30886 )APPLICANTTO FILL IN INFORMATION WITHIN RED'LINES.j USE BALL POINT PEN ONLY
CITY,OF CUPERTINO BUILDING-ELECTRICAL. x ,F PERMITNO. 3
BUILDING DIVISION .APPLICATION/T`ERMIT PLUMBING.MECHANICAL, 1 J 0886
.
BUILDING PROJECT IDENTIFICATION -
1LDINGADDRESS: _ 'SANITARY NO. - APPLICATION SUBMITTAL DATE
Z11?EkS A E: - PHONE: CO RACTOR S NAME:• 1 r_ LIC NCO: a
.N)e)c 10FJ ?O +•f��!
SIC
CONTROL#
RCHITECT/ENGINEER: - LIC NO:�. DREgS: 'G ❑ -
2 Zo LPlL 6bf-n9i� :mss
CONTACT - .rEHONE: - * BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant QnlNal) BLDG. ELECT PL B MECH
❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 he eby affirm that I am
' 00 - f . d d p f Ch,d 9(commencing JOB DE-
SCRIPTIONnwz Bs nPrfe;uwae and RESIDENTIAL '
IbPERMIT ISSUANCEollf ndeffeet
(� I" Lice Class -Lm(# ❑SPDWf. Uffll'CHEN REMODEL
y Date Commdor ' APPLLANCES-RESIDENTIAL ❑ADDITION �7 ",PMBING BETTE
art g, ARCHITECTS DECLARATION +y PANELS ❑MULTIUNIT STRUCTURAL
Z 0+/+ Ieeadecupnd my plans shall he usede puhl'c records - MODIFICATION
ONTO Gym e� UP To 200 AMPS r ❑INTERIOR El CHIMNEY REPAIR
�,",,, a� xw'pressman, - 2011WOAMPS - - IMPROVEMENT •'
pp�� ER Bxempt h DE CLARATION OVER 1000 AMPS ❑BATH REMODEL/REPAIR El DEMOLITION
0, T naso affirm that I em exempt s m theContra at r License L for me
OyU following (Section 70315 business d Iffinfiessicas CJ Any city or countySIGNS ELECTRICALI []OTHER
which requires a permit 10 consumer,alter, prove,demolish r repair any structure -
FJ�6 prior to hos issuance,also requires the applicant for such permit to file a signed statement SPECIALCIRCGIT/MISE. p
thaw he is licensed pursuant1 th provisions of the Cmitractars l L (Chapter 9' - a
GO (commencing with Seco ]000)offirvisioni of the Bt
isness andP f ns Code)., TEMP.METER ORPOLE INST. COMMERCIAL
d Oo z that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION 'El DEMOLITION.
(i�$ ❑•
Section 7031.5 li,waynEdiciatf apermt subjects the applicant t 'l penalty of POWER DEVICES ❑ ❑
TENANT a. FOODSERVICE
t in than Five hundred dollars($500)
.it 7I.a,owner ofthepropry, y employees with wages asi their"sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT'
will do the k dine structure is netintended cautionedf r sale(See,9044 B sinesw , HER
and Powea,mrs Code.The Cmaneque,License Law does n t apply t it.owin,of OUTLETS-SWITCHES FIXTURES
pmpeny who builds or improves thereon,and who does such work himself or through - -
his own employees,provided that such improvements we not intended or offered for NEW RESIDENTIAL ELECTR SQ Cr. "
+ sato..lChowever,thelooldingmiro oncemeni issoldwl[hlnone yearofcompletlon,the "SQ�Ff.FLOOR AREA it $/SQ.Pp.
ownerbuilder will have the burden of pmvmg that he did not build or mprove for pub - y'Qy1•' -
pose of sale)
❑1,es owner of the properly,am exclusively contracting with licensed contractors to TOTAL:''
construct the project(Sec.7044,Business and Professions Code)The Con[mmor's Li- REC
'nue Law Does not apply to an owner of pmpeny win builJsor improves thereon, ad, QTY, PLUMBING PERMIT FEE APR
who contracts for such projects with a comrecmr(s)licensed pursuant(o /�the Contractor's +
License Law. '' A.
PERMIT ISSUANCE. A '
❑1 am exempt order Sec. ,B @ P C for this mason CITY Uh wrrhi'lNu '
Owner
ALTER-DRAIN@VENT,WATER(EA) - -.VALUATION
- - Date • _ - ,
WORKER'S COMPENSATION DECLARATION ' BACK FLOW PROTECT.DEVICE I
I hereby affirm tinder Penalty of perjury we of the following declarations: •I
❑I have and will maintaion Certifican of Consentto self-insure for Worker's Conn,ii DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
union,as provided for by Section 37M of the Labor Cedn,for mnce of the a performa - .- `,
wnrkfarwhehthtspermt' d rT
FIXTURES-PER TRAP
❑1 have and will maintain Worker c Comp r m I u un a.as nNinond by Section h - '
37W ofthe Labor Code,lir the performance offlue work for witichdo,permit is issuedGAS-EA.SYSTEM-I INC.4 CUTLETS OCCGROUP APN
My Warkers Compens en.Insurance carver and Polity number no:
1-10 Carrier: Policy No.: GAS-EA.SYSTEM-OVER4(EA) •.
CERTIFICATE OF EXEMPTION FROM WORKERS' +
COMPENSATION INSURANCE' 1, GREASB/INDUSTRL WASTE INTERCEPT' R'
BUILDING DIVISION FEES
(Thisseadon need net be completed ifthe permit is furore hundred dollars Dust) GREASE TRAP,.
orless.) • " PLANCHECK FEE I_ .
1 readily fo
t n he performance fine kr which thisTp t" ed,label] SEWER-SANITARY-STORM EA.200 -
not employ y any Person in any manner so a.t become subject t theW k Compen- ENERGY FEC
O,Z sation Laws of California.Date - ' ., WATER HEATER WNENT/ELECTR -
�O Applicant _ GRADING FEE
y NOTICE TO APPLICANT.If after making tin.Certificate of Exemption,Y should „ WATER SYSTEMITREATING
.� become subjectm the Wmkers Cian,amettionpuner,curniefdae Labor Cade,you most SOILS FEE
LaLI A forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE ,
Uz0. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI.MB. SQ.FT. - PAID '
I hereby affirm that them is a construction lending agency for thepeffmnumeef _ Data Receipt#
the work for which this permit is "and(Slc:3097,Civ.C.)
O U Lenders Nume L:
..
• TOTA
4L1 Lender s Address _ a
I carol,mut I have read this application and state that me shove information is BUILDING PEE
faq career.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT .x" FEE
U building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE -
above-mentioned property for inspection pnowsns. t - - -
(Wm)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE -
liabilities,judgments,costs and expedses which may in any way accrue against said City ALTER 01RADDTOMECH.
In am segmemse.(the gun id,of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,003 CPM) 1 ,
SOURCE REGULATIONS. - - MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTIONTAX ,
-giglprye ofApplican cur Dat EXHAUST HOOD(W/DUCf7 HOUSING MITIGATION FEE
AZA OUS MATERIALS DISCLOSURE
Will the applic rfumre building art,xim samccr handle hazardous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety _
Cale;Seetion 25532(x)? , ' I HEATING UNIT(OVER 100,000BTU) t
❑Yes „ ❑N - " VENTILATION FAN(SINGLE RESID)' - PAID
Data Receipt#
Will the app ontt fi bolding occupby
Be,useea Air
rdevices which BOILER-COMP UHP OR I BLOW BTU
t ic zartl us air containt d fined by the BArca A r Qunl ty Management 1 '
TOTAL:
Districty: BOILER-COMP(OVER 100.000 BTU) _ ..
❑Yes Fl No _
CONDITIONER
I have read the hazardous materials man mpo nus wider Ch pt AIR 6 95 f me Cali- '_ ' ISSUANCE DATE
Foods Health&Safe,,Coda.9ectmirc 25505 25513 ad 25534 1 understand that if the �^ NEW RESIDENTIAL ME
SQ.FT. h '
build g0 e not cm dy have a tenant that it myresponsibility' t notify the circular
o the requirements which most be war priore,issuance ofa Cciificcte of Occu cy.
4 ILO
_sssrhan or numonzed ag Dute NOTAL: ISSUED BY:
OFFICE .