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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING - RLECrRICAL r1iRMITNO. 29376
BUII,UINO DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION -
„ BUILDING ADDRESS ! .. _ / ^., I SANITARY NO. APPLICAHONSUIIMITTAL DATA
1
LICENSEDCONTRACI'OR'S DECLARATION
1 hereby affirm that 1 um licensed i n ss; provisions of Chapter 9 (nam,.ccom g
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with Samearid00ofDivisionJofthe Business and Pmfessians Cod dray license is
LiceneCla unJ effect.'
V License Clasp �Lionv n' ['
1 Dale - - Contractor' I
y _ ARCHITECTS DECLARATION
Z 1 nnJcmend my plans shall be used es public records
OWNER - BUILDER DECLARATION
1 hereby uffirm that I our exanya from the Contractor's license Law for the
6 FFU.. following mason. (Section 7131.5, Business and Professions CnJC: Any city ur county
y which requires a permit m construct, alas, improve, demolish, or repair any swmure
gprior to its issuance, also requims me applicant for such permit o rile a sigindsencment
} that he is licensed .....nuothe pmvuronsuf the Cannot License Low (Chapter 9
00 (commencing with Sect ion BXNB of Division jut he Businessand Professions Code) or
y' that he is exempt therefrom and the basis for the alleged exemption Any vielwion of
N Section 7031.5 by any applicant for a permit subjects doe applicant to n civil penalty Of
== not mom than Bve hundred drift. ($501n_
O ❑ 1, as owner of the pmpeny. or my employees with wagesmtheir sole compenmtion.
wall do the work, end the sanctum is not intended wolfered for sale (Sec. 7140 Business
and Promainns'Code: The Connector', License L.nw duos oat apply to .n owner of
propery who holds or Ingnnves therms, load who does eueb work himself or Ihrnugh
his own employees, provided that such improvements we not intended or offered far
sale. if, however, the building ur impravement is sold within one yearof completion, the
er- builder will have the burden of pmving that he did not build or improve for Eur-
pose of sole.).
❑ 1, as owner of doe property. .m exclusively cont whia, wish licensed caravan s to
oonsaoct the prajem (Sec. 9044. Business and Professions Cloth:) The Contractor, Li-
cerise Law does not apply ht on owner of property who builds or improves thercan, and
who contracts fmsuchProjects with a commands) licensed pursuant o the Contractor's
License Law.
❑ 1 am exempt under Sec. ❑ &P C firms mason
Owner ()am
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one sal following declaration:
,Fl I have and will maintain a Certificate of Comentto self-insum for WwkdsCampen-
"new, es provided for by Section 3700 of the Labor Code, for the performance of the
work I'll which this permit is issued. -
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Cade, for the performance of the work for which this permit is issued.
My Work Cy�Pe ti I r and Policy numbe ere:
Carlo ee (' / run e Policy No.: / Za 2 :2 4
❑ Consultant Fees Paid by Applicant (Initial)
ELECTRIC PERMIT
111ZRNI T ISSUANCE
APPLIANCES — RESIDENDAl,
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT /MISC.
TEMP . METER OR POLE INS 'I'.', / 0,"s
I - I SWIMMING POOL ELECTRIC
NEW RESIDENTIAL ELECT R SQ ET.
PLUMBING PERMIT
PERMIT ISSUANCE '
ALTER— DRAIN & VENT V "�RF
BACK FLOW PROTECT. DEVICC '
DRAINS — Fl,OOR, ROOF, AREA, CON,.
ITS '1' ORES —PER TRAP
GAS — EA. SYSTEM-1 INC. 4 OUTLETS Ns
GAS — EA. SYSTEM -OVER 4 (EA)
GREASEffb DUSTRL WASTE INTERCEPTOR I
OFFICE'
f
FEE
FEE
B
FEE
N/C CON at or
BUILDING PERMIT INFO
_ ■vow ■ ® ■�
JOB DESCRIPTION
('Thissection neeA nrnhcomplemJ iflho permit Ls fnnmehund molded ... Sl X))
or less.)
❑ KIJ'CHEN REIdoUEL
GREASETRAP'
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7
I certify that in the jacrinmance of the work forwhiVh,his permit is issued, l shat)
not employ any person in any manner so as to become subject to the Workers' Compel-
tattoo Lawsof Cothfomia. Date
Applicant " t -
[]STRUCTURAL
SIiWER— SANITARY —STORM EA. 20E Ff.
-
MODIFICATION
WATER HEATER WNENT /F.LIiCEN
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NOTICE TO APPLICANT: IL after making this Cenificam of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with suchsouivaimis or this permit shall be deemed revoked.
CONSTRUCTION LENDING A617NCY
I bunchy affirm that lucre isa construction lending agency fm the peritwounce of
the walk for which this permit Is Issued (Sec. 3097, Civ. C.)
Leaders Name
+
WATER SYS'fEM/fREA'fINC
OTHER
WATER SERVICE
NEW RESIDEN'1'IALPLMB. SQ. let'.
- e
-
Lembes Address
I certify that 1 have read this application and state that the above infor n Lion is
., ,TOTAL.
.�In
` U G
coma. l agree m comply ![It .11 city and... my ordinance, and late laws relating to
building c..nstmmion, mad hcroby n thorize re,no,onnawc,al'this city to enter upon the
above - mentioned pmpeny for inspection purpose S.
(We) agree an save, indemnify and keep harmless the City Of Cupertino .g.inI t
QTY, MECHANICAL PERMIT
v
PERMIT ISSUANCE I . s
ALTER ORADDTOMECH. "
liabilities, judgments, costs and expenses which mayinany way acemeagainst mid City
in consequence of the granting of this permit.
AIR, HANDLING UNIT (TO 10,000 CPM)
-
n
APPLICANT UNDERSTANDS AND WILL COMPLY WO 'H ALL NON -POINT
SOURCE' REGULATIONS. '
Y` (rt ' /I �. / 1 v`���
/
AIR HANDLING UNIT (OVER IB(gBCPM)
Sign Slgnat�ievflCppl�cam /ConOaaor Dan
EXHAUST HOOD(W /DUCO
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous mnmrial
HEATING UNIT (TO 100,000 BTU)
'
as defined by the Cupertino Municipal Code, Chapter 912, nndlhe Health and Safety
Cade, Section 25532(a)9
HEATING UNIT (OVER 100,000 BTU)
❑Yea ❑Nu
VENTILATION IAN(SINGLP, RESID)
Will the applicant or future building occupant use equipment or devices which
ran hazarJous air connnainun , as defined by the Bay Arc. Air Quality Manvgcment
BOILER — COMP' (3HP OR 1(111,1X0 BTU)
Ulsuin7
Yes a. (]No ,
BOILER —COMP' (OVER 101,000 BTU)
AIR CONDITIONER
I have it the haeardous materials requitement under Chapter 6.95 seldom Cali
flows Health & Safety Code, Sections 25505; 25533 end 25534. 1 macesumd that if the
building does not eurently have a mount, that it is nay rcaponxi hit ity m notify the Occupant
of the m lairentems which must be na n prlorto issuance of n Cell licnte at Occupancy.
NEW RESIDENTI AL MECH. SQ. let'.
Owner or mounrized not - Date
TOTAL
OFFICE'
f
FEE
FEE
B
FEE
N/C CON at or
BUILDING PERMIT INFO
_ ■vow ■ ® ■�
JOB DESCRIPTION
RESIDENTIAL:
❑SPOWL
❑ KIJ'CHEN REIdoUEL
❑ADDITION
- El PLUMBING RE-PIPE,
❑MUUI'FUNIT
[]STRUCTURAL
MODIFICATION
CJ INTERIOR.
El CHIMNEY REPAIR
•IMPROVEMENT
+
HA9'I I REMODEIIRIiPAIR El DEMOLITION '
OTHER
COMMERCIAL;
❑NEWBLDG /ADDITION 40DEMOLITION
El ENANT OFOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ, FT. FLOOR AREA S/SQ. ET
P A B '
MAR 4 1996
C11I
• Ah ATIO tV
STORIES I YPE CONS 'I RUCTION
OCC, GROUP APN
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY
GRADING FEE
SOISP d,
PAID - -
Data Recelpt4
TOTAL:
BUILDING PPE
SEISMIC FEE „
ELECTRIC FEE
PLUMBING FEE or
MECHANICAL FEE
CONSTRUC IONTAK
HOUSING NIITIGATION PER
PAID
Dote Receipt or
ISSUANCE DATE