31360 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED.LINES-USE BALL POINT,PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. e] /�J�O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
BUILDING ADDH�f$: SANITARY NO: APPLICATION SUBMITTAL DATE
OWNFIi'.S PgDNE: CONTRACTOR'S NAMC:_�../Y� LIC NO: N/C CONTROL
RCHIITTECT(ENGINEER: 1 LIC NO: ADDRESS:/V`•Vw,+\`,TYS•I_'\0./ ❑
CONTACT: \\ PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) - BLDG HLECT PLUMB MECH
r '
LICENSED CONTRACT'OR'S DECLARATIONsofC
I QTY ELECTRIC PERMIT FCC JOB DESCRIPTION
QWZ1 Section
affirm that 1 am licensed under p,PrLL tons of Chapter i(commencing
IIy1 00 withhll form and effect.
Business end PrMcssions Code,laid my license is
1-'OO L ease la end effect. PERMIT ISSUANCE
'RF- I,$DFNTIAIr
�F,UZV License Class LiaN ❑SIeDWI. , OKD'CHFNREMODEL
N6w Dale Contractor APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING RE-PIPE
,=o, ARCHITECTS DECLARATION ❑MULFFUNIT ❑STRUCTURAL
y p v4 a I understand my plans shall be uud as public records PANELS
_ MODIFICATION
OZ-, - � UP TO 200 AMPS � C1 INTERIOR El CHIMNEY REPAIR
Licensed Professional 201-I000AMPS IMPROVEMENT
��dd ..•.,..41I1 that I a exempt
m Ce Contractors
'OVER 1000AMPS ❑BATH REMOUEL/RuPAIR DEMOLITION
m Q 1 hereby affirm that I am exempt from the Comracmrx Li<enu Law r the
3 d O following renaon.(Soetlnn]031.5,Business and Pmfesalons Code:Any city or c ty SIGNS ELECTRICAL ❑OTHER
p.LL O which requires a permit to construct,alto.improve,demolish.or repair any soma
�j prior to its issuance,also requires the applicant for such Permit to file a signed statemen SPECIAL CIRCUIT/MISC.
abuthe is licensed'mannnothepsvisionsofthe Camructors License Law(Chupmr9
Y6'1�00 (commencing with Section]OOIp of Division Sof Ne Business and Professions Code)m TEMP.METER O POLE INST, COMMERCIAL-
Q, that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W stn Section 7011.5 by any applicant for a Permit subjects the applicant to a civil penalty of VW151 DEVICE' NANT ❑FOODSERVICE
F Qnot more Nan five hundred dollars(5500).
D 1,as owner of the propeny,or my employees with wages as their sole compensation, SNVMTNG POOL ELL IMPROVEMENT
O will do the work.end the saentoo is not intended or offered fored,(Sm.7044,Rosiness ❑OTHER
and Professions Codi,;
The Contractors License Law does not apply to an owner of DOLE -SWITCHES-Fl S
6 a^ propeny who builds pe improves thereon,and does such work himself or ct rnugb 4
his own s,persuaded ed Net such improvements vnot intended or oReud for NEW RFS EN'1'IAL SQ IT '
r sale.IL however the building or improvement ixsuld within one year ofcomplerion,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not huildor improve for par,
youofsale).
❑I,as owner of Ilia property,am exclusively contracting with licensed contrnetors'm TOTAL: 11 A/i I D
construct the project(Sec.7044,Business and Professions CNet)The Convectors Li- �-
cense Law back not apply to an owner of property who builds or improves thereon,end QTY. PLUM G IT FEE OCT ��
who contracts for such projects with a contmctooto licensed utsuanunthe Cmdrouni'; A^
License Lew. PERMIT ISSUANCE quo
\�❑I am exempt under Sce, B&P C fe. this reason
jner foodiffrF140120N. Date ALTER-DRAIN&VENT- ATER L VUYLVS'�YBTI
WORK CR' COMPL'NSATIONDHCLARATION BACK FLOW PROTECT.DEVI
1 hereby allies under penahy of perjury ane of the following declamrinnc -
❑I have and will maintain a Certificate ofConsenuo self-insure for Worker's Compen- DRAINS-FLOOR,ROOF AREA, OND. - STORMS TYPE CONSTRUCTION
s union,as provided for by Section 3]W of the Latwr Close,for the Perl'smunce of the
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
37M of the Lubar Cade,(,a,Ne performance of rbc work for which this per mit isieard. IMPAL'a—rhl" iL OU'TLS OCC.GROUP APN
My Worker's Compen mien Insurance carrier and Policy number are:
Currier Policy No.: - GAS-PLA SYSTEM-OVER 4(EA) s
CERTIFICATE OF EXEMPTION FROM WORKERS' s. tis
COMPENSATION INSURANCE USTRL WASTE RC_'PTO f .pUIhQING DIVISION FRES
Massamben neednothecomplded ifthepmmit i.sforonchundommulars(81 W) C. : r. - t
.. or less.) '� •, PLANCHECK FEE
I certify that in the perfaromme oflhe work for which this permit is issued,l shall AR{'-5f Mlv(�21HfFi --' t'"k"°'-14i
nm employ any person ie any manner so as m bxnme subject m the Workers'Compete ENERGY FEE
,Z smion Laws of California.Date
Z T/ELECI'R GRADING FEE
Z Applicant "
V] NOTICE TO APPLICANT:If,after making this Cmificme of ExnnpOon,you should
abecome subject in the Worker's Cnmliens;nion provisiona'of the Luton Code,you must - SOILS FEF.
l2a fnnhwiN cmmply with rah pmvisimnn or Nis permiuhellMJcemN revoked. - 1
{ tv (,le`.r Uj 1r
� z CONS'1'RI1CI'I(IN LENIIING AGENCY - IiW HF.SIDENTIALPLMB.. SQ.FT. 'PAID
V TherebyaRrm then Nem isecorotmctinn lending agency for the perfonmanc<of Dote Receipt#
INF Ne work far which this permit is issued(Sec,309],Civ,C) •�
Vlender's Name
WLenders Address - T TOTAL:
yt I sonify rbut I have read m s application ane state that the above infornodon isnab-ireG PEE.
4 VI correct,I again,to comply with all city and county ordinances and state laws miming to QTY. MECHANICAL 'IERMIT !%�
U 7- building construction,and hereby authorize representatives ofthis city ill enter upon the EE
above-mentioned Property for inspection purposes. -
(We)ague to soup indemnify and keep harmless the City of Cupertino egainm FEEliabilities,judgments,costs and expenses which may in any way accrue against said City ACI'ER OR ADD TO MECH,in consequence of the granting ofthis permit. iME APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTqIR HANDLING UNIT(TO 10,(gp CFM)SOURCE REGULATIONS. LFI7Eit AIR HANDLING UNIT(OVER 18000 CFM) IONTAXSignaluunfAPPlicant/Conamemr Date EXIIAUSTHOOD(W/DUCTMITIGATION FEEHAZARDOUS MATERIALS DISCLOSUREWill the applicant or future building occupant stouor handle bnmNous material HEATING UNIT Off,100.000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12.and the Health and Safety
Code,Section M53260? HEATING UNIT(OVER 100,000 BTU) _VENTILATION PAN(SINGLE RF.SID)Will the applicant er future building occupant use equipment or devices which Date Receipt pemit hazardous air conmm mane u defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,1100 B'I U)
extin? TOTAL:❑Yes ❑Nu BOILER-COMP(OVER 1080110 BTU)
I have read Ne hmardous materials requirements under Chapter 6,95 ofthe Cali- AIR CONDITIONERISSUANCE DATE.forma Health&Safety CNe.Saliuns 25505,25533 and 25534,1 understand Nat if rhe ryLsW RPSIUF.NTIAL Mf:CH. SQ.FT.building does not currently have a moan,Nat it is my responsibility to notify Ne occupantof the requirements which must In mer priorto issuance of a Comficae of Occupancy.
Owner or authored agent Date TOTAL: :
OFFICE 0.
CLOSED/
EXPIRED
TEMPORARY
PERMITS