30648 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUB.DBvc-ELECTRICAL PERMIT No,:30648
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG-MECHANICAL.
tI BUILDING PROTRCI'IDENTIF'ICAT'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
► .
OWNER'S NAM?' PHONE: CONTRACTORS NAM?.: 11II LIC NO: t6
2 ?AN WC CONTROL.
1NCHITECUENGINEER: LICNO, - ADDRESS:
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S LO,uM R LJV . uS %s/l
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CONTACT: a PJ`fON� BUILDING PERMIT INFO
Ltpc �n ❑ Consultant Fees Paidby Applicant(initial) �B,L�tD�O ELECT PLUMB MECH
Ju— 10� •L_7� .
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affiro that I am]]chased under provisions on,Cops 9(commencing , JOB DESCRIPTION
OCZ al llXNp ofDivision3ofthe Businessland Professions Code,and mylimrise le RESIDENTIAL:
00 wi PERMI'1'ISSUANCE
in ful,eciaand effect. �����S
wF []A DWL GKITCH IN RE-?IPI.
U U License Clua Lim.,
p
�<4 Omc Contractor APPLIANCES-HCSIDF.Nf1AL []ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION PgNE1S
F.D m 0 MULTI-UNIT 0 STRUCTURAL' ,
OZ y2 Z I undersand my plans shall he used as puM1lic mcoMs MODIFICATION
=4 o Licensed Pndusimal UPT0200 AMPS ❑INTERIOR MODIFICATION
.��.4I OWNER-BUILDER DECLARATION 201-1000AMIS IMPROVEMENT
' 6 1 hereby affirm that I am exempt from the Coronals License Law for the OVER 1000AMPS I]BATH REMODEURF.PAIR ❑DEMOLITION
{�g O L U following reason.(Section 7031.5,Business and Professions Cade:Any city m county SIGNS IiLECTRIGAI. ❑OTHER
V10it,NN¢ which reyuirus o permit m emernmet,aloe,,improve,demolish,nr repair any nmeture p B
X0ya.1 prior to its issuance,also requires the applicant lir such period to file a signed diumant SPECIAL CIRCUIT/MISE. A
Y that he is licensed pursuant tmhe provisions of the Contra is License Law(Chapter 9 11 (� ftn�w��AT
teat he
ingwit thecrionniandfDivisi for ofthec,oBim,dssandAnionsCode)or TEMP.METER OR POLE INSt SMML
Ni��iIViY"
So he is exempt therefrom and the basis for the allegedapplicant
ascription Anyil parody
of BI.OG ION
fisc] h Section lar five
hundreday dollrs(S500mir subjects the vpplicannnucivil penehy oL POWER DEVICES ANT ❑FOOD SERVICE
F Z Y t more than f ve hundred dollars(SSm).
a0 ❑I,as owner of Ne pmpeny,or my employees with wages as their sole compensation SWIMMING POOL ELECTRIC IMPROV
will do the work,and the structure is not intended or offered(or sale(Sao.]1144,Business OOTHER P��f GUFaH1-INU
and Professions Code:The Conhuctols License Law docs nm apply n)an owner of OUTUO S-SWITCHES-FIXTURES - ZA '
Property who builds or improves then w n,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
mtln.If.hvon...the hnilJingorimpmvement i.c sold within nneyennif completion,the SQ IT.FLOOR AREA $SQ.f.
caner-builder will have the burden of proving that he did not build or improve for pur-
you of sale.).
❑1,as owner of the property,am exclusively contracting with licensed co trial to TOTAL:
,,swat the project(Sec.7044,Business and Professions Code p The Canhadnr's LI-
cease Ww does not apply man owner of property who builds or improveuherenn,and QTY. PLUMBING PERMIT FEE
who comma for such projects with a command s)licensed promam to the Contraemrs y
License I.uw, PERMIT ISSUANCE
❑ I um exempt under Sec. ,B&P C far thin rmismi
ALTER-DRAIN&VENT-WATER IEA)
•Owner Date ALnUATION
WORKER'SCOM(ifLa IONof DECLARATION BACK FLOW PROTF,Cf.DEVICE ^ ♦✓��'
'Iherchy affirm unscrpenalty of perjury enc of the faliawing declarations:
I have and will maintain a Camped,of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA.COND. 2_0
saapresided on,0 pvided for by Section 37W of the Labor Code,for the performance of OneSTORIES TYPE CONSTRUCTION
-
work far which this Permit is issues, Z ES
FIXTUR -PER TRAP 0
I have end will maintain Workers Compensation Insurance,is required by Section '
3918 of ae laborCode,for the Performance of the work for whieladds permit is issued GAS-EA.SYSTIIM-I INC. OUTLETS OCC,GROUP - AI'N
My Worker's Compensutinn Insurance artier enJ Polity numMr are:
Carrier: - Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRBASIIINDUSy'NLWAST'hINTERC13PfURAZ
-
COMPENSATIONINSURANCE BU (' IVISION FEES
(This section need not becompleted Ran,permit is forone hundred dollars(SIM) CREASE TRAP
or less.) PLANCHECKF /
leemythatin the perfannunceofthewnrk fnrwbichthntiannit is issued,l shall . ' SEWER-SANITARY-S9'ORM EA,200 PI'.
not employ...person in any mnnnvr m as to become subject 10 the Workers'Cooper' ENENGY PIin '
lotion laws of California.Due�O Applicant ' WATER HEATER WHEN z({a.�ur �D. GRADING FIR
NOTICE TO APPLICANT:IL ufarnwking this Cerificam nr Exemption,you shnuld WATER SY$TEMIrREATiNG
tui become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEC
forthwith comply with such provisionz nr this permit shall he deemed revoked. WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB, SQ FT. PAID
U Iherehynflirm that hem iso constral leading agency for the perfomtance of Dom Reser N W. F the work for which this permit is issued(Sec.3097.Civ.C.)
U
AL
Larider's Name
LerPlAddress TOTAL: :
PWi I candy that I have read this application and sant that me above information is BUILDING FEC am
r
'U7I eorteet.l agree to comply with all city and county ordinances and nate laws relining a QTY. MECHANICAL PERMIT FEE
U a building construction,and hereby authorize representatives of this city a enter upon the SEISMIC FEE S 2
above-mentioned property far inspection pu pumal PERMIT ISSUANCH !
011 agree to save,indemnify and keep harmless the City of Cupertino against , • ELECTRIC FEE
liabilities,judgments,costs andexpcnxs which may many wayvccmeagninst said City ALTER OR ADD TO MECH, p' �.
consequencein of the granting of this permit. Q PLUMBING FEF. -
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APPLICANTUNDERSTANDSANDWILLCOMPLYWITH-ALL NON-POINT AIR HANDLING UNIT(TO III,INgICFM)
SOURCE REGULATIONS. MECHANICAL MEblk
AIR HANDLING UNIT(OVER I0i"CPM) CONSTRUCTION TAX
Signature of ApplicanUCnntrudor Dam EXHAUST HOOD(W(DUCO HOUSING MITIGATION PGE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant score or handle harallous material HEATING UNIT CTO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Ihealth and Safety
Code,Section 25532(.)4 - - HEATING UNIT(OVER I(k1,0(q BTU) ..Q �,./�
O Yea ❑Nn VENTILATION PAN(SINGLE HESIU) PAID / � [W/
Will the applicant or future building occupant use equipment or devices which Date Receipt.
emit hazardous air conmminants as defined by the Bay Area Air Quality Manual BOILER-COMP QHP OR 100,000 RTU)
Ld�s
TOTAL: /
s ❑Nn BOILER-COMP(OVER 100.000 BTU)
read the hazardous materials mmimments tinder Chapter 6.95 of the Cull- AIR CONDITIONER ISSUANCE DATE
&Safety Code,Sections 25505,25533 and 25534.I understand des,il'rhe NEW RESIDENTIAL MECH. SQ.FT.
natcumntly havea reruns,thin it is my respasibllity anotify aenxwpantmena which qqhahopi em Date TOTAL: .IV4srrljtxI BY:
OFFICE