31447 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. /I A4(�p
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 31447 1
BUILDING PROD C'1'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER AMU 1'li(INB: C RAC N'SN E: LIC NO: • +� ��
I N/C CONTROL#
1I i - iN �S - ;�3
F ARCHIT[Cf/P EER: LIC NO: ADSS: ❑
IIIc{ CON FACE. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) III. G ELIECIPLUMB- Ivi
i ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC P17RMIT FEE
I hereby affirm Nm 1 am Ecenxed under provisions of chapter 9(eomme..cing JOB DESCRIPTION
DCZ withSm111017)of iof the Buzines Professionsetde,.nam I' n t
u)0p y me se's PERMIT ISSUANCE RESIDENTIAL:
F .full force and cf
oW� ❑SFUWI. C1 KITCHEN REMODIEI.
ZUO License lass Lic.p
�Q� Dme Comranm AI'PLIANCBS-RESIDENTIAL ❑ADDITION �PLUMBING RE-PIPE
Dy ARCHITECTS DF.0 ❑MULTI-UNIT ❑STRUCTURAL
z85K- Iunderstand myplans shall beuseaspublic recads /f/J�fj�( ✓ PANELS ODIFICATION
UP TO 200 AMPS
'FA�Joz-O - ❑IMPROVEMENT, IMNEY REPAIR
LLI Licensed Professional 201-1000AMPS IMI'NOVP.MENT
CGCG raj OWNER-BUILDER
asenfi DECLARATION
CounsON OVER IOW AMPS []BATH REMODEUREPAIR DEMOLITION
I hereby affirm thus I am exempt from the Counselors License Law for the ykDLV
following..arm ISection 7031.5.Business am Professions Code:Any city or county SIGNS ELECTRICAL El OTHER
W 3 LL F which calcines a permit to conum r,slier,improve,demolish,or repair any structure
FSO pd ,1. . iummue,alsorequimx the applicant for such permit m file.signed loccuu a SPECIAL CIRCUIT/MISC.
uSiy�y' y that he is licenced pursuanua the provisions ofthe Contractor's license Low(Chapter 9
00 (commencing with Section 7000)of Dividon 3 ofthe Business unit professions Colv)or TEMP.METER OR POLE INST. COMMERCIAL
p,m y that he is<e<mps therefrom and the basis for the alleged exemption.Any violmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
Wk 4y,
Section 7031.5 by my applicant fm a permit subjects the applicant a a civil Penalty of POWER DEVICES OTENANT ❑FOODSERVICE
z�ya no",don five hundred dollars(1500), IMPROVEMENT
Fq
El 1.as ownerafthe property,or my employees with wages as their sole compemation. SWIMMING POOL ELECTRIC
will do the work,and tha nrtcome is not intended or offered outside(Sec.7144,Business ❑OTHHR
and Professions Cade:The Contractors License Law docs not apply to an owner of OUTLETS-SWITCHES-FI X'TUBES
a' property who builds or improves thereon,and who does such work himself or through
his own employees,provide that such improvements are not intended or offered for NEW RESIDENTIAL ELECIR Q
sale.ILhowever,she building or improsement is sold within one year ofeampletion,the SQ.FT.FLOph ARCA4 NSQ.FT.
owner-builder will have the burden of proving that he did not build or improve for ptr-
note.f. $�P
F-11,as owner of the pmpeny,one exclusively connecting with licensed contractors m TOTAL: as
construct the project(Sec.7044,Business and Professions Gale:)The Contractors Li- �N g RECT
cense law does not apply to an owner ofproperty who builds or improves themon.am QTY. PLUMBING PERMIT FEE TTp as
who commas liawContinuitiesfor Inch Projects with.emossums) ed Panama to theContinuitiesC�11 Ur
License Law. PERMIT ISSUANCE _ VUrL'ITlllgy
❑l on exempt under Sec ,It&PC for this rcaxon
rt ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
If. WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE O
I 'Ihereby affirm under penalty of perjury one crone following declaration:
❑ Ihvve unJ will maintain aCenifcau wf Cons cut to self-insure for Workers Campem DRAINS-FLOOR.ROOF,ARBA,COND. RIES TYPE CONSTRUCTION
sntioo,as provided for by Section 3700 of the Labor Colo,for.be performance of the
work ichfini, nitisiwtwd. 171XTURB-PER TRAP
ave and will maintain Workers Compensation Insurance,as required by Section
3]W.f the tabor Code,for the performance of.he wait fm which Nis permit/ixissued. GAS-EA.SYSTRM-I INC. OUTLETS
Work . OCC.GROUP APN
CarMy rier
e s rvsCrJ]Iic No�`_L /_9✓J
j/e Ic�l CAS-EA.$YSTBM-OVER J(13A)
CERTIFICAI i OF EXEMFI'(ON FROM WOR KIERS'
COMPENSATION INSURANCE GREASE(INDUSTRL WASTE INTERCEPTOR
COns section need and Mcomplete ifthe permit is ford e,hundreddolinm IS IW) BUILDING DIVISION FEES
or less) GREASETRAP
PIANCHECK FEE
Loy mythminthe any nmtwceo ine a slobekfor mewhbject to lermit is okesu Conn. SEWER-SANITARY-STT)RM.IEA.204 IT.
oat employ any person in any Inunner se,as m become Inhjat in the Workers Cmnpem ENERGY PEP.
sationlawsaf California,Date
z ,Z Q Applicant WATER HEATER W/VENTRiL1ECfR GRADING FEE
C0 NOTICE TO APPLICAWP If,atter making this Certificate of Exemption,you should WATER SYSTEMOREATING
abecome subject o the Workces Compensation provisions of the Labor Code,you must SOILS FLEE
h7 forthwith comply with such provisions or this permit shall he deemed revoke. WATER SERVICE
Q
CONSTRUCTION LBNDINGAGENCY NEW RF.SIUEN'fIAI.PLMB. SQ.IT. PAID
LJO I for which
that isucm¢trect301D,lending agency Air the petformenceof Date Rec<ipt#
P. Iti the wad for which this permit is issue(.Sec.lW],Civ.C.)
O VLenders Name - TOTAL:
Lenders Address TOTAL:
Fr-t G 1 uInil'y that I hove read this application and state that tha alwve in( midi o I is BUILDING FEE
hy cotrect.l ogres mcnmply with all city and county ndiwnce.x end state lows rdming to QTY. MECHANICAL PERMIT FEE
G
(,) building constmctinn.and hereby authorize representatives ofthis city to enter town the SEISMIC FEE
above-men.ianed mopeny for inspection purryucs. PERMIT ISSUANCE(We)agree m save,indemnify and kcep harmles the City of Cupenina against ELECTRIC FEE
liabilities,judgmeno.cmts and expenses whichnmyiu any 'ay accrue,against said City A UTBR OR ADD IO M ECH,
inconxet cert the grantingol this lsenniL PLUMBING FLEE six
APPLE.ANT DE ANDS Np WILL COMPLY LTH ALL NON-POINT ALR HANDLING UNIT(TO FROM CFM) MECHANICAL FEE
SO'
AIR HANDLING UNIT(OVER 10,00a CFM) CONS101(270NTAX
Signatureof Applicant/Con"s Dam (EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEEHAZAR NS MATERIALS DISCLOSURE
Will theapplicant or I I build' ocwpum store or handle hazardous m:neriul ((EATING UNIT TO 100.000 HT U)
as defined by she Cuperdno Muniti Cale.Chapter 9.12,and the Health end Safety
Code,Section 25532(.)? HEATING UNIT(OVER 100.000 BTU)
E]Yea No PAID
VENTILATION PAN(SINGLE RESID) Data Receipt#
Will daus,air contntor utature building the
use ea it
eld or uality Manages ement
emit nus air c.maminums eo deft ythe Hay Arca Air Quality Managemem IIOIf.ER-COMP(3HPDR IW,1gN1 BTU)
District? TOTAL:
Cl Ycs BOILER-COMP(OVER 100.000 BTU)
Ih theh,mdouammm.ls AIR CONDITIONER
rcqI.)of.
under Chapter 6.95 of the Coli- ISSUANCED
forma alth& vfery Gde,Sect s 255(15. d 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Irl'.
buil d mu yhev t.thus itonsibiliry to notify she occupmt
If
'char poor. Ea fD�j fT'yl�
Owneror umhorize agent Date ITOTAL: ISSUED BY;
OFFICE