31032 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL - I-ERMrr NO. ^ 03 L^/�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL JK
BUILDING PRIIJECT IDEN'TIFICA9'ION
BUILDING A%ESS:. / - �^ �n ,r SANITARY NO APPLICATION SUBMITTAL DATE
L L4
OWNER'S HO. COM Cf 'S AIR ICJI / NIC CONTROL p
144
4RCHITECT/ENGINEER: LfC NO:' p � 5 �5 (�J ❑
BU
CONTACT: n v � PHON l ILDING PERMIT INFO
(N ❑ Consultant Fees Paid by Applicant(Initial) BLDG )(T PLUMB M
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ ❑
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
��Z bit Section 9IX10)of Division Jof the Business anJP oitssi trsCNe,and my license is RESIDENTIAL:
0C, . PERMIT ISSUANCE
C u'F
in full force and effect 1 GSFDWI, ❑KITCHEN REMODEL
aUU License Clyses Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
yGuu Dam Contra cmr
E-7m ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O In Z 1 understand my plans shall be used as public records MODIFICATION
UPTO2W AMPS GINTERIOR GCHIMNEY REPAIR
a�E]ul
Licensed Pmfessionul _ 201-1000AMPS IMPROVEMENT
W 99 OWNER BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEUREPAIR GDEMOLITION
yy C C d 1 hereby affirm that 1 an exempt from the Comracou,License Law for the
p(�F U following remnn.(Section 91131.5,Business odd Profession.Code:Any city or roomy SIGNS ELECI'RICA]. ❑OTHER
I+)3�h which requires a permit m construct,alter.improve,demolish,or rcpaie any swcure
,F„��� prior units issuance.also requires the applicant for such permit m file a signed smmment SPECIAL CIRCUIT/MISC.
��} that he is licensed purwamns the pmvivons of the Contractor's License Law(Chaphn9
IWaC) (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL,
M.a e C that he is exempt therefrom and the hasis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
Xmlr. Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
W^m C-1 TENANT' [I FOOD SERVICE
E=0 not more than five hundred dollars(9500).
01,as owner of Ne property,or my employees with wages as their wle compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
F. will Bothe work.and the structure is not intended oroffcred for sale(Sm:?014.Business GOTHER
¢j—m and Professions Code:The Contractor's License Law does not apply m Fl
an owner of OUTLETS a.6 3 property who builds or improves Hereon,and who does such work himself or through
his own employees,provided that such improvements an,not intended or offered for NEW RESIDENTIAL F.LECTR S
sale.If.however.Ne building or improvement is sold within one year of completion.Me SQ.FT.FLOOR AREA s1SQ.ET.
,builder will have the burden of proving that he did not build or improve for pur-
pose ofsalc.).
0 property,am as owner of the propam exclusively contracting with licensed contractors m TOTAL:
construct the project(ties.IIlW,Business and Professions Cade:)The Contmctors Li-
censeLaw does net apply term owncretpropertywho buildsorimp foves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a conancums)licensed pursuaa to the Contractor's ,
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. _ .B&P C for Nis reason
Owner Date
ALTER-DRAIN&VENT-WATER TA) ��g//DVALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
• I hereby affirm antic,penel
ally of paryomcfthe following diminutions: V G�y
I M1ave unJ will nwinuinnCcnilicac of Consent to self-insure Por Worker's Comprn- DRAINS-FLUOR.BOOR AREA,FOND. STORIES TYI'ECONSTRUCTION
,duon,as provided for by Seaton 3'100 of Nn Labor Ctme,for the perfon acme of the
r Ibr we'L Nis p�ndit i.v i.vsucJ. FIXTURES-PERTRAP
wo 1 have anti will maintain Worker's Con.peno tion Insurance,us required by Section
3 b fN 1 h CoJu N I t nc fN kl' winch he,perrole;surd. GAS-EA SYSTEM-I INC.40LTIXTS OCC.,GROUP APN'
My W k carrid,undPolicy
Cam � Policy N
;��
GAS-P..A SYS TEM-OViR 4(EA)
CERTIFICATE EEXEMPTION IRWORKERS'
COMPENSATION INSURANCE
GR[iASIIINDUSTRh WASTE INTERCEPTOR -
BUILDING DIVISION ITIS
(This senior recd not be rmnpincJ it the permit is Tatars hundred Jnllurs(SIM)
or less) GREASE TRAP - PLANCHECK FEE.
I certify that inthe perrarmoreof the work for which his perour is issued.i shall SEWER-SANITARY-STORM HA.200 FF.
not employ any person in any manner so as m subject Become subjeco the Worker;ComPcm- ENERGY FEE
ZZ cation laws of Califomia.Due WATER HEATER WNHNT/F,IXE R
Q Applicant GRADING FTI;
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTENVI REATING
C > SOUS FEBbecome subject m bo
the Worker's Compensation provisions of the Lar Code,you must '
fsohwith comply with such pmrisimi,or Nis permit h.11 fir deemed revoked. WATER SERVICE
a �
CONSTRUCTION LENDING AGENCY NEW RESIDF.NI'IAL PIA H. SQ.FT. PAID
AL
0 (hereby affirm that Nem is a construction lending agency for m
the performance of Dae Raniptx
the work for which this permit is issued(Sec.3197,Civ.C.)
F' Lender's Name
C) U Len sive,AMlress TOTAL:
0. 1 certify that 1 have mud this application and state that the above information is BUILDING FEE
iFi V]
comes. to agree m comply With all city and county ordinances and state laws relating vs QTY. MECHANICAL PERMIT FEE 0
U Z building construction,and herchyauthoose repre.dnestivesof Nis city Renter ups the SEISMICFEE
above-mentioned propbny lin inspection purpoe, '
(We)agree m me,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE _ O ELECT RIC FEE
Iiatudities,judgiumts.costs and expenses which may in anyway accrue against said City ALTERORAIID OMF:CH.
nscyuenc tthe gmnI of this famdt. . 1 PLUMBING FEF.
APPLICA NIJF.RS"fANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I(I,IIW CFM)
SOU 'IONS / MF,CfiANICAh Flili
W AIR HANDLING UNIT(OVER 100MCFM) CONSTRUCTIONTAX
ran r9 of ApplicanVCnntruaor Y� _Dom EXHAUS"I'HOOD(WNUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will heopplicantm furore buildingormormsureorhandle baardous material HEATING UND'(10100.000 BTU)
m dm rd by Ibe C.,ninn Municipal Code.Chupmr,9.12,sed rhe Berlin and Safety ,
Cede,Section 25532(u)1. HEATING UNIT(OVER I00,01M BTU)
. Yes (Nn VENTILATION PAN(SINGLE RESID) PAID Dare ReceiptM
Will the applicant or future building occupant use equipment or devices which
ch
ha>adme,air corm onion,as defmN by Nn Bay Area Air Quality Management HOILER-COMP(3HP OR 10o"BTU)
�emi g TOTAL: �-
District? BOILER-COMP(OVER 1(K),WO BTU)
Yes
`�T( AIR CONDITIONERAz; a
1 have read the ha vJeus trinomials"iflecenerm under Clupum 695 of Ne Cali- ISSUANCE DATE
forms Health&Safety Cade.Sections 25505.25533 and 25534.1 understand Nat;Tune NEW RESIDENTIAL MF.CH. SQ.EE / ��/ r ��
building does dy have auction.that it is my responsibilityt etdy tempant /W�s Co
of Ne a whsIt Rua be met prior to issuance of a C/,pif ate o uppncy. /
O ro err Iz Jagent 1 Dte TOTAL ISSUED BY.-
OFFICE
Y:OFFICE