31532 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. ��
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION -
UILDINGADDRESS SANITARY NO. APPLICAFION SUBMI TIAL DATE
� ; heeds Aue - 12S-.176
DJp$'SN IaE� ;r asPHONE: 1 CO R CfOR'S NA LIC Nn5_ 0
V / N/C - CONTROL#
ARCH1 I ITL UENGINEER: - ' LIC NO: - DDRF S ❑
CONTACT: PHONE: 1V BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby aff that I am licensed under pras;sions of Chapter 9(commencing 10B DESCRIPTION
DMZ with Section]00O)of Divi6on3ofthe Business and Professions Code.and mylicens,is
FW 00 PERMIT ISSUANCE RESIDENTIAL:
WF in full force and effect ❑SFDWL ❑KITCHEN REMODEL
aUZU License Class Lie. APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RF.-PIPE
H Q 2 Dam _ Cumruaar
Foy ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
Z 0 m Z 1 understand my plans shall be,used ac public 1ecoNs /� MODIFICATION
OZ= GPT020IAMPS ` aa C1 INTERIOR ❑CHIMNEY REPAIR
F4F"W Licensed Professional 2014010AMPS . IMPROVEMENT
Z ag;F'.2I OWNER-BUILDER DECLARATION OVER 1010AMPS ❑BATHREMODF EPA ION
_+C Q 1 hereby affirm that I am exempt from the Contractor's License Law forthe 1� eE
j'yy`j 3 L U following reason.(Soxtion 7031.5,Business d P �f..ions CalA y city or county SIGNS ELECTRICAL OTHER r�
LLwhich requires is mismadd.Ol¢n imp demolish. pair any strum au -
ii)n priori 't issuance.ce.also qu th PPlicantf such Permit fl mpnmtru
edstant SPECIAL CIRCUIT/MISC. 1 •'/'�•�
flyE
that he is licensed pursuant to the provisions ofthe Contractor's License law(Chapmr9
1a+1�Qp0 (commencing with Sedion]alfB ofDivision3af the Business and Professions Cale)or TEMP.METER OR POLE INST.,/,/ COMMERCIAL:
M y m eL that he is exempt therefrom and the basis for the alleged exemption.Any violmian of - ❑NEW BLDG/ADDITION, ❑DL'MOLLFION
W {i. Senon]0315 by any applicant 1'or a permit subjects the apPlicam to a civil penalty of POWER DEVICES
41^v1 [_1 TENANT ❑FOOD SERVICE
not more than five hundred dollars($500).
IMPROVEMENT
�SpQ ❑Lo the woult nd property,or I, rmploy,eswith hall astbcir sole compensation. SWIMMING POOL ELECTRIC
�Fm will do the work.and the structure is not mmndeJ oroRered for sale(Sec.7044,Business ❑OTHER
43-• and Professions Code:The Contractor's License Law does not apply to an owner of OVfLCI'S-SWITCHES-FIXTURES
property who buildx of improve,dumwo,and.ho it,.,such work himself or lhrougM1
his own emplayces,provided that such mon,emems Ire not intended m offered lou NEW RESIDENTIAL ELEC'TR SQ ET.
sale.If.however.the building or improvement is sold within one year of completion.th, Q.FT.I7LOOR AREA $/SQ.Pr
caner-builder will have the burden of proving that he did not build or improve torpor- t
pox of sale.). P A ' D
❑ 1,as owner of she prepcny,am exclusively contracting with licensed contractors to T
construct the project(Seo.70W 1.Business and Professions Code:)The Conrmemrs Li- DECcense Law does not apply mnnownet ofprop<•ny w4m buitds or improves thercon,and QTY, PLUMBING PERMIT FEE C (]
who contracts for such projeeswith acommetm%)Ilccnedpursoant othe Contmeods C _ FI 1996
License law. PERMIT ISSUANCE
❑Into enc under ee. a .B&PCrthis ea C I s- t`
Owner Date sen ALTT:R-DRAIN&VENT-WATER RA) pL ATION
WORKF.N'S OMPENSA'fIf1N DEChARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under D:nalty of perjury one of the following dee amtions:
•❑l have and will maintain a Cenificateof Consent to self-insert for Workers Camper- DRAINS-FLOOR,ROOF.AREA.COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37W of the labor Cade,for the performance of the
work for which this pemdt is issued FIXTURES-PER TRAP
0 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700411h.Lubar Code,I the podannance of N,work for which this permit is ixvcol, GAS-II.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Workers CU cted,atlon hosannas,earner and Policy number arc:
Cartier Policy No.: GAS-F.A.SYSTEM-OVER 4(EA)
- CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE V GREASE(INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thissectimnmeed not becnmpleted iffle permit is Eaton,hundred dollars($1001 GREASETRAP
or less.) � � I'LANCHECK FETE
Iccnifydbut in tbeperik... cc ufthu work far which this pcnnit is issuW.Ldiall SEWER-SANITARY-STORM EA.21X0 FT'
not employ any person in any attorney so as to became.subject to the Winker,'Compcn- ENERGY FEE
Q Z cation laws of California.Dam
WATER HEATER WNENT/ELECTR GRADING FEE
Z O Applicant .
y
NOTICETO APPLICANT.H,Crer making this wimansaf of Exemption,you should WATER SYSTEM/TREATING SOILS FEE
.h polovi subjecty the Worker's Compenaohi, provisions of the I-ubnr Cade,you must
ToMwith comply with xdch provisions or Nis pumtit aha116e deemed revoked. WATER SERVICE
aQ •
5z CONSTRUCTION LENDING AGENCY NEW RFSIDENTIALI'LMB. SQ.FT PAID Dam Receipt
V Q Ihertby affrn that them isaconstrvniun lending agency for the performance of .
e work for which this permit is issued(Sec.37,Co.CJ
I""' th19Leaden Name TOTAL:
U Lenders AJdrco - TOTAL -
D+ - BUILDING FEE
1 cmee not 1 have rend Ibis city
ad coup and stag thin rhe sMwe information is
Z correct Iogrtrctcomply withallant and countyordinances and liar,]awerelatingm QTY. MECHANICAL PERMIT FEE
V Z building construction,and hertby auNnnze representatives of this citymrnmr upon Ne SEISMIC FEE
above-mentioned poperty for inspection purposes. PERMIT ISSUANCE
(We)egrt,w save,indemnify and keep harmless Ne Ciry of Cupenim against ELECTRIC FEL
liabllities,judgcurio,costs mndexpenses which maylnany way accrue again said City ALTH R OR ADD I'OMECH. '
cunxquence m the gmming oif unix permit ' PLUMBING PEI
APPLICANT UNDERSTANDS AND WILL'COMPLY WITH ALL NON-POINT, AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL FEE
SOURCE REGULATIONS. -'
AIR HANDLING UNIT(OVER 10,010 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) 11OUS ING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhandle leowedous material HEATING UNIT(TO IW,ODO BTU)
as defend by the Cupertino Municipal Code,Chapter 9.12,art the Health and Safety
Cade,Section 25532(x)? , I HEATING UNIT(OVER 100.000 BTU) -
❑Yw [-I No VENTILATION FAN(SINGLE RES]D) PAID
Will thea applicant or fidnte building o,.Pon axe 1 rr devises which Dote Receipt N
PP b pun .Air n BOILER-CAMP(1HPOR 100.00(1 BTU -
emit hazallous civ contaminenk es defined by the Bay Arcn Air Quality Management TOTAL:
�.Distncfl
❑Yes F1 No BOILER-COMP(OVER 100,000 BTU)
'I those read the haardous mumrials rcquirementn amdcr CM1apter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
grain Health&Sonny Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ_EP. _
building does not c urearly haac a tenamq thot a k ir,o sponsibility to notify the occupant
of the normicments which most be and Prior to issuance of s Cenificagnf Occupancy.
w -
Oneror authorized agent Date TOTAL: ISSUED BY:
OFFICE