31311 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PCRMITNO. 's 3 /k
VK
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
11
BUILDING PROJECT IDRJPIIF'ICAT'ION
ILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
�W A L>: HONE: CO ACTOR'S NAME LIC NO: •��`�
V�01 SI /`�k p{,T NIC CON1HOLN
r�A ITCNGINF' LIf M ESS: �� `IR 1� ❑ F�/
CONTACT: 1 is BUILDING PERMIT INFO
-7.0-201
_ /� ❑ Consultant Fees Paid by Applicant(Initial) B� .6 PLUMB C
LICENSED CONTRACTORS DECLARATION 7V� QTY. ELECTRIC PERMIT FEE ❑
I hereby affirm Nat I am licensed under provisions of Chapter 9(commencing JO DESCRIPTION
Dat with Section 7.00 of Divisinn3ofee Buzinasand Professions Code,andm license iz --
�0O y PERMIT ISSUANCE RESIDENTIAL:
in full force and effect.
�OF ❑SFDWL ❑KITCHEN REMODEL
;Z(X License Class Lica
6� Dme C.ntracmr APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
1„pifARCHITECTS DECLARATION PANELS ❑MUI.TI-UNIT El STRUCTURAL
zona I undersonl myplans shall beusedaspublic records MODIFICATION
Oz-qOO UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
FSI-•' Licensed Professional 201-1006AMPS IMPROVEMENT
ayl OWNER-BUILDER DECLARATION OVER]Bob AMPS y�y M el 1 hereby a0irm that 1 son exempt from the Comroctors License Law for the ❑BATH REMODEIJREPAIR ❑DEMOLITION
pe RiN following reusoo.(Section 7031.5.Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
YYII�O which requires a pmait to construct,alter,improve demolish,or repair any structure
yr.1 pliant.its issuance,alsorequiresNeupplicwt for such permit to tile.signedstaremern SPRCIALCIRCUIT/MISC.
yWWy Nat he is licensed pursuant to the pinvlsion.or the Contractors License Law(Chapter 9
Cp0 (commencing with Section 7")of Division 3 of the Business and Professions Cole)or TEMP.METER OR POLE.INST. COMMERCIAL:
a Mm that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�p4, Y• Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of POWER DEVICES
fu"m ' NT ❑FOOD SERVICE(
not more than Eve hundred dollars(empl. ROVEMENT
�z47Q ❑Lnaowner ofthe property,ormy a ateyeeswiNwa,cs nsoleirml<compensmion. SWIMMING POOL ELECTRIC
�� =it do Newark.Codec structureisnots lateen.Law dopes not apply 7(W4,Businese THEE
3 and property
who b illsCode:The Contractors License dev does urn work
hi s if owner of "LETS-SWITCHES-FIXTURES
pmpcny who builds or improves thereon, pro who dors such wank himself of through
his own employeese building
r m such improvements vre not imm�ded mpleered tfarhe NEW RESIDENTIAL ELECTR SQ Irl'.
sale.If,haweveq Ne building urimprovemcnt is mid within one,carol completion,the Q.Ff.FLOOR AREA SISQ.14.
rocconbuilder will have the burden of proving that he did rat build or improve for put. L �/� ^
- pose of saleJ. 4.iIV a�
1,ns owner of Ne property,um exclusively wntmcting wiW licensed enmracp.a p. T AL: {1.
construct the project(Sea 7044,Business and Professions CaleU The Commetore Li p�
c se Law does urn apply to an owner of pmpcny who hnilds ar improves thereon,and QTY. PLUMBING PERMIT FEE PAI Y
who contracts for such projects with a commands)licensed pursuant to the Contractors
License law. PERMIT ISSUANCE
I oro exempt under SeP c. .B& C for this reason
ALTER—DRAIN&VENT—WATER(FA) VA A 1QPT 0
Owner Dme
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE f i•
I hereby affirm under penalty of perjury nn..f the follawing deductions: CI�0:,w
I1m,,md will nommen.CerifiemeofCcosenl to self-insure for Workers Cionpen. DRAINS—FLOOR,ROOF,AREA,CONO
,anon,at provided for by Sanson 3710 of the Labor Code,far the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES—PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
3700ofthe Lobar Code,forthe pe immune tithe work fur which this permit i,issued. GAS—ISA.SYSTEM-I INCA OUTLETS OCC.GROUP APN
M Won r' tin Insu r and Policy aumlverure:
Coltec (icy N..; GAS BI
-OVER4(PA)
�FICATE 0I+EXEMPT ON FROM which
GRCASI%]NDUS3'Rl.WASTE INTERCEPTORCOMPENSATION INSURANCE
(Thissection need not be completed if be permit is forone hundred dollars(SIM) BUILDING DIVISION FEES
orlcssJ OREA513 TRAP LANCHE.CK FEE
Loy any that inthe anymrzoerrformance of the work for shich ubject to pee Woo issued SEWER—SANITARY—STORM M.200 PT.
not employ any person in any mannenn us to become subject to me Worked Co.,.-ompenENERGY FEE
saion Lows of California.Date
O Applicant WATER HEATER WN6NTIEL[CI'R GRADING FF.E
VJ NOTICE TO APPLICANT:If,after making this Cendwon.of Exemption,you ehoulJ WATER SYSTEA1lBEATING
aberate subject to the Worker's Compensation previsions of the Labor Code,you must SOILS FEE
DJ forthwith comply with such provisions or this permit shall be accrued revoked. WATER SERVICE
1 �
tU. z CONS anham is.const[.ENDING AGENCY NEW RESIDENTIAL PCMB. SQ.14, PAID
I hereby affirm that isumnmrumion lending agency for performance n( Rec ptM
LUk, � the work for which this permit is issued(Sce.3097,Civ.C.) -
0 UendL
Lattices Name TOTAL.
WLender's Address TOTAL:
I verify eat I have ed this application and state that the above infommtia
� .is BUILDING FEE
N recorrect.l agree to comply withal]city and county ordinances and spam laws relating to QTY. MECHANICAL PERMIT FE
U building construction,unit herebyaothmizee'reuutmises of this city to enter open the SEISMIC FEE
abrve-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to smw,indemnify and keep harmless the City of Cupertino ugains, ELECTRIC E l
Iiohilities.judgmenls,costs and expense,,which may in any way oceme against said City ALTEROR ADD TO MECH.
seq
inconuence of the grerning of Nis pemrit. PLUMPRISGFEE
APPLICANT JNDERSTANDS AN D�L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MIANICAL FEE
SOURCE �ULATIONS. F I
AIR HANDLING UNIT(OVER 10JsM CFM) ONST0.UCfION TAX
Sign rc ApplicnMC morJS MATERIALS DISCLOSURE Duro EXHAUSTHOOD(W/DUCT) ry0 (MITIGATION FEF.
DOI
ill Nea ca or fwuni buildings,Chaptsmreor handle Health and Safety HEATING UNIT(TO IW,IXkI BTIO
vs dcfittW by Ne
no Municipal Cale,Chapter 9.12,and the Health end Safety
CoJc.Section 255 2(a)'! HEATING UNIT(OVER IlX1,f0p BTIO
❑Yes ❑No PAID
VENTILATION FAN(SINGLE RFSID)
l Dam Receiptp
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as dcfinbytheBay Area Air Quality Management BOILER—CDMP(311P OR 100,00OBTU)
TOT
District?
HOILER—COM('(OVER 100,000 BTU)
Ldo.mu
ON.
real the harallous materials isuirearents under Chapter M the Cali- AIR CONDITIONER
H P ISSUANCED
Safety Cale,Sections 25505,8533 and 5534.1 undersand thet If the NEW RESIDENTIAL.MECH. SQ.FT.
m eurendy havea mn..1,the,it is my resp risibility to notify Ne mcupaments which must he ntet prior to maintain of a Certificate, ICochrane,
mzed agent Dam ISSUED BY:
OFFICE