31381 (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 q q Q p q
BUILDING PROJEC'EADFATIFICATION J 1 J O.L
BUILDING ADDRESS:
SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER' NA .I^ 1116NE: NEI RAM NAME ICNO:
' — I `• r .` N/C 'CON TROL#
RCIIITECFIENGINEER: I. NO, ADDRESS: w'7. 1, ��I N — ❑.
0 LD12-
kii cap"
coM1'ACf: PHONE: - BUILDING PF,RMIT INFO
❑ Consultant I'l Paid by Applicant(Initial) BLDG ELECTPL,�U/�MyB� MECH
LICENSEDCONTRACfOR'S DECLARATION � 'a"" 'U"
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Q FY' ELECTRIC PERMIT FEE JOB DESCRIPTION
�OZ with Sarlim7(g0)of Division Jol'Ihe Baminessand Pmfesnans Code,Ondmyllcense is
I"0C in full me,madeffeat - �2/J PERMITISSUANCE �- RESIDENTIAL•
aUU Licmm�•Clns- Lica f/ ❑SFDWL ❑KITCHEN REMODEL
tF�6 Dec Comranor API'hIANCES-RESIpEN'1'IAI. CADDITION C PLUMBING REpH,E
p.Om ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z O�Z I understand my plans shall he used as public records
OZ-0 / UPIO200AMPS MODIFICATION
F�1;41 1,¢enud Professmonal ❑INTERIOR ❑CHIMNEY REPAIR
�Yg,,1 OWNER-BUILDER DECLARATION 201-10NAMPS IMPROVEMENT
al U I hereby.firm that 1 am exempt fmm the Contemnors License Law for the OVI7R ItHOAMPS ❑BATH REMODEI/REPAIR El DEMOLITION
6 following reason.(Section 7031.5,Business and Professions Code:Any city or county
41aLL SIGNS ELECTRICAL ❑OTHER '
6 which requires a permit m cams'mcn.alter,improve,demolish,nr repair any stmc'urc
prior.its issuance,-Is-rcquiesthe 0111 icon'for such Demot I.file usigncd statement SPECIAL Cl RCUIT/MI SC.
Y p0 thulhcisliecRsedpureuon'tnlhoprovlxionsofthe Cnmracmr''sl.iocnse Wtw(Chapter9 mamnancntg with Section 70co)of Division 3 of Ne Business and Promasi.ns Cmm)ar j 'rIiMP.METER OR POLE INST. COMMERCIAL
6 6 6' that he is excmpl therem froand the basis for the alleged exemption.Any violation of C NEW BLDG/ADDITION El DEMOLITION
I Semm
Section T031.5 by any applicant liar a larmit subjects Ne applicant a civil penalty of POWER DEVICES
not more No five hundred dollars(5500).
h PANT C1 FOOD SERVICE
�Q ❑I,asowner , and pr.peny,mmyemntended wiNwages asthei(Sm.'AW,Business SWIMMING POOL ELNCTRIC IMPROVEMENT
Wdo lie work,and the he Cue is not intended.Law do for tele(Sec.o1 n Business OTHER and Professions Code:The Contractor's License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves'hemon,and who does such work himself ar through
his Own employees,provided that such inmprovemenes arc no'intended or offered for NEW RESIDENTIAL ELECTR 2 ,SQ Ff.
sale.If,however the building s imprescamat i,sold within onu ycmrel con, dii'n•the SQ.FE FLOOR AREA VSQ.ET.
owner-hander wilt have the burden al proving that he did not build nr improve fur pur-
ptnse article.).
❑ Las owner of the property,am exclusively contracting with licensed tnatmnors m TOTAL: S
cnnswn the project(Sec.7014,Business and Professi.ns Cade)The Coutmcmh Li. a O
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such Fatima,with o cotnrec'ons)li¢nsed pursuant in he Committers
License Law.
❑ l am eaemp'under Sec. ,I3&PC far this reason PERMIT ISSUANCE
10wncr pate ALTF,R-DRAIN&VENT-WATER TA) VALUATION
WORKER'S COMPHNSNEEON DECLARATION BACK FLOW PROTECT.DEVICE '000,90
I hereby affirm under penuhy of perlury nue of the fallowing JccDnninmms:
Ihave and will maintain.Cartifcofe of C.nsen"o self-insure foroMrker'a Compen- DRAINS-FLOOR,ROOF,A1t1IA,COND.
anon,os provided for by Section 3900 of the Labor Code,fn the perso mance of the - STORIES TYPE.CONSTRUCTION
KOwork or
which this Fermis is issued FI%TURES-PER TRAP
hove and will maintain Worker's Compensation Insurance,as required by Sermon
f Ne labor Coda fire he performance afthe work for which his pcmmit is ismer. GAS-EA.SYSTEM-I INC.4 OUTLETS
My WnrySe.Cmapcnsvio srance tend Policy OCC.GROUP APN
Camera } �°.Y.oly pOicy"Z.0 '" (�') GAS-FA.SYSTEM-OVER 4(EA)
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COM PENSAi'ION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
(This setdoo need net he ammpleted ifthe permit is for one handled dollars IE 1011) 'HU ILDI NO DIVISION FEES
Or loss.) GREASETRAP
I'miry the in'in any manner
of Hat work for which this permitisen,,Colsha0 PLANCHECK PEH
latio.111 nLOw any person in any manner so as to become subject Nu Wnrkcti Compen- SEWI?R-SANITARY-STORM IiA.21X1 FT
,� Applicant
of California,Dente ENERGY FF.E
WATER HP.A'IER WN ,.L r �urc I
z Applicant
.N., NOTICE TO APPLICANT.IL e0er making this Certificate of ExemptionGRADING FEE.
y, ou should WATER SYSTEM1TRE VHNG
become subject no the Worker's Compensation previsions of the LaMar Code,you must
0.W Afonhwilh am-PlY with such previsions or this permit shall he deemed evoked. SOUS FEE
N'ATIiR SERVICE
,Z) z CONS'1'RUCTIONLENDING AGENCY NEW RESIDENTIAL PLAID, SQ T PAID
UO l hereby affirm that them is.nnnstruc'ion lending agency for the permanence of Dwa Reaipf#
� : the work far whlchthis panni t is i"I'mi(Sec.3097,Civ.C.)
Q U Lender,Name -
IJa Landcr's Address TOTAL'
TOTAL 5
4 I certify that I have read this application and state that the above information is #
BUILDING PEE
h amen.I.&,,ato comply without ally ad..my ordinances andnam laws relating m QTY, MECHANICAL PERMIT ME
U z building construction,and hoohmmubonm repre...ativesof Nis city In amerupan the SEISMIC FEE
odrve-rumioned property fur inspection purposes.
(We) arm ba.,a,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City
in comcip ence of the griming of this permit. ALTER OR ADD TO MECH. PLUMBING FEE
APPLICANT UNDERSTANDS AND\ - OMPLY IVITH ALL NON-POINT AIR HANDLING UNIT IWalll CFM) #
SOU . !REGULATIONS. • MECHANICAL FUR
AIR HANIILING UNIT(OVER I tLNX)CPM)
CfINSTRUCTION TA%
Si mor pplicanUComta"or Ute EXHAUST HOLD(W/DUC')
u HAZARDD SMAMRIALSDISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building Occupant store or handle hmardous material HEATING ON]F(TO 100,000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cale,Section 25532(.)? HEATING UNIT(OVER 100,000 BTU)
Fl Yo., Obo
VENTILATION PAN(SINGLE RF_SID) PAID
Will the applicant infuture building by the B use equipment(or devices which Dam Receipt N
mnllic'?nlous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME(3HP OR IOIl,(no ifPD)
Dislric'9 '
❑Yes 71 No BOILER-COME(OVER 00,M)B'IU) TOTAL:
1 have read the barallous materials equircmem s under Chapter 6V5 of the Cali- AIR CONDITIONER :
(aria Deuhh&Safny Code,Sermons 25505.8533 and 25534.1 understand that if Ne ISSUANCE DATE
building does nor normally have o mount,that it is my ra,poamility in notify the ne,upam NEW RESIDENTIAL MEC H. SQ.ET. -
of the mequfrounwas which must he mem prior to amounre of a Cenifete of Lecupamey.
Owner or authorized agent Date
TOTAL: ISSUED BY:
OFFICE