31094 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES'-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. 31094
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL lJJ
BUILDING PROJECT IDENTIF'IC'ATION
ILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
w4m CA
WNER'S NAM C: -�'/ PHONE: -) CONTRACfOR'SNAME: LIC NO:
cl• 2ic _; N/C CONTRA
ARCHITECT/ GINEER: I LIC O: 6.D )8/ ADDRESS: ❑ �/F nn
CON'PACII PHONE:_ Vll�r. BUILDING PERMIT TIINFO
s NT,_1d`a ❑ Consultant Fees Paid by Applicant(initial) BLDO ELECT PLUMB MBCA
LIC SED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
CMZ 1 hereby affirm Nat 1 em licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
a10
with
Section 7")ofDivision3 ofthe Business and Professions Code.and my license is RESIDENTIAL:
infullforceandcRea. PERMITISSUANCE
F�.Up� License Class Lic.# ❑SF'DWL ❑KITCHEN REMODEL
NZ Dan.-_ Contract... APPLIANCES-RESIDENTIAL DDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION MULTI-UNIT ❑STRUCTURAL
O Z. Z I understand my plans shall b,used as public records PANELS
MODIFICATION
UPTO 20(1 AMPS
Licensed Padewsinnal ❑1 ERIOR ❑CHIMNEY REPAIR
OWNER- 2fll-IINN)AMPS PROVP.MENT
OiU ER-BUILDER DECLARATION OVER RNNIAMPS ATH REMODEL/REPq(R DEMOLITION
WCWC I hereby affirm that I um exempt I'rmn Ne Contractor's Li.o,c Law for the Ifs /y
a t], following vision.(Section 7031.5,Business and P1.1i swimns Code:Any city or county SIGNS ELE ICA OTHER
which requires a permit m conamet,alter,.impress,dentinfish,om
r repair any stmurc
prior to its issuance,also requires the applicantfor such permit to file a signed statement S,,C Cut CAPR I y
y that he is licensed pursuantto the provisions of the Contractors License Low(Chapter 9 ^R U
W a£O (commencinis Section That of Division 3 of to Business and Pmfessime,Code)., TEMP. TCR POLEI �I IYI
that he is exempt therefrom and the basis for the integral exemption.Any violation of ❑NEW I_glA2F1GN ❑DEMOLITION
Senion70J1.36y any applicant fora permit subjects the applicant macivil penalty of POWf:R DEVI { +
F.Z> not more than five hundred dollars($500). ❑TENANT a(//t��00taSERVICE
Tp ❑1,ta owner ofthe property,or my employees with wages as their sole compensation, SWISHES'POOL ELECTRIC IMPROVEMENT �����VV
F will dolhe work,and the suuctue is not intended oroRered for sale(Sea 7044,Business []OTHER
a rand Parafecuisor Code:The C.imsel rs License law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
pmpsny who builds re improves thereon,and who does such work himself or through
his own employees,provided that such improvements sere not intended or offered lin NEW RESIDENTIAL ELECTR SQ BT.
sale.If,however the handing or impnwemcnt is sold within one yearofecouldrion,the O SQ.IT PLOD g/SQ,FP,
pWmcnhuilder will have the harden urproving that be did nor hand or improve fortune. I �
'xaIs)c
r of the propeny,am exclusively contracting with licensed contractors to
mleteen the project(Sec.7044,Business and Professions Ciii The Contractor's Li.
crse Law does not apply to an owner ofpmpcny who builds or improves thereon.and QTY. PLUMBING PERMIT FEF.
who contracts for such limiters with a cmnmector(s)licensed pursuant m the Coatrecmrs
License Low. PERMIT ISSUANCE
❑Tum exempt under,Sec. ,B&P C for Nis remon
ALTER-DRAIN&VENT-WATE IE VALUATION
r Dote
w r yyr�I�ffrm undeRpenOty of perjury onePENSAriON of Nr.Ce fnllowiOng declarations: BACK FLOW PRO'fELT.DEVICE IZ� /'
har�,enJwiI1m.t01.10 a Craifivme of Consentto setNasure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA.COND.
sation,us provided for by Section 3700 ol'the Labor Code,for the performance of rbc STORKS TYPO CONSTRUCTION
work for which Nis permit is issued. FIXTURES-PER TRAR
❑ I have and will maintain Worker's Compensation Insurance,as required by Section -
3700(if the Labor Code,for the performance of the work l'or which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLITIB OCG GROUP APN
My Wurkrra Compen,ation l a imme,wrier and Policy numbm
number a :
Cartier: Policy Nn: GAS-EA.SYSTPM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' b Al-)
COMPENSATION INSURANCE GREASEoNDUSTRL WASTE INTERCEPTOR (VISION FEES
section need our be completed ifthe permit is fortune hundred dollars IS I00) GREASETRAP
or leas) PLANCHP.O !E
I madly that in the performance ofthe work for which this permit is issued,)shall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner to es to become subject to the Workers'Compete ENERGY FE
,z satiun Laws of California.Date �-
O Applicant WA'IEk HEATER W/VENT/ELECTR GRADING FEB
V2 NOTICE TO APPLICANT:If,idler making this Cer ificale of Exemption,you should WATER SYSTEMTREATING
afes^ become subject to the Wnrkefs Compensation provisions of the Lubin Cade,you must SOILS up.
kT1 �y forthwith comply with such provisions orchis permit shall he dermad revoked. WAI RR SERVICE
Q
CONSTRUCTION LENDING AGI!NCYNEW RISIDENTIAL PLMB. SQ.F?'. PAID
V Ihcrchy uffrm rheuhene is aconswctinn lending agency lbr the performance of
Dole Receipt#
LTs tti the work liar which his Noun is issued(See 3097,Civ.C.)
Q U Lender's Name - TOTAL:
Lenin's Artiness TOT
y1 cenify that I have read this application and state that the uhove information is BUILDING FEE r
(A correct T agre to comply with all city and county ordinances and some laws relating to QTY. MECHANICAL PERMIT FEE
C.) Z building construction,sort herebyauturim rcpresenmtiecs ofthis city to Caner upon the SEISMIC FEE
`+ above-mentiunal property for hatermars purposoa.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PHRMITISSUANCE ELECTRIC FEE
Imbiliries.judgainum costs andexpenses which mayunity way accmeagum,said City ALTER OR ADD TO MECH. C
in consequence of the gmming ofthis Nunn]. PLUMBING FEE 7
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITOD 10,00OCEM)
SOURCE REGULATIONS. MECHANICAL THE
- AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signature of Applicanu Comrrcmr - Date EXHAUST ROOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupanbturcor handle hamrdsus material HEATING UNIT(TO 100,000 B'TU)
as dtOned by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532nd? HEATING UNIT(OVER 1110,000 BTU)
❑Yes ENo PAID
VENTILATION PAN(SINGLE RISIII)
Will the applicant or future building occupant use equipment or devices which Date Receipt#
:mit hassrel air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP OHP OR 100,000 BTU(
District? TOTAL-
7 ytt.
OTAL:❑Yew FIN. MOILER-COME(OVER 100.00)BTU)
I have rued the hazardous mmatiuls requirements under Chapter fi.95 mf the Cnli- AIR CONDITIONER ISSUANCEDATE
fnrnla Health sa Sri Cale,Sections 25501 send 25534.1 understand that if the NEW RESIDEM(Al.SUCH. SQ.Cf.
hudding doe,me cmremly have a tenant,that it Is my m,pesihility m acuity the o cupam
of the rulutremems which..in he met priori isamnce of.Certificate of Occupancy.
Owner m mimnrimd agent Data A.. ISSUED BY:
OFFICE