31041 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO _ BUILDING-ELECTRICAL - PERMIT-NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL CAT'I
/ 10 'fir.
OWNEAME: P ONE' / CONIRACfO
v /J NIC CONTROLp
ARCHITECT/IiNGINEER: LIC NO: U) & /, _ + ❑
CONTACT: �j�� PHONE ' !/— BUILDING PERMIT INFO
Consultant Fees Paid by Applicant(Initial) BOG ELF PLUMB McC
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under pmvisions of chapter 9(commencing JOB DESCRIPTION
Opwith Srction7NXDofDivisio i lathe Bminrss and Pro es ions Cmdc, nd my license is RESIDENTIAL:
PERMIT'ISSUANCH -
�.. mfall force and¢ t
�UF' L¢ense Class Li<.M ❑SFDWL ❑KITCHEN REMODEL,
6U APPLIANCESRESIDENTIA
a Dam C.macmr - L. +0ADDITIDN � ❑PLUMBING RF.-PIPE
A C ITT=DECLAR PION PANELS
un ❑MULTFUNIT [3 STRUCTURAL'
Cz 7� I derstmW1, MODIFICATION
mydmo,I 11 be toed tspublm me u.
p'Z L�'Q UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
I- INTERIOR Licensed Pruessianal 201.1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
R 6 1 hereby alfirm that I ant exempt Gun the Conuacor's license Law lOVER IIXIIIAMPSin the ❑BATH REMODEUREPAIR ❑DEMOLITION
ip5, F U fallowing orien..(Section 7031.5,Business and Professions Cat Any city m umaty SIGNS ELECTRICAL D OTHER
I.3�y which requires a permit to construct,alter,improve,demolish,or repair any structure A
„F' 0Id
15 prior to is issuance,also requires the applicant for well permit m file a signed stamatem SPECIAL Cl RCUIT/M ISC. _4
E a� that he is licensed pursuant o the provisions of the Contractors License Law(Chapter 9 Wa
aL'1 a (commencingwith Section 7000).1 Division 3 of the Bodressond Prolesxions Codc)nr TEMP.METER OR POLE INST. COMMERCIAL:
0.qp�qo 4 that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION EI DEMOLITION
W^ Seetion]031,S by anynpplicant for a peemitsubject, he applicant loo civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
>>m t marc than Five hundred dollars 05001.
� d q ❑ IMPROVEMENTLSWIMMING POOL ELECTRIC
11 do the work,and the sbucture is not intended omfRmd for sale(Sec.91144,Business []OTHER
6 3�• and Nstboislnts Cade:The Catharines License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
properly who builds or improve thereon,and who does such work himself or through
his own employees,provided that such innprovements are not intended or offered for NEW RESIDENTIAL LECTR' SQ PR ,
sale,11 however,the building or impmvmnent is sold within one year of completion,the SQ.FT,FLOOR AREA 9SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put-
you oxide.).
❑1,us owner.1 the property, at exclusively commuting with licensed criterion,to TOTAL
construct the pmj9m(See.7044,13 me,,and Professions Ctdu)The Cmmrveor's IJ- -
censeLawdoesnotupplytoannwner.f propeny who builds or improves thereon,and QTY, UMBING PERM IT FEE
who contracts for such projects with a ca mucic fs)licenud pursuant m the Contractors
License Law. PE TISSU F
❑ lenuempttnderSw. ,B&PCfmlhv eaten
Owner Date
ALTER- E -WATER EA) VALUATION
•
WORKER'S COMPENSATION DECLARATION BACK 110 CB DE /
1 hereby affirm under penalty of perjury one of the following declarations:
❑Ihave and will mainmina Certificate of Consent to self-insure for Worker's Compete DRAINS-FLODR, .ARF,A,COND. STORIES TYPF.CONSTRUCTION
cation,as provided for by Section 3900 of the Labor Cale,for the performance of the
wpK
for which this permit is issued. FIXTURES-PERTRAP
1 have and will maintain Worker's Compensation Insurmce,as required by Section
31700 fill L.In Cale,f. the ped'ormaa til the work:fm which this Pt Tis issued, GAS-FA.SYSTEM.I INC,00 ,-U OCC.GROUP ANN
My Wnr mnsvi cr ler and PnlicY / GAS-EA.SYSTEM OVER 4PEA)
Comer Policy No. _
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRI.WASTE INTERCEPTOR
(This section need ma be completed il'the permit is formas hundred dollars(51(0) BUILDING DIVISION FEES
less.) GREASETRAP PLANCHECK PEE
I certify that in the performance ofthe work for which this permit is ismad,I shall SEWER- -
cut employ any person in an menner s.as o became subject .the Workers'Certifier. SANITARY-STORM FA.21q PT
YENERGY FEE-
Qz sulem laws of California.Date WATER HEATER W/VENT/F.LECI'R
Z Applicant GRADING FEE
y NOTICE TO APPLICANT:IL alter making this Certificate of Exemption,you should WATER SYSTEMOFREATING -
a ! bec.mecubjeco,the Wukers Compensation provisions of the Latin,Code,yoomast SOILS FEE
GL7 G forthwith comply with such pool sions stoic permit shall he deemod r<v.ked. . WATER SERVICE
Q
UZ CONSTRUCTION LENDINGACENCY NEW RESIDENTIAL PUPIL SQ.FC PAID
VQ I far
pememisac.nsSee 30lending agency Toth¢performance of Data Receiplp
LL the work fu which this permit is issued(Se..31199,Civ.C.) ,
0`U Lender's Name TOTAL:
L) Lenders Address TOTAL:
y1 rectify that 1 have read this application and state that the above information is BUILDING PEE
ti
h correct,l agree to comply with all city and county ordinances and spite laws relating to QJV M17CIIANICAI-PERNIIT FEE
z bnllding cnnsmuctinn,and barcby authorize representatives of role city meinsr upon the SEISMIC FEIi
above-mentioned progeny for impecloo putposex' PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against O ELECTRIC FEM.Iiobilities,jidgmens,ecedimd expcascc whichatay in..y way ocamengaimst 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 Igag1 CFM) MECHANICAL FEE
SOURCE'REGULATIONS.
AIR HANDLING UNIT(OVER FEW)CFM) CONSTRUCTION TAX
Signature of A,ilemn/Comnunar Date EXHAUST HOOD(W/D(1C'q HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicaat or future building oecupant some.,handle hazardous material HEATING UNIT(TO 1110.000 BTU)
as defined by the CuNnino Municipal Cade,Chapter 9,12,end me Health and Safety
Code,Section 25532(t)'I r HEATING UNIT(OVER 1110,0(11)BTU)
[I Via, r
VENTILATION FAN(SINGLE RES ID) PAID
Date Receipt 0
Wi11 the aL.,
r contm ordure building by the Bt sac equipment or devices which BOILER-COMP(JHP OR I00.0fid BTU)
. is air nmmminnns its defined hY the Bay Area Air Quality Management 'i'OT'Ah:
No I101LER-COMP(OVER 100,3X10 BTU)
madmc hazardous umcrials rcyvircments under Chap ter 695 of the Cali- AIR CONDITIONER - ISSUANCE DATE
&Safety Code,Sections 25505,15533 and 25534.1 tnMmmnd that a the NEW RESIDENTIAL MECH. SQ.FT. 3 -]
tcurtently h .notify heasvpuat Jm nz J ge t t - TOTAL ISSUED BY:
OFFICE