S 0272APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
PF§[T NO
C
O�i7.2IFICATION
BUILDING PROJF,C2'IDF.NT
V L 1
BUILDING ADDRESS: -
'z12_4:577___ 6 L (2T
SANITARY NO. APPLICATION SUHMITI'AI. DATE
NIC CIINTR(11,8
❑
OW : A aa' PHONE
1 ARCH]LECTIENGINEER: LIC NO:
CONTRAMOR'SNA�E:,. I`IC NO: _
[IIIRESS� J ^
CONTACT: PHONE.
BUILDING PERMIT INFO
✓� / _
(/J�VI
❑ Consultant Fees Paid by Applicant (Initial)
_ BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR' DECLAkn5ON
I hereby alum had I am licensed under provisions or chapter 9 (emnmendmg
Z with Section 9fxx))af Divisinn3ofche Business and Professions Cade. enJ my licensees
in full force ani CRPERMIT
H Z
J Liccnsc Li0.M
til Date Contrano
. i
QTY. .. ELECTRIC PERMIT.. FEE
- -, -
JOB DESCRIPTION
RESIDENTIAL•
❑ D ❑ KITCHEN REMODEL
❑ADDITTITION ❑PLUMBING kI PIPE
❑MUITI-UNIT El STRUCTURAL
MODIFICATION.
DINTERIOR CHIMNEY REPAIR
❑
IMPROVEMENT E]SWIMMING MOM
❑ BATH REMODEUREPAIR ❑ DEMOLITION
1101HER
ISSUANCE
APPLIANCES—RESIDENTIAL
n ARCHITECTS DECLARATION
Z I understand my plans shall he used as public records
W
PANELS 2LfG A Af /
U P T021N1 AMPS z 0
Licensed Profession.)
OWNER -BUILDER DECLARATION
Q 1 hereby affirm then I an, exempt front the Comore 'a License Law mar the
Ffollowing reacon. (Senior ]03 1.5, Business and Professions Code: Any city or county
which requires a permit to common, alter, improve, demolish, or repair any saucmre
primo its Issuance, also requires the applicant for such ptotic to file a signeddifemem
Nm he is licensed pursuant m the prevismns of the Contmaor's license Law (Chuptcr 9
D formmencing with Section 7") of Division 3 ofthe Bwlneu and Pmfecsions Cook) or
X that he is exempt therefrom and the haus for the alleged exemption. Any violation or
nLITION
Section 7031.5 by any applicant for a permit subjec's the applicant to a civil pent by or
H not marc than five hundred Jailors($500).
2n1 -1(X10 AMI'.9
OVER I"AMPS
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC.
TEMR METER OR POLI; 1NST.
COMMERCIAL'
❑ NEW BLDG/ADDITION ❑ FOODDEMSERVICE
[I TENANT El FOOD SIeRVICIi
POWER DEVICES -
SWIMMING PDOL ELECTRIC
OUTLETS—SWITCHES—FIXTURES
? ❑Lae owner of the properly, or my employees with wages as their sole cmnpeneation,
will do the work, and the structure is not intended or oBered for sale (Sec. 76/4, Business
and -Professions Code: The Contractor's License Law does nm apply to an owner of
IMPROVEMENT
❑ OTHER
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such impmvemems are nm metrical, offered for
NEW RESIDENTIAL HLECTR SQ FT.
-
.to. If. hcweventhe budding arimpnwementlssold within one year of cmnpletion.the
owner famider will have the herder, of proving that he did not build or improve for per -
-
SQ.FTFLOORARRA
$/SQ. FI'.
you of sale.).
TOTAL:
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
onsava the pr jac (See. 7044, Business cad Professions Cal...... Cnatmcmr's Li-
-
QTY, PLUMBING. PERMIT. FGF,
cense law Notes nm apply to an owner of properly who builds or improves thereon, and
who cnatroasforsuch prttjects with u comma... s) licensed rursmun to the Contractor's
License law.
❑ Iamexrrourndef Sec. ,B&PCfonhisreason
PERMIT ISSUANCE
ALTI?R— DRAIN & VENT— WST 1?k (EA)
/
Owner Dam
- VA. PION
F
WORKER'S COMPENSATION DECLARATION
' I hereby aRtn under penalty of perjury one of the following declarations:
BACK FLOW PROTECT. DEVICE
DRAINS—FLOOR. ROOF,AREA.COND.
❑Ihove rune will mainmina Cerllliwmof Consent to aolGinxme fur Worker's Contpen-
satinsthe , as provided for by Section 3]W id Lahr Code. retina performance afire
bz'
S'1'ORIP_S
1'YPECONSTRUCTION
FIXTURES — PER TRAP,
work for which this permit is issued.
E]1 have end will maintain Worker's Compensation Invumnct, rte required by Section
,
37M of the LaMrr Court, fill the performance of the work far which this pemtit is issued.
My Workds Campenmtion [.comma, cattier and Policy number am:
GAS —EA.SYSTEM- I I NC. 4 OUI'I.E'I'S
OCC. GROUP
APN
GAS —EA. SYSTEMFOVF.R 4IEA)11
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE/INDUSTRL WASTE INTERCEPTOR
GRFASE TRAP
BUILDING DIVISION FEES
(This section need not be completed tribe permit is forene hundred dollars IS 00)
cur less,)
for which this the Wiisiss'Comer-
Ioy any chs in the anymmaneeo ilhe as
not employ any person in any munncno a nt M1crnme subject the WnrkcrF Compen-
• cation ant of Calirnrniu. Dale
1 ant
I'LANCHECK THE
SEWER — SANITARY — STORM HA. 200 FT.
ENERGY FEE -
WATER DEALER W/VENT/ELELTR
-
GRADING FEE
NOTICEAppli
becomeTO APPLICANT: R. after nmeenit this Cenidis of of Exemption, you should
• becomesubjectd the Worker's Comas or this pmvisinnl of the Lned Code, you nnust
fonhwilh comply with such provisions colada permit shall be dented revoked.
1
WATER SYSTEM BEATING
SOILS FEE
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hereby alirm that there is a amatructinn lending agency for the performance of
I the weak (or which chis permit is issued(Sec. 3197, Co. C.)
PAID
Date Receipt It
NEW RESIDEN'T'IAL PLMB. SQ, pen
TOTAL:
e Lender's Name
Lender's Addreas
TOTAL:
BUILDING FET?
1 certify that I have read this application and state that the aMrve information is
comet. 1 agree to comply with all city and county ordinances and state laws relatingm
building construction, and hereby awhnrim represenmtivep
s nfthin city to enter the
QTg -MECHANICAL PERMIT FEE
SEISMIC FEE
above-mentioned propeny for impation purposes:
(we) g
( agree m save, indemnify and keep harmkas the City of Cu nino a aeon
Iiabilities,judgmems, costs and expenses which may in any way accme against said City
in onsequencc of the grand ng of this permit.
PERMIT ISSUANCE
ELECTRIC FEE O
ALTEk OR ADD TO M ECH.
PLUMBING FET?
AIR
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
FEE
SOURCE REGULATIONS,
HANDLING UNIT('I'D Iq(xx)CFMK�ECHANICAL
I•'v._r.. _
AIR IIANDLINO UNfC (FIVER 10,1X10 CPM)
CONSTRUCTION TAX
Signature of ApplicanJCmttmnor Date
MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
OUSING MITIOA'I'ION FEE
HEATING UNIT (TO Her fX10 BTU)
HEATING UNIT (OVER IW U
ION DEP
Will the applicant or future building occupant store or handle batatdnus material
a defined by the Cupertino Municipal Sale, Clasper 9. 12, ani the Health ..it Safety
Code, Section 25532(a)Y
F7 YO, E] No
Wi11 the applicant ornes futurebuilding occupant use equipment or devices which
I emit hueardous air contaminants us Joined by the Bay Area Air Quality Munageenem
DinricT!
❑Yes ❑No
, t 1'_v,p7
.2z a2f-5L
Datc Rmeipto
VENTILATION FAN (SINGLF.RGSID)
Y F CUPERT t'#�D7
BOILER—COMP (3HP OR 1 00,000 BTUI'
'TOTAL:
BOILT:k—COMP(OVER I00.010 BTII) _
AIR CONDITIONER
I have read the havardous materials requirements under Chapter 6.95 of rhe Coli
Health & Safety Code. Sacions 25505, 25533 mal 25534. 1 understood that if the
building does not currently have a tenant, that it is my responsibility m rorify thenceupant
of the mquirements which must be, met prior lit Issuance of a Ccrtlficale of raced ay.
ISSSS
ISSUANCE DATE
ISSUED try:
NEW RESIDENTIAL MECH. SQ. FT.
Owner nr amhnnzed agent Dam
'TOTAL: -
OFFICE / - "