31483 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO RUILDLNG-ELECTRICA L PERMIT NO.
BUILDING DIVISION APPLICATION/PFRMIT' PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 31483
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT-1
O.WNFR'S A E: PHObLE CO R Cf SNAME: LIC NO:
C _l\� �S540 NIC CONTROL 0
�AR EC-UHNGINEER: IC NO:-�J D)R SS: S�O,YiV O
CONTACT -PHONE: WG BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) - BLDG ELECTPLUMB MEC
L-
LICENSEDCONTRdunderSDECLARATION QTY ELECTRIC PERMIT FEE
I m71)affirm That I r3 licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
V110Z withllmme de of Division3o0he Business and Prnfesxions Coda and my license is
EE++ in full force trade ' I. PIeRMIT ISSUANCE ��s
Q Vz(C� License ayl, — Lic.M w FDWL ❑KITCHEN REMODEL
�E�6 Dvm CommcbrAAM APPLIANCES-RESIDENTIAL ❑ADDITION O PLUMBING RE-PIPE
ZO=ne ARCHITECTS DEC A ION ❑MULTI-UNIT ❑STRUCTURAL
'Z l understand m Tans shall use used ss blit monis PANELS
YP Pu MODIFICATION
OZ UPT02MAMP5 ❑INTERIOR - El CHIMNEY REPAIR
I=g Licensed Pmfessianal 2UI-1000AMP5 . IMPROVEMENT
OWNER-BUILDER exempt
OECe RAI Contractor's
� I hereby affirm that 1 am exempt from the Cnmrazmr's License Law for the OVER 1000 AMPS [-1 BATH REMODEf/REPAIR �DEMOLITION .
3 a cJ following mason.(Section 7831.5,Business aM Professions Cade:Any city or county ❑OTHER
u• which viresa SIGNS ELECTRICAL -
LL mq permit re cores the elms,i t for such
h peornit t file
repair any swcmre
m panheisacense pumuam to e,Also requires theApplicantCommsrmiuofiieasLmedatetemcm SPECIAL CIRCUIT/MISC.
P Net he is licensed pursuenuo the provisions of the Commnols License Law(Chapter 9
Q� (commencing with Section 7")of Division 3 ofthe Business and Professions Cods)m 'rEmp.METER OR POLE INST. COMMERCIAL:
4 a that he is exempt therefrom and the basis for the alleged exemption.Any violation of
N Section 7031.5 by an applicant fora ) [I NEW BLDG/ADDITION ❑DEMOLITION
ydre pemdt sub'eds the vpplicammucivil lznuhy of POWER DEVICES OTENANT ❑FOODSERVICE
not am than five hundred dollao($SW).
G I,as owner of the pmpeny,or my employees with wages ax their auk rompcusation, SWIMMING POOL ELECTRIC IMPROVEMENT -
3 will do Ne work,end Ne strut...is not mundedmuttered fmsale(Sec.71W4.Business ❑OTHER
ti unit Profcs MI,Cale The Comranors License Law does not apply ,,an owner of OUTLETS-SWITCHES-FIXTURES
•� property who builds or improves thereon,and who doca.mch work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR' SQ rL
side.If,howevea the building or improvement is sold within one year ofcumpletion,the .FP.FLOOR ARTA SISQ.PT.
owner-builder will have the burden of praying that he did not build or impmve for put- �\
you of sale.).
❑1,as owner of the prapeny,ran exclusively contracting with tlaensed contractors to TOTAL.
onse La desase jet(Sec.o an Business and Proproperty
who
Cmde:)The vesm emin, La-
sense lawdaesnmapply ma,withowner contractor(whosedporimprovee Commm,ond QW. PLUMBING PERMIT PEE
wbo commune for xuch pmjatx with u contractor(s)IiecnscA pursuant to tho Cnmmnnr's
License Law. PERMIT ISSUANCE-"
❑lam exempt under Sec. ,B&PCfor this reason
ALTER-DRAIN&VENT-WATER(EA)
Owner Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations.
0]have and will maintain a Cerlificas ofConsenOo self-insure for Worker's Compete- BRAINS-FLOOR,ROOF AREA,COND, STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
foo for which Nis permit is issued. FIXTURES-PER TRAP '
I have vd will maintain Worker's Compensation Insurance,as acquired by Section
700 of the Labor Code.for the performance of the work for which this permit is issued.. GAS-EA.SYSTEM.I INC.4 OUTLETS IxC.GROUP APN
My Wor�Cotuce�a.n IpiY�tCcartitt and Palify.p�y uas��
Cartier: FCTI Policy Nr✓lL'-�/LJL V GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' ' E
GREAS /INOUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE
Clhis section need not be completed ifthe permit is forme hundreddollars($100) BUILDING DIVISION FEES
or less.) GREASETRAP
I omit thm in the rfomurmce ofthe work for which this PLANCHECK FEE
y pe the Wor s.'CM sha ` SEWER-SANITARY-STORM EA.200 FT.
not employ any Califon in any manner fo as m become suhject m the Workers Compcn ENERGY FEE
cation Laws of California,Date s
�y O Applicant WATER HEATER WNENT/ELELTR GRADING FEE
q NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTF.M/TREATING
�i become subject to the Worker's Compensation provmmns of me Labor Code,you must SOILS FEE
forthwith comply with such provisions or this permit shall the em
e deed revoked. WATER SERVICE
a �
r7z CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
I for which his
that them issued(eucti097.Cis, agency for the Performance of ukv/ Receipt
w l� thewoik for which this permit is issued(Sec.309],Civ.CJ
Izndets Name TOTAL:
Lender's Address TOTAL:
y 1 send,thus 1 have read this epplis.tiom and state that be above information is BUILDING FEE
N coma.l agree to comply wit ere city and county ordinances and state laws miming to QTY, MECHANICAL PERMIT FEE
LJ building consmrnion,said hereby authorize repreunmtives ofthis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and kaha
p rmless the City of Cupertino against ELECTRIC F
liahilities.judgmems,costs and expcnwx which may in any way aceme against said City ANTER OR ADD TO MECH. ^
in consequence of the granting of this permit PLUMBING FEE U/
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,008 CFM)
SOU .F 'GULYDONS. - MECHANICAL FEE
ALR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
g m oApplicant/Contmctor - Or EXHAUST HOOD(WIDUCF) HOUSING MITIGATION HE
HAZARDOUS MA'T'ERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazmdnus material HEATING UNIT ITO 100.000 BTU)
0 defined by the Cupertino Municipal Cade.Chapter 9.12,and the Halth and Safety
Cade,Section 25532M)? HEATING UNIT(OVER 100.000 BTU) .
E]yea ON. VENTILATION PAN(SINGLE RE.SLD) PAID 0
Dote ReceiptM
Will the applicant m furore building by the B use equipment or devices which BOILER-COMP(3HPOR 100,0(1(1 BTU)
emb hezordous air romaminams as Jelined by the Bay Arca Air Quality Management TOTAL:
niau an
' ❑Yes ❑No BOILER-GDMP(DVER 100,000 BTU)
1 have real the harardovs mamriols mquimments under Chapter 6.95 of dra Cali- AIR CONDITIONER ISSUANCEDAT�E/
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if Ne NEW RESIDENTIAL MECH.
building does nm currently have a tenant,that it is my responsibility to notify the occupant /
of the requirements which must to met prior to issuance of a Certificate of Qxupancy.
Owacr arauthm edagcm Data TOTAL: ISSUED BY:
OFFICE