting JOB DESCRIPTION
�"�yZ with Section 700).f Division 3man,Business and Professions Code,and my license is RESIDENTIAL:
F00 in full force and effect. PERMIT'ISSUANCE,
41� ❑SFDWL ❑KITCHEN REMODEL.
<Z VU Dam Cum
Litems Class o.M APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
FF W mnm
Vs60. ❑MULTI-UNIT ❑STRUCTURAL
UDw ARCHITECTS DECLARATION PANELSZ uX�Z Iundmund my plans shall Fe used as public records MODIFICATION
OZ-O UPT0300AMPS ❑INTERIOR 11 CHIMNEY REPAIR
F:.m..~„W Licensed Professional 201-1000AMPS IMPROVEMENT
,...4I OWNER-BUILDER DECLARATION OVER IIXNIAMI'S ❑BATH REMODEL(RF.PAIR El DEMOLITION
M W Q 1 hereby affirm that 1 an exempt form the Contractor's License Law for the
�a O a U following mason.(Section 7031.5,Business and Nnfesdoars Cede:Any city or county SIGNS ELECTRICAL ❑OTHER
413 W(y" which requires a permit to construct,alter,impmvc,demolish,or repair any sanctum
F�Da priorm its issuance,also requires the applicant for such permit in file a signedstatement SPECIAL CIRCUIT/MISC.
Natheislicenscapursuant m the prosbamsofibe Conuacme,Liters,e U,,(Cbapmr9 COMMERCIAL:
ap C0a (commencing with Section 7")of Division 3 of the Business and Professions Code)a, TEMP.METER OR POLE INST
0.y 04 that he is exempt therefrom and the basis for the alleged exemption.Any violation of LNEW OGIADDITION ❑DEMOLITION
Section 7031.5 by any applicant far a pcand subects the applicant m a civil p, ahy of POWER DEVICES T ❑FOODSERVICE
ant mom than five hundred dollars(5500). EMENT
O I,as owner ofthe properly.or my employees with wages av their sole compensation, SWIMMING POOL ELECTRIC
willdotheworkandthc.structum is not intended err offered far sale(Sea7044.B-ams
4W and Professions Calc:no Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
3 property who builds or improves daemon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECIR SQ IT
arde.If,however,the building or impmvemcm lswld within one yearof cnmpletimn the SQ.FE FLOOR AREA wC,FT.
overser-builder will have the burden of proving that M did not build or improve for put. /�
psm of soled. P A
I,as owner of the properly,um exclusively contracting with licensed contractors rot TOTAL: D
,orwh ct the Project(See.7014,Business and Prof e..mr,code:)The Cnmra<tur'a Li- p�
terse law does not apply m an owner of prmpeny who builds uT impmvc,'theroon,and QT'Y. PLUMBINGPERMIT FEE U /9
who contracts for such projects with a contmcoms)licensed pursuant to the Contractor's 4,_ (�19
License Law. PERMIT ISSUANCE. v yJ
I am exempt under Sec. .B&P C for this rcama I��'I 6
Owner Date ALTER-DRAIN&VENT-WATER(G) ('ty Ys).,(stJ(TION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Coniliaate of Comenuo self-insure for Workers Cooper- DRAINS-FLOOR,ROOK AREA,COND. STORIES TYPECONSTRUC ION
onion,i s provided fin by Suction 37(X)of the Luber Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as inquired by Sectionis
3700 of the Labor Code,far the pedarmameofthe walk for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLET'S OCC.GROUP APN
My Work¢ roto
non Insurance anter and Policy number arc:
or. rGAS-EA.SYS'IEM-OVIiR4(EN
CBRTIFICfit OF EXEMPTION FROM WORKERS' GREASF/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section nosed not be completed time penal is forme,hundred dollars SIM) GREASE TRAP
or less.) PIANCMECK EFP
ID
I cenify that in the pcbmuanec of the work for which this permit is issued.)shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any runner so as m Owe nse object to the Workers Comtism ENERGY FEE
Z cation Laws of Califumia.Dam WATER HEADER WNENT/ELECTR
z 2 GRADING FEE
Applicant
NOTICE TO APPLICANT:If,after making this Certificate,of Exemption,you should WATER SYSTEMC REATING
h ^^ become subjsect m the Worker's Compensation provisions of the labor Codc,you nnsl SOILS FEE
fordwith comply with such Provisions or this permit shall be deemed revoked. WATER SERVICE.
Q
7 z
CONS]RUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.FT. PAID Date Receipt W
U 0 Thereby affirm that them is a construction lending agency for Ne performance of
W F' the walk for which this permit is issued(Sec.3097,Civ.CJ
OLenders Address
U lender's Name TOTAL:
Wy 1 cenify that I have mad this application and sum that the above information is BUILDING PEE
Vi correct.l agree in comply with all city and county ordinances and sum laws relming to QTY. MECHANICAL PERMIT FEE
U 7 building construction,and hereby amhorimclovanutives of this city In order upon the SEISMIC FEE
rte- .love-mentioned prnpeny for inspection pu,mics. PERMIT ISSUANCE
(We)agree to ave,indemnify and keep harmless the City of Cupertino against ELECTRIC JIM
liabilities,judgments,costs and expenses which may in any way acerae against said City ALTER OR ADD TO MF.CH.
PLUMBING FEE
in asequence of the graining of this permit.
APPLICANT W ERSTANDS AND WILL C MPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB,UM)CFM) MECHANICAL FEE
SOURC TION.
AI R HANDLI NO UNIT(OVER 10.0010 CFM) CONSTRUCTION TAX
WOffalsl;,ofApplicaraf5intatchor One, EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mention stomorhandle haeurdous material HEATING UNIT(TO 101,11(1)BTU)
as def ud by the Cupenim Municipal Code,Chapter 9.12,and the I calth and Safety
Code,Section 25532001 HEATING UNIT(OVER 100.000 BTU)
❑Yes ON. VENTILATION CAN(SINGLE RESID) PAID Dore RaeipiM
Will the applicant or future building occupant use equipment or devices which
emmBOILER-COMP(3HPQR 100,OIIU BTU)it barlous air omminninano as defined ay by the BAra Air Quality Management TOTAL:
District? BOILER-COMP(OVER 100,0(0 BTU)
❑Yes ON.
I have read the lascivious materials requirements under Chapter 6,95 of the Cali- AIRCONDITIONER ISSUANCE DATE
loma Health&SO Cole,Sections 25505,25533 and 255311 understand thou if the NEW RESIDFN TIAL MECH. SQ.FT.
Wilding docs nm currently have a tenant,that it is my responsibility as notify the occupant
oI dm requirements which must tic met poor to issuance of a Cenificam of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE