31133APPLICANTTO FILL IN INFORMATION WITHIN RED LINES'- USE BALLPOINT PEN ONLY
CITY OF CUPERTINO - BUILDING - ELECTRICAL
BUILDING'DIVISION, APPLICATION/PERMIT - rLunlsmr.. MECHANICAL
- BUILDING PROJECT IDENTIFICATION .
PERMITNO.
31`133
BUILDINGADDRESS. ., "' .,
SANITARY NO.
r
APPLICATION SUBMITTAL DATE
OWNER'S NAME: - ✓ - PHONE:
f 7
CO TRiCT g'S NAME:' "LIC NO:
/ (/ OO
N/C
#
CONTROL# -
.2CHITFCT/ENGINEER:. LIC NO: -
ADDRESS:
CONTACT:' " r . PHONE:
-,_
BUILDING PERMIT INFO
`
Consultant Fees Paid by Applicant (Initial)
BLDG ELECT .,PLUMB ,MECH
LICENSED CONTRACTORS DECLARATION
I herebyfirm that I am licensed under f Chapter 9 (coin nencin
a pt p g
QTY ELECTRIC PERMIT FEE
- JOB DESCRIPTION ,
Poicnsa
with section 70W)oct. Sof the Business dna Professeoos code, trod my license is
'n full Pores and effect � ''"
PERMIT ISSUANCE
RESIDENTIAL• '
❑SFDWL TCHEN REMOUEh
- -
APPLIANCES - RESIDENTIAL
License.�jass Lic°#
Uam—$—Ul-may——Cmenecor•
ADDITION PLUMBING RE -PIPE
❑ MULTI -UNIT - 9DSTRUCTURAL
.MODIFICATION
y A CH EC 'S DECLARATION
ue�icruor ds
amnal
PANELS .e -
i
UPT02MAMPS
El INTERIOR C1 CHIMNEY REPAIRLicensed t
IMPROVEMENT
.• s
201 I0MAMPS
OWNER -BUILDER DECLARATION
I h by affirm that 1 am'exempt from the Contractors License Law for the
❑ BATH REMODEIJREPAIR ❑DEMOLITION
OVER IMF AMPS
-
SIGNS ELEC DUCAL
following reason. (Section 7031.5. Business and Professions Cale: Any city or county
OTHER
which requires it permit to cons"ah, alter, improve, demolish, or repair any structure
prior in its issuance, also requires the applicant for such permit e file a sigaeasmmmem
SPECIALCIRCUIT/MISC.
'
out he is licensed pursuant to the provisions of the Contractor's License Law (Chapter Si
TEMP. MEIER OR POLE INST.
COMMIDKIAL, ,
(commencing with Section 7000) of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption, Any violation of
❑ NEW BLDG/ADDITION.. ❑ DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mere flan five hundred dollars (5500). -
I, as owner of the property, or my employees with wages nn met r sole rota t'
[] pBusi ieq
will dothewark, ande
POWER DEVICES
❑TENANT. ❑FOODSERVICE -
IMPROVEMENT `
❑OTHER
SWIMMING POOL ELECTRIC
,
Tire Contcturera torintended Liceer ivs are,red
and Professions Code. Tire Contractors License Law does sol apply m an owner oq
notapply o an iterer of,
OUTLETS-SWITCHES-PIXTURF.S
.property who build, or improves thereon, and who dues such work himself ar through
t
'
his own employees, providedOat such improvements are not intended or offered for
sale. If. hmobvic. he building or improvement is sold within one year of completion, the
NEW RESIDENTIAL ELECfR SQ ET.
- _ SQ. FT. FLOOR AREA $/SQ. Fp.
tun r bmlder will have the M1 d f prow g Out he did not build improve forper.
'pose f I ). I
I a. owner of the property, am exclusively convecting with licensed contractors 1.
p' -
P 1
A ,
T
eree rten the project (Seo. 7044, Business and Professions Code:) The Contractors Li-
cense La d t apply t u owner of property who builds oimproves thereon, and
who contracts fr such paler ce
with a contmetuhs) I nsed pursuant the Contractor's
QTY. PLUMBING PERMIT PEEz-
A N
�� r� V�
PERMIT IS$DA CE
License Law. v
E1.1 am exempt order Seo. °,B& P C for this reason
`
it, I IV-
L
ALTER - DR N EN' WATER (EA) -
Owner '' Date
BACKFLO PROT .DF E`J�OQ
WORKER'S COMPENSATION DECLARATION
'I hereby affirm under penahy ofperjury one ofthe following declarations:
!
'
-
DRAINSFLOOR,R EAR D.
--
Cl l have and will maintain a Certificate ofCoreent m self -insure for Worker's Camper-
Olmm-xs presided for by Station 3710 of the Lalw, Cale, for the performance of the
workforwhichthispermitkissued ' -
- STORIES 11
,
TYPECONSTRUCTION
.,
FIXTURES -PER P
❑ I have and will maintain Worker's Compensation Insurance, os required by 9ectinn
-
-
3700ofth�er:taClorCade,f the permuntunrcieeufthe work f9arrwshiichthis ppeeerrmmiitttiissiisssuedd
GAS' -EA. SYSTEM -1 IN OUT TS
OCC, GROUP'
API
Wor/Yn y�t(and Policy
Carrr�ON1� `Abol cy Ism, "1L/ -
!""
CERTIFICATE a EXEMPTION FROM WORKERSQ 1
COMPENSATION INSURANCE
(This section need not be completed ifthe perms is for one hundred dollars (SIM)
erle sJ
,
GAS' EA. SYSTEM -OVER 4 (EA) �i
- GREAS_EANDUST_RL WASTE INTERCEPTOR
t ,
', BUILDI, O°DIVISIO frLtjs: -
r
GREASETRAP
PLANCHP.CK FEE t
tSEWER - SANITARY -STORM EA. 2M FT.
(certify Oat in the perform:mce of the work for which this permitisissued,IshaO
not employ any person in any manner eo es to become subject w the Workers' Compev-
ENERGY FEIV I-
WATER HEATER WNENT/ELECTR
smion Laws of California. Date_
Applicant - - -
GRADING - -
NOTICE TO APPLICANT If, afix, making this Cer00cate of Exemption, you should
become subjed to the Worker's Compersation provisions of the Labor Code, you must
WATER SYSTEM/TRBATING
SOILS F
forthwith comply with such provisions Or this Permit shall be deemed revoked
F
WATER SERVICE I
1,
NEW RESIDENTIAL PLM B. SQ. FT.
- CONSTRUCTION LENDING AGENCY -
I hereby affirm that ahem is a construction lending agency for the performance of
PAI
Da - Receipt# '
- t
the work for which this permit is i ... ed (ice. 3097, Civ. C.) I--.,
•'- -
Lenders Name
oftTOTAL:
Under, Address -- �
..UFAeV
BUILDING �+#
f 1 bxd ify that I have reed this application and stale that the above information is
freed agree to comply with all city and county ordinances and slate laws existing to
building conservation, and hereby authorize representatives of this city to enter upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC FE
above mentioned prop city for inspection purposes.
jt. (Wed agree to save, indemnity and keep harmless On City or Cupertino against
PERMIT ISSUANCE
ELECTRIC H
ALTER OR ADD TO MECH.
liabilities,judgments, costs and expenses which may in any way acerae against said City
in consequence of the granting of t' pe it.
PLUMBIN FIiE
AIR HANDLING UNIT (TO 10,(100 CFM) ,
MECHANI AL FEE
APPLICANT UNDERSTANDS ILL COMPLY WITH ALL NON -PO NT
S
AIR HANDLING UNIT (OVER 10.000 CFM),
CONSTRU TION TAX "
Signet mcmr ate
HAZARDOUSMATERIA SDISCLOSUR .'
EXHAUST HOOD (W/DUCT)
HOUSING MITIGA NFFE
HEATING UNIT (TO 100,000 BTU)
- Will applicant or future building occupant score or handle hazardous material
,
as defined by the Cuperdno Municipal Code. Chapter 9.12, and the Heahh and Safety
Code, Section 25532m)9,
-
HEATING UNIT (OVER 100,0M BTU)
❑Yes .' EINo
Will the applicant or future building occupant use xgoipinent or devices which
nit hazardous air contaminants as defined by the Bay 'Area 'Air Quality Management
Distriat'I - y
❑ Yes Oise',
PAID s• •
Date Ree t #
VENTILATION FAN (SINGLE. RESIDj
--
BOILER -COMP QHP OR 100.000 BTU)
TOTAL:
-
BOILER COME IOTW0 BTU)
•
AIR CONDITIONER -
I have tend the hazardous materials Tequlrements under Chapter 6.95 of the Cali-
- 'ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. PT.
fume Health & Safety Code Sections 25505 25533 d 25534 I understand Om d the
building tloesncurrently h 'tenant, that it is myresponsibilityt notify Oeeccupam
r - t
of Oe q t h hmu.tbe met prier to eofe Cedf r fOccupm¢y
,
ISSUED BY,
Owner r authorized agent -Date
GFFICE - -