31092 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION � � APPLICATIONIPERMIT PLUMBING-MECHANICAL
IIIIILIIING PROJECT IDRNT'IFICA'1'ION
BUILDINGADDRFSS: SANITARY NO. APPLICATION SUBMITTAL DATE
1134(v ' S av7- STEL(_ ( NG G 3-- luc-D
OWNERS NA E: PHONE: CON'1'BACTOR:SNAMI3: ��--Lb,NO:
M q Ir NIC CO p
�;Y1ITECT/IiNGINEER: 'NO: IDD f�GL • ❑
L $ • E
CONTACT: PHONE: I ILD fNG PERMIT INFO
5LJA.CA Ak&TLIttat ❑ Consultand Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENS17)CONTRACTOR'S DECLARATION QTY HLECTRICPHRMIT E.
I hereby affirm war I am licensed ander provisions of chapter 9(eom
menciog JOB DESCRIPTION
D0Z with Section Division 3 ofhe Business and Professions Code. ad my license is
�00Wr y a PERMn'ISSUANCE RESIDENTIAL
rdl raree sins en
�UU�U License Class _Lic.a WL ❑KITCHEN RF.MODF.1,
rFz-aa Date Cntnreaor_ ' ,`,.p AI'PLIANCiiS-RESIDENTIAL DITION ❑PLUMBING RE-PIPIT
A CHITECTSDECLARATM ❑MULTI-UNIT ❑STRUCTURAL
PANELS
OLk..U-1Z I understand my plans shall be used as public records MODIFICATION
ZZU UPT02MAMP5 C1 INTERIOR ❑Cf1IMNEY REPAIR
�� ; Licensed Prolessinnnl 2111-I WIIAMI'S IMPROVEMENT
J OWNER BUILDER DECLARATION
6 I herehy.(firm that 1 am exempt from he Committees License Law far the OVER IgXIAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
O 0,U following reason(Section](131.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
ywhich requires a permit to consumer,alter,improve,demolish,or rcpuir any structure e
pinata its ionievee,vlsa remirestheapplicant fmrsudt peanut mfleusignednatement SPECIAL CIRCUITNIS G
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 1 (I
sR�pO (commencing with Section 700p)of Division 3 ofwe Bmintcomal Professions Cale)or TEMP.METER OR PULEI i conmlltiJ d
6
firm he is exclum themfrom unit the basin for the alleges exemption.Any visitational r;n k �,P}yss.
nLITION
❑N/PPf'FN's/I)BLDG/ UDITIGN Iszwa„�yiy0^)SERVICE
Z nor moe than
LSby hundred
dollars
svbjeetsthe oppllennnnudvli penuay of POWER DBVICES El 01 �/.�L `IJ DSRRVICE
F Z i not more wan five hundreJ dollars yempl IMPROVEMI:NY
C ❑Lasowner ofthe propcny, �is a.,playeeswithwages asaleir role compensation, SWIMMING POOL ELECTRIC V/-�-lJ�/NA
will aothework,vnde: he Contractor's
License Law ulfar
otsale
apply t(M4.BenineseO�V ❑OTHER zl
m aad Professions Gdc:The Co,,,1aor's Liconse Law docs not apply toll owner of OUTLETS-SWITCHES-FIXTfIRES
Property who M1uilds or impmvcs thereon,Dna who w,es such work himself or through ,
his own employees,provided that such improvements arc not intedacd or offered for NEW RE ) IAL ELECTR SQ FI'.
sak.16however,the building or improvement issold within one yearnfcompletim,the SQ.FEE FLOORA pA SJSQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pair,
poseofsale.).
El 1,as owner of the propcny,am exclusively contracting with licensed cnnrm seas to I `
connmct the project(Sec Shad.Business and Pmfcssinns Code:)The Commerce,Li-
cence Law does not apply to an owner of property who builds or improves thereon,and QTY. UM PERMIT FEF,
who contracts for such projects with a contractors)licensed pursuant ter the Contractor's
License Law. - PERMIT ISSU +
❑ lam exempt under Sec. ,B&PC forthisrtason
Owner Data ALTER-DRAIN&?-!6
. WATER IEA)
IIATIO
-� WORKER'S COMPENSATION DECLARATION BACK FLAW PROTE
I herehy affirm under Iienehy of perjury one cattle following Jalmmions:
I have and will maintain a Cenificme of Consent to self-insure for Worker's Camper- DRAINS-FLOOR,ROOF AREA,COND.
sation,as provided for by Section 37W of the Labor Code,for the Performance of the STOBIFS TYPE CONSTRUCTION
work for which this permit is issued FIXTURES-PER TRAP
1 have eta will maintain Worker's Compensation Inmmonce,as required by Section
3700 afthe labor Code,for the performanceof the work far which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GBOUP APN
My Work& .tinct lnsumnce c'/^ d Policy aamba ere: Q/ GAS-G.SYSTEM-OVF:R4(EAI
Carticc I ) Policy No.: 9-4Tr
L:
FIT CA MI'Pol FROM O E S'
COMPENSATION INSURANCE. GREASEIINDUSTRL WASTE INTERCEPTOR
(This section need not liecnmpleted ifthe permit is forone hundred dollme(SI(g)I BUILDINGDIVISION FEES
or kss.) GREASE.TRAP '
PLANCHECK IEE
Ims any hminthein performance any
as he
Ice For which th1.theperiod,W.leasuedlshall SEWER-SANITARY-STORM EA. FT.
ern employ any person in any nwnnu so us m bacnmc suh,ja:un the Workers'Cantpmt- ENERGY FEE
O Z smion Laws of Cslifomk.Dore WATER HEATER WNHNTIELECTR
Z Applicant GRADING FEE
ti NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
a ' become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FE
JN 7S,
1 Q forthwith comply with such provisions or this Dental shall he deemed revoked. WATER S17RVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMO. SQ.FE PAID
U Q 1herehyaff,.chat there iso construction Radingagency fonhe porformanceof Da Neeeiptg
4. ;t the work for which his penitis issued(Sce.3097,Civ.C.)
0 U�R Lender's Name
TOTAL:
LIJ IanaeYS Addreen
sir 1 certify thm 1 have cera this application and state that the strove information is BUILDING F
los) come(.i agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE G �y
(,) Z building comtmetion.and hereby authorize representatives orals city m enter upon he SEISMIC
P
aMwm
e- emiuned property far inspection p irinses. PERMIT ISSUANCE.
(We)agree m save,indemnify and keep hamdess the City of Cupertino against ELECTRFEE t
liabilities,judgments.costs and expenses which may in any way accrue,against said City DETER OR ADD TO MECH. PLUM LNG FEEin consequence of the good ng of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON]T(TO I f0a)CFM) MEC ANICAI.PITH
SOURCE REGULATION
3 AIR HANDLING UNIT(OVER HILL(W CFM) CO S'TRUCTION TAX
f Applican nor � Date
Sig nature oEXHAUS T GOOD DAIMUCf) HO ITIGATION FEEL
MATERIALS DISCLOSURE
Will theapplicantsir future buildimgoccupant,intent handle hazmdoas material HEATING UNIT(TO I00.0i BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Codv,Section 25532001 HEATING UNIT(OVER 1110.0110 BTU)
❑Yes ON.
VENTILATION PAN(SINGLE RHSID) PAID
Date He tY
Will the applicamnt or futurefuturebuilding occupant equipment lir devices which
.ithtmm rdover coaminantsmdefined by the Bay Area Air Quality Management BOILER-COMP(JHPOk 100,00OBTU)
.aistrid?' T I.
E3 Yes ON. IfO1LER-COMP(OVER 10!1,011()BTU)
I have and the hazmdous=serials rtuirements under Crater 6.95 of the Cali- AIR CONDITIONER
9 P ISSUANCE DATE.
fomia Health&Safety Calc,Section 25505, ad 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT,
building does not currently have a tenant.that
my that it is my tuspxpnnsihllity to notify the oreupwn
of the unci mments which must Ie met prier to issuance rfa Cenificme of Occupancy.
Owner or authorized agent Date ISSUED BY:
OFFICE