31082 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPC'RTINO BUILDING-ELECTRICAL. PERMIT NO. 31082� O H L
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BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL. J
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARYIN APPLICATION SUBMITTAL DATE
1043, N • f orl-uk vc Cv t,--fiw U4 9,Sal .
OWNs NPr (LI- Z1ZGNLfoY _ CONTRACTOR'S NAME: /G LIC NO:
N/C CONTROL
Bq,-.(5
(Joe ARCHITIiCT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑.Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE ]OB DESCRIPTION
1 hereby arm But 1 am licensed under provisions of Chapter 9lcnmmencing
,O„�Z affirm
withllfimm�Od e)ocDivisian 3nithe business and Professions Cale.and my license is
FOO in full Cies, effect. PERMIT ISSUANCE ,,�,, �
�UUUF Liccnnc Class Lica FDWL '(MITCHEN REMODEL
F�fil Dmc CnnvWar APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUM BI NO RHPIPE
f�,py ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
>> PANELS
VLO q Iundemand my plans shall he uuA us public records - MODIFICATION
O,ZI-O UP T0200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
FSI❑-Y1 Licensed Professional 201.tMMAMPS IMPROVEMENT
S0.bjr OWNER-HUILDER DECLARATION OVERIMOAMPS ❑BATHREMODEVREPAIR ❑DEMOLITION
G W ante Q I hereby infirm that I am exempt from the Convacmts License Low for the
3 L eJ following reason.(Section 7071.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
tL�j which¢quirtmi
s u perr m construct,alter,improve,deman
demolish,or¢pair y structureO prior to its issuance.also requires the applicant for such pemut or a signed statement SPECIAL CIRCUIT/MISO
yIhot he is licensed paaoanuo the provisiomrifthe Convectors License Law(Chapmer9
d00 commencing with Section 7000)of Division J ofthe Business and Pmfessions Code)or TEMP.MITF.ROR POLE IN L COMMERCIAL•
y e e' that he is exempt Mawfmm and the busis Ru Hct ullegcd sxempnian.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
x�t4 Section 7011.5 by any applicant on a permit subjects the applicant to a civil penalty of POWER DEVICESl
{4sl1 rn ❑IMPROV ❑FOOD SERVICE
FxM nn un ase shun lose thundred e property.
ormycrop' 41, IMPROVEMENT
D ❑Lothe owner afinep,opedy,or mycmntended wofferewages rsale( ee.cam.Business SWIMMING POOL ELECTRIC
will Jct the work,and the he Conci...t intended or offered s notl apply to
an BusinessV ❑OTHER
3 and Professions Cade:The Contractor's License tow does not apply tu owner of OUTLETS-SWITCHES-FIXTURES
his..y who builds or improves thereon,and who does such work himself or through
his awn employees,e provided]Nat such improvements arc not intended orofferedfar NEW RESIDENTIAL ELGLTR SQ I4.
saleerbuddevenllhave Me burden
en ofpment isin year improve
the SQ.FT.FLUOR AREA 5lSQ.PT.
owner budder will have Ne budcn of proving that he did not build or improve fur pur-
e of sa ^le).
oro
�sl.us r of the proprry, exclusively contracting with licensed contractors to TOTAL O PAID I
consent thesproject(Sec.7M4,Business and Professions Code:)The Conlmnur's Li-
cense Law does not apply turn owner ofproperty who builds o,improve,thereon,end QTY PLUM RING PERMIT FEE •I '1 1'1C11aD
whncoulamR for such projects with ucnmrunnr(a)Iicenapd Formant to the Cnmmemr's MAR 11 RLl!
License law. PERMIT ISSUANCE❑ I am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(F.A) ALUATION
Owner Dam
RKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affum under pc..try of perjury one of the following declarations:
I have and will mamma a Certificate of Consent to self-insure for Workers Camper- DRAINS-FLOOR.ROOF.AREA,CONE) STORIES
TYPECONSTRUCfION
Ration,as providM for by Section 3700 of theTabor Cade,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
7700ofohe Lahor Code,for the perannunceof the work for which this penmim is issue, GAS-EA.S YS TIN.I INC.4 OUTLETS OCC.GROUP N'N
My Workers Compensation houmnce carrier and Policy number on: CAN EA
Carrier Policy No.: ( )
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRI.WASTE INTERCEPTOR
(7Lis cation need tat be enmpined if the pemdl is for ons hundreJ dallms(SI00) BUILDING DIVISION FEES
or less.) GREASE TRAP PLANCHECK FEE
Lecnify Niminthe performance ofthe work for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 FT.
nom employ any person in any manner so as to become subject to Out Workers Cape.. ENERGY ITE
,Z samion Lows of California.Dam
7�O Applicant WATER[]EATER WNENT/ELECITt GRADING EEE
G to NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTEMH RPATING
abecome subject to the Workers Coinpcnsmion provisions of the Laor Code,you must SOILS FEE
Liz
forthwith comply with such provisions or this prod,shall be Deemed,waked. WATER SERVICH
Q
.�. Z CONSTRUCTION LENDING AGENCY NEW RIiSIDEM'IAI.PLMH. SQ. PAID
(� O work
afFum mhauhere isand(See. 097.Cing agency far me perfomrvnce of Data Receipt
v the work for which this permit is issued(Sec.7097.Civ.CJ
01--� Lenders Nemo TOTAL:
V Lenders Artifyt TOTAL:
0. I certify that 1 have read this application and some that Ne above information mining
iR BUILDING hEE
h wilding agree to comply withal]city and uapsereativeso ais state laws QTY. MECHANICAL PERMIT FEE
U z building asmwcdon,and hereby emhorim repreunuoives of Nis cloy no caro,upon the SEISMIC FEE
above-menlioned property,for inspection purposes. PERMITISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupeninn nguinn ELECTRIC PCI:
liahilities,judgmenms.costs and expenses which may in any way accme agmuQ said City ALTER OR ADD'TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
SOU F.REGULATIONS. MECHANICAL FEE
5- t AIR HANDLING.UNIT(OVERHL0011CFM) CONSTRUCTION TAX
Signature ofA lipmWConvactor Date EXHAUST HOOD HVMUCp HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will he applicant.,future building occasion store orhmdle hasardnus mmerial HEATING UNIT(TO 100,000 BTU)
as Jeftal by the Cupertino Municipal Code,ChaPte,9.12,ad Ne Hcahh and Safety
Code,Section 25532(ap HEATING UNIT(OVER 100,000 BTU)
❑Yes 0 N PAID VENTILATION PAN(SINGLE RF_SID)
Dmc Receipt N
Will the
-11 emanmoffuture building by meBuseequipmentor deviceswhich
BOILER-COMP OHP OR 100,000 BTU)
nthict? us Cir conmminanu as Acfimud by the Bay Area Air Quality Management TOTAL: 3
Drcvst
❑Yes ON. BOILER-COMP(OVER 100,000 BTU)
L have mad me hares mm,materiels u veer Cha tar&95.f the Cali. AIR CONDITIONER
Haltinreg2remen p ' ISSUANCE T�
fomin g does&Safety Code,Sece.to ar 255115,is on,and 255]4.L understood that if dte NEW 0.ESIDENTIAI.MECH. SQ.FT.
building ntrate is which
have. Nam.issom responsibilitytonotify Ncoccupant
of the requimnmms which must h<mel prior m issuanm of a Qrificme of Qcupuncy.
Owner oruuthmixeda cto Uaie 3 -' G TOTAL: ISSUED BY:
=( OFFICE