31081 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO - BUILDING-Eu?CTRICAL t PERMITNO. 31081.
BUILDING DIVISION APPLICATION/PERMIT PI,UN1BING-MIcCHANICAL
BUILDING PROJF,CT IDBNTIFICA'1'ION
BUILDINGADDRESS. SANITARYNO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHONF,:. CfOR'S NAME: LIC NO:
' - NIC CONTROhp
nRCHII'ECTIENGINEER'. AC NO: - RF.SS:a�
CONTACT. PHONE: - - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initlal) B��LLDyDG.� ELECT' PLUMB MECH
LA ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMITPEE
1 herehy affirm that I am liceu...I under to+.'..ions of chatter 9(commencing JOB DESCRIPTION
WOO with Section 700(fi Division 3 of the Businessond lkofessions Codgandmy license is RESIDENTIAL:
FEW in tall force and affect. -
PERMIT ISSUANCE ❑SFDWI. KITCHEN RF:hIODF.L
Q ZUZU Liccnu Class Li APPLIANCES—RESIDENTIAL C1 ADDITION ❑PLUMBINGRE-PIPE
NQW Date Contractor
ARCHITECTS DECLARATION:"'. - ❑MULTI-UNIT ❑STRUCTURAL
zOma I understand my plans shall W used as public records PANELS MODIFICATION'
N 'r UPTO200AMPS j
oz—, . . ❑INT PRIOR ❑CHIMNEY REPAIR
FEW Licensed l'mfessionnl 201-IfxNIAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
CouniON 'OVER 1000AMPS ❑BATH REMODEIJREPAIR�Lf1iMOLITION
O< 1 cousin:
:(firm that 1 L exempt from the Contra,m'sCod License Law for the
ippiS5,aOyV following rear m.(Section'co3Lr t,aiter,imdne, entoli Cnoe:Anycily.r county SIGNS[LECTRICAh - ❑OTHER
u+3 W~
which requires o perms t constrict, ¢ immune,do fish repair any structure
�1410 prior to its issuance u1smocappres the applicant liar such permit ale asigreadtatenent SPECIAL CIRCUIT'/MIS!
that he is licensed connotations,provisions ofah Comoscanex Licemo,La (Ctrma9
(commencing with Section 700(l),I'Divtslon 3of the Baines.:td Pmt cos:ms Codc)or TEMP.MEIIiR 011 .IN. COMMERCIAL:
00 that he is exempt therefrin and the busis for due alleged exemption.Any violation of
g [I NEW BLDG/AUDITION ❑DEMOLITION
4q Seclion 0831.5 by any applicant for a jronnit subjects the applicantm n civil penally of
POWER DEVICES
ul=y ❑ FOOD SERVICE
•gip,
not room than fivehundred dollan($StIMPRop. - IMPROVEMI3NT
� O I]Lasownerk,the the structure
r myotatoployac.sintended or offered wages ,sale,Sola 0n 1.B siren, SWIbIMING POOL ELGCfRIC
will do the work,nod the s o Con<a sots License Lwit..not a(Sec.t Diu.Business ❑OTHIiR
and Profwhons Colo:The Contra,.'.License Low tines not apply himself am ownemN OUTLETS—SWITCHES—FIX'1'UNES
progeny who builds or improves thsuch i and who rices such work uadOror through
his own employeese provided that m such mens isemann are sol intended or offered for NEW RESIDENTIAL CI.ECTR SQ FT.
owneL uildor ill h ve building orprovinl ia3old within ant b ild or improve
the - 'SQ.FT.I LOOR AREA $/SQ.Ef.
owner-builder will have burden ofPmving that he did not huild or improve for par- PAID D
pose os own. - r ►i
❑ I,rr owner of the progeny,ran sines and Cnnasains with licensed contract i- - TOTAL:
_ constmn the project(Sec.'/Bid,Boniness and Professions Cale)The Contracmr's Li- - ,
cense Law d.O,,,.apilit)an owner of property who bmilds or improv es thereon,and QTY. PLUMBING PERMIT NEE MAR 19 RECD
who contracts for such projects with a commends)licensedu
pursuano the Contractor -
' License Law.
PERMIT IS, ,C
'r]I am exempt under Sec. .B&P C far this casco CITY Ur
Owner Dote
ALTER—DRAIN& '—WA �R(HA) VALUATION
� - ' - '
WORKER'S COMPENSAi'ION DECLARATION BACK PLOW PROTECT.DC:
I hereby anion under penalty of Perjury one ofthe following declarations 6606--' ,
❑ Ihave and will maintain aCeniticae of Cousentcoself-inter,for Worker's Compem DRAINS—FLOOR,BOOK iA.0 STORIES. TYPE CONSTRUCTION
silica,as provided for by,Section 37W of the Lalx)r Code,for the performance of the _
work for which this permit is issued. FIXTURES—PER TRAP -
1 have and will maintain Worker's Cntnpeneaion Insurance,as required by Section
3700 of the Labor Code,for the serformance(if the work for which this Internal,is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS (ICC.GROUP APN
MyWoder's Compcnsationlnsuranceca erandl'nlicynumher Lv
Cartier: Policy No: - GAS—FA.SYSTEM-OVER 4(EA) ,.
CERTIFICATE OF EX17MM]ON FROM WORKERS'. -
COMPENSATION INSURANCE GREASF/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FE!S
(This section conduct be completed ifthe permit is for one hundred dollen($101)
or less.) GREASETRAP PLANCIIECK FEE
I codify that in the Performance ofthc work forwhich this permit is issued,Ishan ^ SI:WEN—SANI'T'ARY—STORM F.A.21X1 FT. --
net employ any pernm er any manner m as to became mlocat m the Workers'Comped- - ENERGY FEC
Z an..lows of California.Data WATERHEATERW/VPNI'/ELECIR
0 Applicmnt _ _ GRADING FEE
y NOTICE TO APPLICANT:Jr.alter making this Cenificme of Exwnptinn,yon should WATER SYS I'E IGREA'1'ING
f~ become subject to the Workers Compensation previsions of the Labor Cale,you must SOI I:S I;rr
•ti
forthwith comply with such provisions or arts permit shall be daemei revoked. WATER SHBVICE„
aZ CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB. SQ.IT. PAID
U O l hereby affirm that is a construction lending agency for the performance of Date ItemiptX
Or thew kl h' bd P 1(Sa ,909". C' C)
ULender Name - TOTAL:
Isnde:AJdbmi, I AL:
I versify that I have card this application and state that bove inficurrionionis - BUILDING FEE
W) entree I agree tow.idy whh.all city and ourany ordinaticasand state laws relating in ,QTY. MECHANICAL PERMIT FEET
U X� building comuuction.and hembyamhodxrepreunutivesnfthls city to crona,.the SEISMIC FET:
nhova-(War agree ro save for indemnify
an keep harmless agree to save.indemnify end keep hvmaless the City of Cupertino againq I'ERMI'1'ISSUANCE ELECTRIC FEE
- liabil'ities,judgments,costs anti expenses which may in any wayaceme against said City ALTER OR ADD'10 ill -
ronseyuenceo( a gmming of this pemtit PLUMBING PER
A1, s DS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,M)CFM) ,
)URC -' ONS.. MECHANICAL PER
S js AIR HANDLING UNR(OVER ItI"C_FM) CONSTRUCf10NTAX
". plicunt/Cnmmcmr J /Do,. EXHAUSTHOOD(W/DUCT) - t
HAZARDOUS MATERIA.S DISCLOSURE 'r HOUSING MITIGATION FEE
Will the mplicame,into,¢building occupant more or handle hdzadous material HEATING UNIT(TO I0)(1,000 BTU)
as defined by the Colonic.Municipal Calc,Chapter 9.12,uad the Health and Safety
Coca,Section 2553266? HEATING UNIT(OVER 100,000 BTU)
❑Yes '.QNo - - VENTILATION PAN(SINGLE RF_SID) PAID
a Dae Receipt X
Will the applicant or antra building occupant use ea Air a or devices which BOILF,R—COMP LRIP OR 100.0011 BTU7 '
_t hazardous air atmnminams as JefinM by the Bay Area Air Quality Management TOTAL:
DlsmetP1. r
❑Yes ❑No BOILER—COMP(OVER 110.000 BTU)
.1 have card the ha<rdous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
t
forms health&Safety Code,Sections 25505,25533 and 25534.1 undenmad tam,if the NF.W RESIDENT JAL MECH. SQ.
.IIF buildingrtlwa Tly haveutenant Nm iii.myrespamsihility.tocaffy theaccuparm
I ar duo s, Is winch must he mm rimce prom is OV
Cenli",ol/kcnpuncy.
J )f / 1 I I t t
Own u or aJ agent Dom TOTA1-: ISSUED BY:
OFFICE