31086 _ - APPLICANT TO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO - BUILDING;ELECTRICAL. - - PERMIT NO
'BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. - 3 086
BUILDING PROJECT IDENTIFICATION '
B ILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL HATE
10 w44.(4' he
O NER'S NAMFOV PHUNECONTRACTORISNAME LIC NO: N/C : CONT ROLN
T LC�NO ADDRESS: '❑
Polm KielG .
CONTACT, PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initia) - 'BLDG eLe PLUMB - MECH
❑ ❑
` LLICENSEDCONTRACTORS DECLARATION AQTY ELECTRIC PERMIT FEE
I hereby affirm tit t i licensed a der prof Chapter 9(commercial, •JOB DESCRIPTION
yOCZ with Section 7000)of Di ' 3 fthe Businessand Professions Code y and atlie in
FOO in full farecandefT t. - PERMIT ISSUANCE RESIDENTIAL:
License Class - Lid.is - ❑SFDWL ❑KITCHEN REMODEL
ZAPPLIANCES-RESIDENTIAL
too
Dam Convector _ ❑ADDITION El PLUMBING RE-PIPE
'D,2z ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
ZOnq PANELS `//`,�k,,
I understand my plane shall he used as public records - '�� •'1 MODIFICATION
'OZ.+ � UCT02W AMPS •'1 - '
I✓4 E-'I Licensed Professional - ❑INTERIOR',• ❑CHIMNEY REPAIR
s�d pppp•,•.I1 OWNER BUILDER IJECLARATION - 201-IOOUAMPS IMPROVEMENT
G a�Q I hereby affirm tam I am exempt from Nu Cement.,,.License Low for the OVER 1000 AMPS - D BATH REMODELIREPAIR DE TION
B
a 0.U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL OTHER
0 which expirep 't t t t alt. p d 1'.ler repo Y Irl cture
m priori I I q .tit appl'c tf - hpermit t fl 'g d statement SPECIAL CIRCUIT'/MISC.
apt Ort ha Ice :alp nu tb pm s flit C t t .L' L (Chptcr9 _
q0 (commencing with Section 9000)of Division J fth Business dP f sCode)ef TEMP METER OR POLE INST. COMMERCIAL'
d c that M1 . cop therefrom d the b f the exempt Any violation of
Semon T0315b EI NEW BLDG/ADDITION UDHMDLITIGN
m by euhjeas the tamm�l pumlly of POWER DIiVICES UTENANT
Es not more then five hundred dollars($500). ❑FOOD SERVICE
i=C ❑1,as owner of the property,nr my employees with wages ns theirenle compensation, SWIMMING POOL ELEC IMPROVEMENT,
F will do the work,and the sbvedre is not Intended or ffered for sale(So,7044,Business []OTHER
tat
.it Profession;Cade:The Commcmr's License Law does not apply to au ownu of OUTLETS-SWITCHES I$TU '
property who builds or improves thereon,and who does such work himself or through his own employees,provided Nat such improvements me not intended or offered for NEW RESIDENTIAL.ELL '
sale.If.however,thebudding mrimpeovememt is sold within one year ofaempmtimn,the SQFT.FLOOR AREA -$/SQ.FT.
ovorambuilder will have the burden of proving that he did not build or improve for par-
El assale.). P,A1
Las owner rf Lha property,,B exclusively conrtauon,with:)The
eCanacmrs i- O
construct the project(Sec.9tW4,Business and Professions Cook:)The Contractor,Li-
count,
i-c se Law does not apply man owner of property who builds or improves daemon,and QTY PLUMBINGTERMIT -FEE
who contracts for such projects with a condenteds)licensed pursuant to the Commuters, A �j
License Law. , +II�1 AR
�$$�I t�tson PERMIT ISSUANCE
/
QA
is
Once -
��f--o f— ALTER-DRAIN.$VP.NT WATER(HA) Uly Air V_ .
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penalty of perjury one to following declarato
•❑ Itree and will cadmium.Certificate aC um"If-mothe fini-Vismkiff.Compere DRAINS-FLOOR,ROOT AREA,COND..
,anion, a prov den for by Section 3700 of tit.Labor Code,for the peTlormance of the STORIES TYPE.CONSTRUCTION
weak for which this permit is issued. FIXTURES-PER'FRAP -
❑1 have and will maintain Worker's Compensation Insurance,as acquired by Section "
3900 of the Labor Code,for the performance of the work for which this permit is kand GAS-EA.SYSTEM-I INC,4 OUTLETS OCC.GROUP APN
My Wmwd`,Comdma
peatian Insurance carrier d Policy number are:
Carley. Policy No.: GAS-EA.SYSTW-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRLWASTEINTERCEPTOR
(Thlssection need not be completed if the permit is for on hundred dmllars($IIMBa BUILDING DIVISION FRES
• or less) GREASETRAP PLANCHECK FEE'
I certify per.n the performance,the work forwhlduhis permit is i r,Cd l shall
nalem In any person in an manner eo as'mb¢come sub est lbltie Workers'Cnmpem SEWER-SANITARY-STORM EA.200 FT.
employ y j ENERGY FEE
, wilco Laws of California.Date
C) 0 Applicant - WATER HEATER WIVENT/ELF.LTR
pp GRADING FEE
w+ V] NOTICE. bj APPLICANT:If,after making this Certificate of Exemption,you.heroin WATER SYSTEM TREATING
aI;^ become subject to the Wmkds Coons or[lots provisions of the Labor Code,you mull SOILS FEE'
W forthwith comply with such provisions or permit shall Mdeemed revmked WATER SERVICE _
0
5z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL ELME. SQ.FT. PAID
U C _ I hereby affirm that there is a construction lending cogency for the performance of Data Betteip
w H the work far which this permit is issued(Sec 3090,Cls.C.)
„0 Lender's Name
{U Lender's Address _ NOTAL: TOTAL:
D
P•t 1 certify that I mor,'read this application and state that the above infoimafiou is BUILDING HE
V] correct.I agree to comply with all city and county collision...and stem laws relating to QTY. MECHANICAL PERMIT PEE
U� building construction,and hereby sanitarian representatives of this city to enter upon the 'SETS C '
above-mentioned property for inspection purposes. " ' PERMIT ISSUANCE
(We)aCer m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue aminesisaid City ALTER OR ADD TO MECH.
on
' in csequence of the grading of this permit. PLUMBINGF
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT" AIR HANDLING UNIT OO I(L000CPM)
SOURCE REGULATIONS , MECHANI LFEE
AIR HANDLING UNIT(OVER 10,000 CITD CONST CTIONTAX
'gn mof'ApplicanoContracmr Date, EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOES G TIGATION FEE
Will the applicant or fine building occupant store or handle hazardous material HEA TING UNIT TO 1110,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)9 HEATING UNIT(OVER 100,000 BTU) - -
❑Yes F]No
_ VENTILATION FAN(SINGLE RESID) PAID Date Receipt b
t
will tit applicant m f t e malding ess,upani...'oqu'pment or dances which -
a.emit h ol . air reforromend,as defined by the Bay Area Air Quafty Management BOILER-COMP(3HPOR 1110,000 BTU)
Lionel TOTA
❑Yes ❑NO BOILER-COME(OVER 10(1,000 BTU)
I have read the hazardous rdmdals raluimmenm under Chopmr fi95 of Ne Call- AIR CONDITIONER . ISSUA CE DATE
mind Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that If the NEW RESIDENTIAL MECH. SQ.FT
building does nm eumnlly love.aen
tant,thatil is my reeponslbility to rally the mapant
of the requlmmeties which md.t be met prior to issuance of a Cenificam of Occupancy.' r a v X/`'�_
Owner or am ni,tod agent Date 'TOTAL: ISSUED BY:
OFFICE