31424 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 31424
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL.
BUILDING PROJECT IDENTIFICA'1'[ON
BUILDING ADDRESS: SANITARY NO. - APPLICATION
NSS/UBBMIIITTI/A.L�DATE
'i
fL1 V i `NU !� `V
OWNS ' NAME: 1I''fl1ONE: (' CONTRACTOR'SNAM E: DC NIC CONTRIILM
X2 e /.jam D Y7 li Y IrN�`u (ted x! ❑
FORCHITECf 'G EER: LIC NO: ADDR .S:
CONTACT. PHONE: BUILDING PER INP
❑ Consullant Fees Paid by Applicant(initial) BL00 ELECT PLU MECH
LICENSED CONTRACTOR'S DECLARATION ❑ ❑ ❑
I herebyaffvm that I am Iiceneehl under f Chapter 9 commencin QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
Provisions n P ( g
aZ with Section"1000)&Divisinn3 1dials nessond Prafessinnx Gde.undralicemeis
00 y PERMIT ISSUANCE RESIDENTIAL:
RU Lj full force anJ eRecmCT 3 /'e �'GG ❑SFDWL ❑KITSkIGN REMODEL
a U�j Liccns Cl s. v.l Lic.N t� ✓
H�W Date Contmcto� APPLIANCES-RESIDENTIAL ❑ADDITION PLUMBING RE-PIPE
Fly A CHITECI'S UECLARATI N PANELS ❑MULTI-UNIT []STRUCTURAL
Z O2 Z 1 understand my plare shell be used as Public accruals MODIFICATION
OZ UPT02MAMPS ❑INTERIOR El CHIMNEY REPAIR
F:I:I-'Til Licensed Pavfessioml 201-1000AMPS IMPROVEMENT
pe�pd .J.I OWNER-BUILDER DECLARATION OVER IOW AMPS
'-+T� U I hereby affirm that I am exempt from the Contractor's License Law for the ❑BATH REMODEUREPAIR D DEMOLITION
�O M U. fallowing hav on.(Section 7031 S,Business and Professions Calc:Any city or county SIGNS ELECTRICAL D OTHER
0 F which requires a permit to construct.alter,improve,demolish,or repair any swcmre
prior in its issuance,also requires the applicant for such permit to rile u signed smtemem SPECIAL CIRCUIT/MISC.
;!I} that heis licensed puxusntto the provisionsafthe Comrecmr's Lacnselaw(Chapmr9
CCCCCC�aa�pO (commencing with Section 70(a)of Division 3 note Business and Professions Code)or TEMP.METER OR POLE INST COMMERCIAL'
d e K that he is exempt Ncrefrona end the basis for Ne a11egM aemption.Any violation of D NEW BLDG/ADDITION D DEMOLITION
Y•� Section J031.5 by any applicant a permit subjects One applicant a civil penalty of POWER DEVICES y DTENANTIMPROV [I FOOD SERVICE
�=Qnot shore than five hundred grope Jolles($SW).
I,as owner of Ne proper, em to ns with wa es as aheirsole cote tion, SWIMMING POOL ELECTRIC IMPROVEMENT
O ❑ P Pe Y Y P Y 6 gesso
will do the work,and the swcmre is oat intendetl oro w do lar sale(Sec.]044,Business ❑OTHER
G ' and Professions Code:The cas thenco License Law does not apply ns if owner of OUTLETS-SWITCHES-FIXTURES
" his o
property who build,,,,or improves thereon,and who dcea such work himself or through
bels own employees,provided that such improvements are not invented or offered for NEW RESIDENTIAL I?LEC'PR SQ fT.
sale.If,however,the building or improvement is sold within one year ofcompletiom the - SQ.FT.FLCHOR AREA s/SQ.IT.
owner-builder will have the burden of proving that he did not build or improve for put- PAID p B Dg1
you m sale). P P9
❑I,m owner of the property,am exclusively contracting with licensed contractors to TOTAL NOV
construct the project(Sec.]044,Business and Professions Cede:)The Contmcmrs Li— g 21996
cense Low does not apply m an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE ,st
who contracts for such pmjectn with a contractor(s)licensed pursuant to the Connotation'sPoo v
License Law. PERMIT ISSUANCE
D l htm exempt under see ,B&PC for reason - TY Ur CUFLhI INU
•Owner - Data ALM R-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I herchy affirm under Penalty of perjury one of the following decimations:
(have and will meinoinn CerdOcme of Corrsem to sdf-insurefor Workds Compcn- DRAINS-FLOOR.ROrF.AREA.CON I.
satins,m provided fm by Scratch 37M of the labor Cade,for the performance of hhm STORIES TYPE CONSTRUCTION
work for which this pewit is issued. FIXTURES-PER TRAP
D I have and will maintain Workers ComPeresta on Insurnme,or required by Section
3700 of The L CW,for the pcourmanceof the work for which Ibis permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP APN
My Worker's o ua o�i 4— cnra"and Policy tmm1A[ha(yl.':/\
Curio m Policy No.: GAS-EA.SYSTRM•OVER 4(EA)
CERUFTCAI E OF I3XEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(This sution need nut be completed ifNe Writ is Faroe hundred dollars($i W) BUILDING DIVISION FEES
or less.) GREASE TRAP PLANCHECK FEE
I certify Nat in the performance ofthe work for which this Permit is issued,Ishall SEWER-SANITARY-STORM EA,200 FT.
rs
not employ any peon in any manner to as to become subjecuo the Workers'Compact- ENERGY FEE
Oz saran laws of Cilifro ia.Date WATER HEATER WNENT,ELECfR
0 Applicant GRADING FEE
NOTICE TO APPLICANT.If,after making this Certificate of Ftwor Linn,you should WA ,ySTEMn REATING
Da become subject In the Woores Cnnhpemmmo provisions of the Lahnr Code,you muss Soli's FEL:
LLI forthwith comply with such provisions or this permit shall he tamedowoket. WATER SBRVICP.
�z CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPIAB. .SQ.PT. PAID
U O (hereby affirm that here is a construction lending agency for performance of Date Receipt
{I. r the work for which this pewit is iavuhl(Sec.3097,Civ.C.)
O I'•' Lemlers Name TOTAL.:
{U Lenders Address TOTAL:
I century that I have read this application and state that the above information is BUILDING FEE
f0./) correct,I agree to comply with all city and county ordinances and state laws relating Tru QTY. MC•CHANICAL PERMIT FEE
U �y buildiagcorewction,and herehyuuthorixe representatives ofadIa yla cmerupon the SEISMIC FEF.
uhnve-mentimord progeny for irspectom puapmes. PERMIT ISSUANCE
(We)
agree to save,indemnify said keep harmless the City of Cupertino against ELECTRIC FEE
liabilities.judgments.costs and expenses which may in any way oceme against said City ALTER OR ADD TO MECH.
in conschmence,of the morning of this permit, PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITO'O W."CFM)
SOURCE REGULATIONS, MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicamp2maretor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE:
Will the applicant.11 Turob ding occupant store or handle hmaardous himeriol HEATING UNIT(TO 100,000 BT U)
as define)by the Cupertino ;N.6
uni at Code,Chapter 9.12,and the Health and Safety
Coda,Section 25532D)T BEATING UNIT(OVER 1110,00(1 BTU)
❑Yes No VENTILATION FAN(SINGLE RESID) PAID
Dole Receipt N
Wic1 the applicant or future bas'ding occupant use equipment or devices which BOILER-COMP(THP OR 1 W,OW BTU)
emit hevallous sir comaminmhte u f abed by the any Arcu Air Quality Management 'TOTAL:
❑isWnT
Fl Yes /No BOILER-COMP(OVER 100.0010 BTU)
Imo ad she luau, t maialsrchare I oder Clmpera!)5ofthe Cali- AIRCONDITIONER ISSUANCE DATE
Ratio t &Safety Cn I : limns 25505,25533 and 2.. .1 undersand that if the NEW RF.SIDF:NTIAI.MECH. SQ.FT.
hu' rte .enoounently mnam,thel it is my rte si 'ilyme of
l
there i ntsw ' h s eni0cem of Occupancy.
Ow rem z d gent Dam TOTAL: ISSUED BY:
_- OFFICE