31307 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECFRICAL PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
PUJUDING PROJECT IDEN'T'IFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAPI
OWNER'S NAME: PHONE: CONRACfOR'S NAME: LIC NO:
�, NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑.
CONTACT: PHONE: BUILDING PERMIT INFO
9G-7G2o [__1 Consultant FecsPaid byApplicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CON'TRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEB 29
I hereby affirm that I am licensed under provisions of Chapter 9(umnneneing JOB DESCRIPTION
-DaZ with Section 70(00 of Division 3 ofthe Business and Professions Code,and my licence iv •�
40 i PERMIT ISSUANCE
m full farce and effect.
6 G7 4�0 87 FDWL OKITCH IN RE-PULL
V�j License Class Lic.r��,.
rnQL Date �A�—Contmc�• p��/L 1 C APPLIANCES-RL•SIDENTIAL ❑ADDITION ❑PLUMBING R&PII'F.
' oo ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
O Z @ J� I undesmnd my plans shall be used as public opeCa s MODIFICATION
UPTO200AMPS
- 2BI-IOaBAMI'S ❑iNTERIOEMEN9' El CHIMNEY REPAIR
d3
Licensed Pmfcssinn^I •
sj OWNER-BUILDER DECLARATION OVER IB(IIIAM PS ATH REMODEI/REPAIR El DEMOLITION
I hereby affirm that I am exempt from the Connector's License Law for the
xa01U fallowing reason.(Section]831.5,Business and Professions Cade Any city oramnty SIGNS ELECTRICAL OU ER
ID 3 LL[- which requires a permit to Con.mm�,alter,improve,demolish,or repair any swnure
priorm its issuance,also requires the applicant for such permit o rile a signed demount SPECIAL CIRCUITIMISC.
�f p. that he is licensed puomam m the prnvWool ofmc Contractor's License Law?Chapter 9
OC (Commencing wim Section 990)of Division 3 ofthe Busines mm Professions C(lde)or TEMP.'METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation or O N17W BLDG/ADDITION O DEMOLITION
urn Station 703 LS by any applicant for a permit subjects the applicant o a civil Penalty of POWER DEVICES OTENANT 'OFOODSERVICE
?Q not mare than five hundred dallats(S50d. IMPROVEMENT
Ohas owner of the propcny,or myempinyees withwugcs es theirsole n+mpensation. SWIMMING POOL ELECTRIC ,
will do the work,and the structure is nod intended oroffened for sale(Sec.9194,Business O OTHER
and Four.sanns Cade:The Confolaor's License Law does not apply In an owner of OUTLETS-SWI'PCHE9_FIX TURES �j CD e
�' .. property who builds or improves thereon,and who does such work hanowil'or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAI,ELECTR SQ f.. r90
sale.If,however the building or improvement is sold within one yearofcompletiojo, SQ.FT.FLOd AREeAa $/SQ.IT.
caner-builder will have Bae burden of proving But he did not build or improve for puT-
pnse of sale.).
1,as owner of the Property,Can exclusively commenting with licensed contmemrs in TOTA OCT 16 19 6
n i,amet the project(Sec.7044,11miuCss mad Professions Code:)The Conaamors Lt.
censeLawdocsnotapply to unowner of p,n,.y who hulWs or I.......IIsomm.and QTY, PLUMBING PERMIT FEE ^ ry
who contracts for such projects with a contmm
ered licensed pursuant to the contractor'. V�11 Ur l4umri1 ItlV ^
License Law. PERMIT ISSUANCE
O 1 am exempt under Sec. ,B&P C far this reason
•Owner -WORKERS COMPENSATION COMPENSATION DECLARATIONLARATION ALTER-DRAIN&VENT-WATER IEA) VALUATION
BACK FLOW PROTECT.DEVICE /I /� G'
I hereby affirm underpenalty ofperjury one of the following declarations: V O
I have and will maintain a Certificate ofConsem to self-imade for Worker's Coni DRAINS-FLOOR,ROOF,AREA,COND. •3d
eatio^,as provided for by Section 3]00 of the Latin Cate,for the.permannoce ofthe STORIILS TYPE CONSTRUCTION
work for which this .it is issued. FIXTURES-PER*1 RAP
❑1 have and will maintain Worker's Comper,mant Imamate,as requimd by Section '
1]00 ofthe Lubar Cnde,far the perfnrmaoceofthe work for which this permit lx issued. CAS-F.A.SYS HIM.I INC.4 OUTLETS OCC,0120111' APN
My Workers Comp,reatiim Insurance carrier and Policy another ata
Cartier. Policy N., GAS-EA.SYS'I'EST OVER 41BA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION ITPS
O'hie section need nm be,Completed ifthe pmand,i.far one hundred dollars(S 100)
or less) seGREASE IRAI' I'LANCHECK FF.E
I an i ry don In(hepefformmuc of the work for which this Permit is issncd,I shall S17WER-SANI'PARY-STORM EA.200 PP.
nm soso employ any Pern in any manner as to became subject In the WorkC,,C.mpe
n- ENERGY FEE
Zz union Laws of California.Dale WATER It EATER WNEN/ELECI'R
0 Applicant GRAUINGFEE
y NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMCTREATING
abecome subject m the Workers Complaint mPrevisions of the Labor Cnde,you man SOILS FEE
W fnMwith comply with such provisions or this pvoint shall he deemed revoked. WATER SERVICE
0
UO CONSTRfilacon]ON LENDING
ng.'enY NIiW RESIDENTIAL PLMB. SQ.FT. + PAID .
Iherthy uffinn that Nen isnconnmction lending u6e^cy far the performance of Dam RaeiptM
W. Fthe work for which this Permit is issued(Se,3097.Civ.C.)
Lenders Name O TOTAL:
U Lcudefs Address TOTA
0. I certify thin 1 hC,C,c.d this application and nide then the above Information is BUILDING FEE
Ln 7 caned.I agree Io comply with ah city and county ordinances and state laws relating m QpY, MECHANICAL PERMIT FEE
Z Q
U building construction,and hereby awhadm expresenmtives ofthiscity toemer up.nthe SEISMIC FEE
abovem.ntioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hurmlcu the City of Cupertino against ELECTRIC FEE
liabilitiesjudgments,costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH. e M
in consequence of the granting of this pardia. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT OG 10,010007M) MECHANICAL FRE
REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX'
Signature of ApplicanUContmdar Dom EXHAUSTHOOD(W/DUCT) 14OUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous mammal HEATING UNIT GO 100,IX0 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Healthand Safety
Coda Section 25532(a)] HEATING UNIT(OVER 100,000 I1TU)
❑Yes No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER OR 100,000 BTU)
emit hamrdous air contumacious ue defined by the Boy Area Air Quality Management w'
f District? - TOTAL:
❑Yes 0Ni BOILER-COM('(OVER 100,000 BTU)
I have read the hmardou,antra ds requinmeetx under Chapter 6.95 of the Cali- AI R CONDIT TONER
/k ISANCE DATE
builds Health&Safety Cositlyha Sections 15505.25533 tat i,is my cad 2553.1.It understand that if the NEW RESIDENIAL MECH. SQ.FT. /1
building des a currency have atenant,thoto ismyceof a aCertycanotifythe
pancy t
of the requirements which must M amt prior to issuance of n Certificate of(kcupancy.
Owner or embodied agent Date TOTAL: ISSUED BY:
OFFICE