31495 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3
/IAC
BUILDING PROJECT IDENTIFICATION J.L f-F J�J
BUILDING ADDRESS: — SANITARY NO. APPLICATION SSUU/BMI PIAL DATE
OWE AYM\C: PH YL C A ryt'S NA :: IC NO: '^V
IIx /ell 1 NAC CONTROLp
ARCHITECT/ENGINEER: LIC NO: Ap 55: 1' _ ❑
CONTACT: PRONE: 1 4._T BUILDING PERMIT INFO
❑ Consultant Fces Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm firm 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
0W-z00 fh Sxtlnr7000)ot Di vis ion 3nfthe BnsirvwmdProfessions Code.anJ my license is RESI� DENT'IAL,
x]00 wt PERMIT ISSUANCE
ag n full force and c c ❑SFDWL ❑KITCHEN REMODEL
�U Licen ass hic.p
Q APPLIANCES—RESIDENTIAL ❑ADDITION [I PLUMBING RIi-PIPE
�<LDam CO DEC
f.7rn ARCHITECTS DE LLA I N PANELS El MULTI [:]STRUCTURAL
Z O Z 1 understand my plans shall be used as public record, MODIFICATION
OZ�Q UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Flal Licensed Professional 201-1100AMPS IMPROVEMENT
s J..I OWNER-BUILDER DECLARATION OVIiR 1000AMPS ❑BATH REMODEUREPAIR C1 DEMOLITION
O C Q 1 hereby affirm that I um exempt from the Contractor's License Law for the
5ti O a U following reason.(Section]031 5,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
ty 3 LR N which requires n permit m construct,alter improve.demolish,or repair any suumum fb
as primmits moance,oHuregmiestheapplicant formchpennamfileasigaed statement SPECIAL CIRCUIT/MISC.
9p > that he is licensed pursuant to the provisionsofthe Contractor's License law(Chapmr9
W pEpO (commencing with Section 7")orDivision 3 ofthe Business and Professions CedOor TEMP.METER OR POLL,,INST. COMMERCIAL'
4p,e, that he is exempt therefrom and the hnsix for the alleged exemption.Any violation of ElNEW BLDG/ADDITION [IDEMOLITION
I N Section 7031.5 by any applicant for u permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more Nan five hundred dollen(S510L IMPROVEMENT
SSG ❑Las owner of the propcny.or myempinyreswithwogesa Neirmle compcn.wtion, SWIMMING POOL ELECTRIC ❑OTHER
f will do theand doe work, e scture is not intended ocoffered for sale(Sec.7W4.Business
W 3�m rand Predessiom Code:The Contractors License taw does not apply to an owner of OUTLETS—SWITCHES—FIXTI R ,A
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ
sale.if.however,fire bottom,,,,impmvemem is sold.Minos yamof completion,the / SQ �IIO AEA S/SQ.IT.
owner-builder will have the burden of proving that he did not build or improve for put- AN
RECrp
p.seofsale.). /x
1,as owner of the property,am exclusively contracting with licensed contmvors m y!Iy
y
common the proimd(Sec.70 EL Business and Professions CNe)The Commences Li- OUrCM!1NQ
Li-
sense Law does not apply to an owner of property
y who builds or improves daemon.and QTY. PLUMBING PERMIT
who emuacts for such projects with a coutioctor(s)licensed pursuant m dire Convucmr's
License Law. PERMIT ISSUANCE
M I am exempt under Sec. .B&P C for this raven
ALTER—DRAIN&VENT—WATER(EA) VALUATION
• Owner D
WORKER'S COMPENSATION DECLARATION BACK FLOW PROT[CT.DEVICE
I hereby offiem under pcsmldy of perjury one of the following dttlanx Co
leave and will Lot,by
Cion 37Ne of Conten mCodenfar the for - DRAINS—FLOOR.ROOP.AREA,COND. STORIES TYPE CONSTRUCTION
smirk,as pervaded Tot ra Scvirn 3]10 of the Labor Csvlc,for fire performance of dire
work have
and
this pmma is issued, PI%I'URF.S—PER I'RAI'
have and will maintain Worker's Compensation Insurance, required by Section
3 ofthe la—�bo�or@@CNe.for the perf�orgmance ofthe work for whichh this Permit is issued. GAS—EA.SYSTEM-1 INC.0OUTLETS OCG GROUP AI'N
Caymeer r Co
Y Il"1A Tf hartier gond Polic aft
P lacy Nia. r/VIb�OI GAS—EA.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREnSFIINDUSTRL WASTE INTF.RCEPI'OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
This sedan need not he ennpletcd ifthe pesndt is prone hundred dollars($100) GREASETRAP
or less) PLANCHIiCK PEE
I certify that in the performance ofthe work for which this permit is issued,l shall SEWER—SANITARY—STORM EA.200 FT.
not employ any Person in any manner in)as to become subject o the Workers'Compen- ENERGY ItiE
�Z sadoa laws(if California.Date WATER HEATER W/VENT/ELEC R GRADING PEE
Z Q Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM/IRF,ATING
V) become subject m the Worker's Congxrssution provisions(if the Lahor Code,you must SOILS ITE.
F
Hforthwith comply with such provider, a this permit shall be deemed revoked. WATER SERVICE
aQ
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V O Ihcreby affirm thauhcm isecnnsdmcdon lending agency Rothe performance of Uam Receipg
U. f--' Ne work for which this permit is issued(Sec.3097,Ci,C.) TOTAL:
OU Landers Name
�.s ULanders Address TOTAL
W 1 certify that 1 have read this application and state that the above information is BUILDING FEE
Mh correct,Iogre,tocnmply with all city and county ordinances and state laws retailing to QTY. MFCHANICALPERM IT' FEE
V Z building eomonetion,and hereby aathmam representatives of this city to cater upon the SEISMIC ItiE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamlethc City of Copertinm against ELECTRIC PEE
rss
liahilidies,judgmends.cos¢andeapenves whichmayinanywayicerueagainso mid City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this Perri.
APPLICAN'I'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00 CFM) MECHANICAL PEE
SolN RfiGULATIONS
AIR HANDLING ON]'I'(OVER 10,"CFM) CONSTRUCTION TAX
V In Appliam Contmcmr Y-Yf I to EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATER DISCLOSU
Will the applicant or future building occupant since ter handle hazardous mammal BEATING UNIT('1'O 100.000 BTU)
as defined by the Cupertino Mi nlclp:d Code.Chapter 9.12,and the Health and Safety
Cody Section 255321x)" - I R;ATINO UNIT(OVER I W,000 BTU)
E]Yet 7N PAID
VEM'ILATION FAN(SINGLE RESID) Dole Rci#
Will the applicant or future building occupant use equipment or devices which BOILER—COMP(3NP OR 100.000 BTU)
emit havmdom air contaminants as defined by N ,
<Bay Area Air Quality Management TOTAL:
District? BOILER—COMP(OVER 110,0101 BTU)
E]Yes ❑No
1 have and me,haaNnus materials ostentatious under CONDITIONostentatiousems under Chapter 6.95 of the Call-- ER ISSUANCIi DATE
forma Health&Safety Code,Savanna M505.25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
buildingdoes rad ct ready have a mnand,that it is my mspsnsibilidy do notify the accupam
ofthe requirements which mum he met He,.command.Catl5cate of Occupem'y.
Owner or audhorimd agent Data TOTAL: ISSUED BY: rp
OFFICE