31540 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITS
F—BUILDING PROJECT IDENTIFICATIO 0
ERMITNOO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING.PROJECT IDENTIFICATION
BUILDINGADDRBSS: SANITARY NO, APPLICATION SUBMITTAL OATI
v 18 3 ViGe , Cf_. ('4- 4 6
OWNER'S NAME IRIONE: C RACTOR'S AM is • LIC NO:
1 -il _ -1! NIC CONTROL
A CIIITECT/ENGI LIC NO: AD1)RISS: J ❑
CONTACT. PHONE: BUILDING PERMIT INFO
GCBS L,1_Z7 Od ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
V ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELIiCTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under Provisions of Chapter 9(commencing JOB DESCRIPTION
cog with Section 7000)of Division 3 ofthe Business and Professions Cade,and my license is
00 y PERMIT ISSUANCE _ RESIDENTIAL:
W in full force and eRgqt.
. �F.Uy(I"] License Cl ss CS Lic.p ` ,�s ❑SFDWL [I KITCHEN REMODEL.
NQ
an
Cnntracmr APPLIANCES-RESIDE TIAL CADDITION ❑PLUMBING RE.PIPE
g,pm ARCHITECTS DELLA ION pgNCIS ElMULTI.UNIT ❑STRUCTURAL
z b; j:- I understand my plans shall be used as public records MODIFICATION
,oz UP TO 200 AMPS
O ❑INTERIOR �CHIMNF.Y REPAIR
Licensed Profesaionel 2011000AMPS IMPROVEMENT
OWNEB-BUILDER DECLARATION
Contractors
OVER IOW AMPS C BATH REMODEUREPAIR [I DEMOLITION
yy 6 1 hereby affirm that 1 am exempt from the Cssion,Co License Law for the
id30F followingmown,(Section Oon..5, 1,supe, and improve,
damns Cnde:Any city orcounty SIGNS C1,IiLTRICAL ❑OTHER
{{till WO t,0 which regmm r Permitsoto conswet,alter,improve,demolish, fi repair any ationa c
that hoitscense pursuantto are the
ovisiosof formula onexcmiuoicense Law
SPECIALGIRGDIT/MISG.
that he is licensed pursuant 7 the provisions of the a Business
License Luw(shadier 9
CMGAO (commencing with Seaion]000pd Division3of the Rusinns and professions Calekrt TEMP.MEMO',Q0 INS'1'. COMMERCIAL:
e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of C NEW BLDG/ADDITION C DEMOLITION
as Section]031.5 by any applicant for a permit subjmta Ne applicant to a civil penalty of POWER DEV ICES
m OTENANT IMPROV C FOOD SERVICE
} not mate man five hundred ty,or y curpl. IMPROVEMENT
G ❑Lo the work.
the property,mmy, erployma with wages
red frsaltheir Sm.mm,Busies SWIMMING P00 ,LEC'1'
G
will do the won,;and e: ah ctureContra not s Lunt,.oraffc does i m apply.]OtA,owner
of C DTHER
M
and Pmkssiob Code:The Contractors License Law saes not apply m if owner of OUTLETS-SWRCHES-SWITCHES
pmpeny who builds or improves mercan,and who Jrcx such work himself or through ,
his own employees,provided that such impmvamena arc not imendet nr offered lar NEW RESIDENTIAL ELB SQ
aale.lf,however the building orimprovemem is solJ within one yearof completion,the SQ.FT.FLOOR AREA $/SQ.PT.
awncrvbuilder will have the burden of proving that he did nm build or improve for put
,s outside). �{ng
1,as owner of the property,ain'exclusively contracting with licensed smairielore m 0 ®�R • 1
construct they rect(Sm.70a4,Business and Professions Code:)The Conwc........
ot `A{"I
mom Law dues napply loan owner of pmpeny who builds or improves rheirenn,and QTY. PLUMBING PERMIT FEE ��� t�
who contracts for such projects with a conoicards)licensed pursuant to the Contractors Cds
License Law. PERMIT ISSUANCE
�/• ` / 99 aw
CI am exempt under Sec. ,B&P C for this reason L'
Owner Dam ALTER-DRAW&VENT-WATER IFA) �,P4UATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO TECT.DEVICE Y�
I hereby affirm under penalty of perjury one of the following declarations:
Ihave and will malnuina CeniEcem of Cnnunuoself-insure for Workers Compcm DRAINS-FLOOR.ROOF AREA,COND.
smion,ss provided for by Section 3700 of the Labor Code,for are performance of the STORIES TYPE CONSTRUCTION
work for which this permit in issued. - FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Iraamrce,as required by Section
3]00 of the Inbar Coda far the peHortlmnce of the work for which this pcnnir is issued.
GAS-FA.SYSTEM-I LIC.4 OUTLETS OCC.GROUP APN
My Workee@ Compel( tion insyfaam carrier and Policy nu arc:
Carrier: Sinop FLIn.aGC. Policy Nn: UO7u10 GAS-EA.SYSHNFOVER 4(13A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCB GRBASPIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This serdon need not becumplcmd if thepermit is for one hundred dollars IS IBX))
or Icss.) GREASE TRAP PLANCHECK FEE
I certify that in the performance ofthe work for watch this permit is issued,l shall SEWER-SANITARY-STORM CA.2001T.
not employ any person in any insurer so as to become subject to the Workers'Camped. ENERGY FEE
,�.. smarm Laws of Culifomia.Dam WATER HFATER W/VENT/ELECTR
Applicant GRADING FEE
F7 aat,
NOTICE TO APPLICANT.IL after making this Certilmlic of Exemption,you should WATER SYSTEM/THRATING( SOILS FEE~' become subject m the Workers Compensation Provisions of the labor Came,you must
t-y fanhwith comply withwah pmvmms,nhis permit shall be deemed revoked. WATER SERVICE:
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'LMR. $Q.FT. PAID
V Q Thereby affect that iseconstruction lending agency for the Performance of Gam Rmciptp
W. sr the work far which this permit is ismad(Set.3097,Civ.G)
0 border's Name TOTAL:
WLenders Address TOTAL:
1 certify that E have read this application unit sum that me above information is BUILDING FEE —
Iii) correct.l agree bee comply with all city and county nnliwrees and slam lawn relining Io QTY. MECHANICAL PERMIT FEE
V F7 building construction,and hercbyauthorim repreurt.a...of this city to emerupon the SEISMIC FEE
move mentioned property for inspection purposes. PERMIT ISSUANCC
(we)agree m save,indemnify and keep harmless me City of Cupertino against ELECTRIC FEE
liabilities,judgments,cost and expenses which may in any way occme against said Ci ty ALTERORADDTOMECH.
in consequence of the granting of this permit, PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AER HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER IL0WCFM) CONSTRUCTION TAX
Signature of ApplicanVConwctor - Dale EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Her th and Safety
Code.Section 23532(e)? HEATING UNIT(OVER 100,000 BTU)
❑Yes Fl No VENTILATION FAN(SINGLE RESID) PAID
Date Excerpt p
e Will the air contaminants
i future building by the Rt use equipment of Maas ement '
emit District?
ous air conuminums m defined by me Ray Aree Air Quality Management BOILER-COMP(3Hp OR 1011,000 BN)
DisuimP TOTAL:
❑Yes CNa BOILER-COMP(OVER 1011,000 BTU)
I have read the haabolos materials requirements ander Chapter 6.93 of the Cali. AIR CONDITIONER ISSUANCE DATE
buildHealth&Safety Coda Sectors 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
former ea & cmrcndyal Sect rs 25305,2 53 tunic 2153 i.1 to derstameaccupahe
ofine mama which must be riono' are of CcniIT , of Ocu y.
Ow author'. age /Z Da TOTAL: ISSUED BY:
OFFICE