31000 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO, O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATI
/f osS I '7S� j
OW ER'S N M : PHONE: NTR CIYJ 'S NAME: LIC NO: Z
{ - 4r C, \ N/C ROLA
AR fi;JCf'NGINEF.R: LIQ LIC NO: AQ�}RCS � / �N/�v� � / � G
cow PHONE:PHONE: 7 K//n+ I(.P/•• BUILDING PERMIT INFO)
✓1 /�� L/D�- `�� (sro� ❑ Cnnmllanl Fees Paid by Applicant(Initial) BLDG ELECT PLDMB MECH
1.
LICENSED CONTRACTOR'S DECLARATION VTYY Qpy ELECTRIC PERMIT FEE ❑ ❑
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Hoc with Section 71100 of Division 3 ofthe Easiness and Professions Code. it my license is I-00 ) Y 'IiRMIT ISSUANCE RESIDENTIAL:
in full force anti effort.
WF ❑SFDWL [I KITCHEN REMODEL.
-Z D License Cla s con p
rFQa con us t.0 APPLIANCES—RIiSIDENTIAI. ❑ADDITION El PLUMBING RE-PIPE
1-.Dy ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT OSTRUCTURAL
Z OI2Z ' I understand my plans shall be used as public records MODIFICATION
OZ-•Q UPT0200AMPS [I INTERIOR ❑CHIMNEY REPAIR
rr�(a�i Licensed Professimal 201-1INN)AM'S IMPROVEMENT
Add,
d, thatOWNER-BUILDERIaexempDECLARATION OVER 1000 AMPS O BATH REMODEL/REPAIR ❑DEMOLITION
a f�ly 6 1 I hereby affirm that 1 exempt from the DECLARATION
License haw for the
06 U following reason,(Section 7031.5,Business and Professions Cash:Any city or county SIGNS ELECTRICAL []OTHER
which requires a permit to construct.alter,improve,demolish,or repair any structure
B.LL•O prior to its issuance,also requires the applicant for such permit to flea signed statement SPFCIALCIRCUI'OM1SC.
that he is licensed pumuotn to the provisions of the Contmcter's License Law(Chapteri)
� q0q (commencing witsSee ion7000)of Division 3 ofthe Business and Professimo Crueler TEMP.METER OR POLI?INST. COMMERCIAL•
6 e W that he is exempt therefrom and the basic for the alleged exemption Any violation of O NEW BLDG/ADDITION O DEMOLITION
m Section 7031.5 by my.pplimnt far.purnin subjectstheap,Ikon,..civil pc.ahy of POWER DEVICES ❑TENANT ❑FWD SERVICE
��6not mom than live hundred dollars(E500).
I,os ownernfthe d.mm Io as wird we es as their xole nota nsntinn, SWIMMING POOL.ELECTRIC IMPROVEM� _./�(�
f O ❑ prtaPe Y YemP Y B M �e„�L,>)1ritF••4(�V`
ill do the work,and the nmeture is nm imended orottered fnr tame(Sec.71H4,Business O OTHER
RSI and Professions Code:The Contmmor's License Law dxs not apply m.n owner of OUTLETS—SWITCHES—FIXTUR.S
6 3 property who builds or improves income.and who does such work himself or through
his own employees,provided that such Improvements are not intended or offered for NEW RESIDENTIAL ELF, SQ FT.
sale l(low.veotbe building or improvement is sold within one year ofcompletion.the SQ.FT,FLOOR aAREA
, LSQ.FT.
owner-builder will have the burden of proving that be did not build or improve far pur- a/AALL g�
pose of salt.).
L:
F7 as owner.1 lot property,am exclusively contracting with licensed e.teracmrs to TOTA
construct the projen(SecJOJ4.Business and Professiom Cod The Convectors Li. Q E'EB 25 RECD
cense Law dues not apply tomo owner m,emperty win huildsnr lolmlea themes,and 'Pry, PLUMB( R 1F FEE
who contracts for such projects with a contractims)licensed pursuant to the ContmcttMs PF:
[Amuse Law. PERMIT ISS( Ii CITY Ur LU'
O f"�l lh'V
1 non exempt under Sec. ,B&P C for this reason t
Owner para ALTER—DRAIN&VE —WATER( ) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW ffiPROTECT.DEVIL J �/ /1
I hereby arm under penalty ofperjury one of the following declarations: l CJ V
O I manned will maintains Certificate ofCanscmmsel(-insum for Workers Cnmpcm DRAINS—FLOOR,ROOF,AREA,CON-. STORIES TYPE CONSTRUCTION
sn0on,as provided for by Section 37W of the Labor Code,for the performance of the
work for which this permit is issued FIXTURES—PER TRAP
rl 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of flus,Labor Cade,for the perfnumnce of the work for which this permit is issued. GAS—PA.SYSTEM-I INC.4 OUTLETS OCC.G P APN
My Worker'.Compensation Insurance currier and Policy mun om arc:
Carrier: Policy No.: I GAS—FA.SYSTEM.OVFR 4(EA)
CERTIFICATE OF FXEMITION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE IM'ERCEPfOR
(This section need not he completed if the Lannh is for one hundred dollars(31 Nb BU DI ❑DIVISION FES
or less.) GREASETRAP PLANCH CK1.
Loy any primhat in in ,roumyasm.nceo as to ork become
subjecch hi.permit rkesueo Co.,..mallSEWER—SANITARY—STORM EA.2W FT.
not employ any person in my manner so ser to hecomc snbjcd to the Workers pete I?NERC 'E
O ,z satin,Laws of Cali forma.Dam WATER HEATER WNENf/ELECfR
z O Applieme GRA NG Fulio
ti ti NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
F , become subject to the Worker's Compensation provisions of the Labor Code,you must SOLI
i..., forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION is. ONLENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V Q (hereby affirm llmt them ieoconsvuainn lending agency far the performmce n( D m RettiptN
4. I"' the work for which this Permit is issued(Sec.3097.Civ.C.)
Q Lenders Name TOTAL:
U Lemki'v Address TOTAL:
0. I certify that I have rend this application and state motto,abate information is BUILDING FE
LI) mrmcl.l agree mcnmPly with all city and coumy ordinmccs mJ Stam laws relaingm QTY. MECHANICAL PERMIT FEE
U Z building construction,and mo,hy.tam,im mpmsenmlvcs Othls city tnenterupon the SEISMIC FEE `�
mov>mcntioned properly for inspection Pur,a.. PERMIT ISSUANCE
(We)agree m soon,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiabilities.judgmem,,mou,and expenses which may many wayaccme against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO •POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOUR EREGULATIONS/ MECHANICAL IEE
AIR NANOLINO UNIT(OVER IO,gp CFM) CONSTRUCTION TAX
Signature of Ap,IicmvCwnvuctmr Dole EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURP.'
Will timmplicam ter future hulldia,occupmtsonsmonlle hazardous material HEATING UNIT(TO 1011,000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yes [I No PAID
VENTILATION PAN(SINGLE.RESID) Date R11eipl0
Will the applicant or future building mcupml use equipment or devices which BOILER—COMP(7NP OR I(q,IXq ETU)
..tit hauYes ❑No rdous air conwminants as defined by the Buy Area Air Quality Management :TOTAL:
District? BOILER—COMP(OVER I W,11f10 BTU)
❑
I have read the hazardous mmerials requiremems under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE E
fora' H l h&Safety Code,Sections 25505.25533 and 25534.1 understood that if the NEW RESIDENTIAL MECH. SQ.FT.
inldinpdoear, curtently hn amnant,thm it is my responsibility to notify the mcupmn
club e,Fn^me_nv w fl tat v be roar prise to is.umce of'Cen�m of �cy.
Ownercumbon ru ager / Uam TOTAL: ISSUED BY:
OFFICE