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CITY OF CUPERTINO - BUILDING- ELECTRICAL .,
APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION I r - -, BUILDING PROJECT t �_-
✓IDENTIFICATION
BUILDING ADDRESS: 1000113 P W GV—A NN/ E Gti P E � ` �1 U -
SANITARY NO
62
7T..
OWNGR'$NAME: - PHONE:
CONTRACTOR'S NAME: LIC NO:
N/C
❑
ARCHITECT /ENGINEER: LIC NO:
ADDRESS: `
CONTACT. - PHONE:
-
BUILDING PERMIT INFO
BIL-D�G /-^ELECT PL-UMB MECH
❑ Consultant Fees Paid by Applicant (Initial)
VJ L ❑ ❑
L ICBNSEDCONTRACTOR'SDF,CLARATION ..
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
QTY
-
ra ELECTRIC =PERMIT I,
,, t _
FEE
JOB DESCRIPTION
with Section 7010 of Divi.vinn3arlhe BU Slu es s and pmfcssions Code, andmy license is
in full forceand,ifil
PERMIT' ISSUANCE
RESIDENTIAL:
❑SPDWL ❑ KITCHEN REMODEL
APPLIANCES - RESIDENTIAL
License Class Lic.a
Dale Contractor `
❑ADDITION ❑PLUMBING RE -PIPF.
❑ MULTI -UNIT El STRUCTURAL.
MODIFICATION
[I INTERIOR El CHIMNEY REPAIR
IMPROVEMCNTI E] SWIMMING POOLS
ARCHITECTS DECLARATION
• i understand my plans shall be used as public records
PANELS
UPTO200AMPS
Licensed Pmfcdionm
201- IODOAMPS
OWNER - BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Counselor License Low for the
following reason. (Section 9031.5, Business and Rofenxioos Code: Any oity'nr county
' O BATH REh1 EUREPAIR O DdMOLi'riON
11 OTHER
OVER 1000AMPS
-
SIGNS ELECTRIC_ AI.
which requires a permit lu construct, nlmn improve, thmInh, orrepair any cowrie
priorm its inuance, also requires the applicant Rnsuch permit trifles signed statement
that he is licensed pursuant ro the provisons of the Coma ermr's License Low (Chaptcr9
SPHCIALCIRCUIT/MISC.
-
(commencingwhb Section" 1000)afDivislon3oRhelhsinessand Prferainnv CrNe)or
TEMP. METER OR POLE INST.
COMMERCIAL:
that be is exempt thamfir m Ind the hasis far the alleged exemption. Any violation of
❑ NEW BLDG /ADDITION ❑ DEMOLITION
Section 7 031.5 by any applicant for a permit subjects thcapplicaut to a civil penalty of
are five hundred dollars T$500). �
owner of the property, or my employees with wages as their solo compensation.
will do the work,md the structure is not in_tendedoroReled fim,eli, Sca. 9044. Rosiness
POWER DEVICES _ _
El TENANT El FOOD SERVICE
IMPROVEMENT ,
[-]OTHER
SWIMMING POOL ELECTRIC
and Prufessinns Code: The Contractors License Luw does not apply man owner of
OUTLETS,- SWITCHES - FIXTURES '
property who huilds or improves thereon, and who does such work himself or through
his awn employers, provided that such improvements arc not intended or offered for
sale. If, however, the building or improvement is sold within one year completion, the
NEW RESIDENTIAL ELECTR SQ FT
PppPPFJ��TTT's��x A17
$ /,Q. R.
owner - builder will hove the burden of. proving that he did not build or improve for par-
rsb
MOR
IL_Ii�
pomof add)
❑ 1 owner of Ib property, am exclusively contracting licensed ' u et rs to
construct in project (Sec 9044 Business dP f c d )Th Contractors Li-
cen:eLe d (,ply toanownerof property h mild p th er and
O •����
OCT 2
'
QTY' ' PLUMBING PERMIT0'
t'
..
,FEE'
who contrnus f r. u h pm)eds won a conmacmrts)1 censal pursuant m Ilia eo nrvemr a
PERMIT ISSUANCG, -
ALTER - DRAIN &VENT - WATER (P,A)'
License Law.
❑ 1 am exenTt under Sec. B & P C for this reason
�— _ U
I`
V C/
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations.
�Q
RACK FLOW PROTECT, DEVICE
I have and will maintains Cenificamof Consent to sel f- imnrefn-Worker-- sCompen-
salon, as provided for by Section 3900 of the Labor Code, for the performance of the
DRAINS - FLOOR, ROOF AREA, COND.
ST IES
TYPE CONSTRUCTION
work for which Ibis permit is issued. -
FIXTURES - PER TRAP
I have and will maintain Worker's Compensation Insurance, m requlmd by Section
3900 of the Labor Code, for the performance of the work for which this permit is issued
My Worker's Compensation Insurance carrier and Policy number are:
Cntrier. Policy
_
GAS - EA. SYSTEM- I INC. 4 OUTLETS
DEC. GROUP
APN
O Z G 2 5' Q A9
7
GAS - EA. SYSTP.MOVER 4(EA)
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
' (This section need not be completed if the permit is forane hundrul dollars ($100)
nr IessJ-
-
GREASVINDUSTRI. WASTE INTERCEPTOR
-
�
t °sli U,R.UING �IVfSI NPHIiS
-I'
GREASE TRAP
PLANCHECK FEE
I ready that in the,erformmeacifthe work for which this permit is issued, l shall
not employ any person in any manner sons to become subject to the Workers' Common-
SEWER- SANITARY -STORM EA. 200 FI'.
ENERGY FEE
WATER HEATER WNENTELECTR.
-
GRADING FEE
ration Laws of California. Date _
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you .should
become subject to the Worker's Compensation provisions of the Labor Code, you most
WATER SYSTIEWOMEATING
SOILS PEE
-
WATER SERVICE
forthwith comply with such provisions or this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
I hereby union that hem is a construction lending agency for performance of
PAID
NEW RESIDENTIAL PLNIH SQ. FT.
Dote Receipt N
the work far which this permit is issued (Sec 3099, Civ. C.)
Lender's Name
-
'TOTAL:
I.,ml Address
-
TOTAL:
.,
BUILDING FEE
I certify that 1 have read this application and state that the above information ix
correct.I agree to comply stir all city and county ordinances and state lows relating to
huilding constrdloq and herehy vuthoriu oepreswtetives of this citymemer upon the
above - mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cuponino against
F
QTY, MECHANICALPERMIT,'
FEE .
SEISMIC PEE
PERMIT ISSUANCE
ELECTRIC FEE
PLUMBING FEE
Iiabilitid,judgments, costs and expenses which may in any way aver¢ against said City
in conseqpermit.
consequence of the gmorim, of this per
ALTERORADDTOMECIL
AIR HANDLING UNIT (TO 10,1100 CUM)
MECHANICAL FEE
'
APPLICANT UNDERSTANDS' AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS. -
AIR HANDLING UNIT (OVER IO,000CFM)
CONSTRUCTION TAX
ig are of Appllcara Cmntre or -- Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W /DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building occuparnstore nr handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
HEATING UNIT (OVER 100,000 I3' FU)
❑Yes E] No
VENTILATION FAN (SINGLE RESIU_)
PAID
'-
Date Be
BOILER - COME (3HP OR I00,000 BTU)
Will me applicant or furore building occupant
the B use equipment of devices which
emit hazardous air comaminuntsmde fined by the Bey Area Air Quality Management
'Discoid?
El Yes ONo
L
BOILER- COME (OVER 100.000 BTU)
rGr
AIR CONDITIONER
I have read the hazardous materials uquirements under Chapter 6.95 of the Cali-
$ ANCE DATE
NEW RESIDENTIAL MECH, SQ. PE
fomla Health & Safety Code, Sections 25505, 25533 and 25534.1 undontand that if the
building does not currently have a tenant, that it is my responsibility to notify the owupant
,
ofhemqu' me ich... be a tn'ss ofa Cprllfica (OCCUpancy.
(00 -
ISSUED BY:
TOTAL:
r amh adxm.gent Date
OFFICE