B 0174APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
50001 _ 0174
•�J
BUILDING ADQRESS: -
SANITARY NO.
APPLICATION SUBMITTAL DATE
- � •
/ 2- - Z_sJ
R5 NAME: PHONE:
_
O 'RA IRS NA E. _ - LIC NO:
NIC
❑
CONTROL#
ARCHITECTENGINEER: LIC NO:
ADDRESS: apo
TF' J
CONTACT: PHONE:
-
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MUCH
❑ ❑ ❑
LICENSED CONTRACIOR'S DECLARATION
I heresy sten that 1 am licensed under pmvislona of Chapter 9 (eommenclug
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
wish Seclicn 900y.f Division 3ofmc Business, and Professinns C.de,and myliceuso is
in full force and it �-5 ,
LicereeF'�= Lic.x ` '�1'� •
Date Conwemr
PERMIT ISSUANCE
RESIDENTIAL:
❑SFDITI El KITCHEN RE -PIPE
El ADDITION El PLUMBING RB -PIP#
APPLtANCBs- ReSIDENTIAL
ARCHITEC7CS DECL ON
1 understand my plans shall be used as public records
ElMULTI-UNIT❑ STRUCTURAL
MODIFICATION
ppNELS
UP TO 200 AMPS
[]INTERIOR CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH REMODELREPAIR ❑ DENIOLITION
Licensed Profevsionel
OWNER -BUILDER DECLARATION
I hereby affirm that I oat exempt from the Goatmeat,', License Lew hurtle
201-1009AMPS
OVER IOW AMPS
SIGNS ELECTRICAL
following meson. (Section 90315. Business and Professions Code: Any city or county
which requires a permit to construct, almq improve, demolish, or repair any swemm
❑ OTHER
1
prior m its i,,arde.slociesmirds theaDnicint husuch pennith, filen signedsmmmem
that be is licensed pursuant to the provisions ofthe Contractors License Low (Chapter -9
SPECIAL CIRCULUMISC.
� PF
TEMP. METER OR POLE INST.
COMMERCIAL
(commencing with Section 7") of Division 3 ofthe Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 9031.5 bytny applicant fora peura,msped, theapplicanl to aciA] penalty of
not name than five hundred dollars ($5110).
❑ I, as owner ofthe property, or my employees with wages as their sole campenamion,
will do the work, and the shoran, is nm intended oroBered for sale (See. 7044, BusinessOTHER
❑ NEW BLDG/ADDITION ❑ DEMOLITION
TENANT ❑ FOOD SERVICE
IMPROVEMENT
POWER DEVICES
SWIMMING PWPER�E�f
and Professions Code: The Gmtmcons License Law does not apply to an owner of
OUTLETS-S
property who builds or improves thereon, and who tices such work himself or through
his own employees, provided that such improvements are not intended or offered for
NEW RESiDEsale.
FT FLOOR AREA
$/SQ. PTcobuilder
If,however, the building., impmvemem is sold withinone yearofcompEri.e. theSQ.
will have the burden of proving that he did not build or improve for put,
16 TPato
of sale).❑
1, a.s owner of the properly, am exclusively contracting with licensed contractors toonstruct
the project (Seo 9044, Business and Professions Cock) The Contractors LI-
seLawacesnota I to to owner ofper proper( who or improves thereon, ane
QTY. P
hon sedp
for such projm¢ with a cnntmcut(s) licensed pursuant to the Contrucmrs
so
p IJ ANC
ecommda
License Law.
❑lor. exempt sneer see. ,e&relot lata reax.
'
'
ALTE RAIN & VENT- WATER (EA)
PROTECT. DEV ICE
'
Owner Date
VALUATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following Jed.
❑ I have and will maintain a Certificate of Consenuo self -insure for Worker' s p
,art.., as provided for by Section 3900 of the Labor Cade, for the performanc
� AINS-FLOOR,ROO(,ARRA;MND. -i
��
STORIES
9YPECONSTRUCTION
TURES-PERTRAP x L�
k for which this permit is issued
1�q,,r' have and will maintain Workers Compensation Instant as agoited by It, 1
3?Mloflhe Lahnr Code, failed performaneenfthe work for which this perm it is issoed.
My W.r Can, nsutionlns�ur-avnceccarrieranJPolio jajq
Cartiee� is%t y�y�,_Policy N7 � 010!2)q
GAS -EA.SYSTEM-I INC.4 OUTLE
OCC. GROUP
APN
r
GAS' EA. SYS,7 fW-GWDEUE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
accord need not be completed iftbe permit forced hundred dollars ($1 W)
or le".)
GREASE/IND *RL WASTE INTERCEPTOR
BUILDING DIVISION PEES
GREASETRAP
PLANCHECK FEE
SEWER-SANITAO_= .WFP.
Ioy anymatin in ponanym antero as to odor whicht(c, me WorkrsuComper-ed, Tsball
not employ any person in any manner so as m became subject m the Workers' Comeen-
ENERGY FEE
WATER HEATER WNENT/ELECTR
smmu Laws of Califentor Date
Applicant 1
GRADING FEE
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
momma subjecuo the Workers Compensation provisions of the Labor Code, you must
WATER SYSTEMaRPAT ING
SOILS FEE
forthwith comply withsuch provisions emirs permit shall be deemed revoked
WATER SERVICE.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency, forthe performance of
PAID
m Receipt#
NEW RESIDENTIAL PLMB. SQ. FT
the work far which this permit is issued (See 3097, Ci, CJ
Lender's Name
TOTAL'
Lenders Address
TOTAL:
BUILDING F
1 certit'y that I have read this application and sham that the above information is
QTY MECHANICAL. PERMIT FEE
,red. l agree to comply with all city and county ordinances and state laws relating to
building construction, and hemby authorize representatives of this city at enter upon the
SEISMIC
above-mentioned property for inspection purposes.
(We) give to save, Indemnify and keep harmless the City of Cupertino against
/ PERMIT ISSUANCE
ELECTRIC
liabilitids,judgments, costs and expenses which may in any way accme against said City
inemou,mnce of lhegmntiug ofthi, permit
ALTER FRAUD TO MECH.
PLUMBING EE
AIR HANDLING UNIT (TO 10.000 CFM)
MECHANI LURE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
OU F GULATIONS.
lI
I' �T 9Q
1 UU
AIR HANDLING UNIT (OVER IQOIXI CFMI
CONSTRUCT NTAX
Vital,ofA,diticauCommpor, Date
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant.,future building occupamstoreor handle hazallous material
EXHAUST HUED IW/DUCT)
HOUSING MITIGATION FEF.
HEATING UNIT Off) 100,018) BTU)
�O
as defined by [hit Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Cad, Section 25532(x)?
HEATING UNIT (OVER 100,000 BTU)
E] Yes ❑No
use equipment or Maas which
Will the air contaminants
or ants a building treby the
emit hazardous air comaminants us defined by the Bay Arca Air Quality Management
District,
F1 Yo, ❑No
PAID -'
Date Receipt of
VENTILATION PAN (SINGLE RBSID)
BOILER - COMP (3HP OR 100,000 BTU)
TO AI
BOILER -COMP (OVER I00,0000TU)
AIR CONDITIONER
1 have read the h oto. S a materials requirements under . I mid nwa of Lha Carie
forma Health & Safety Code, Sections 25505, 25533 ane 25534. I u notify m Nat Hire
g does rrentlywhich to isua responsibilityofaCatmtify theoancy.
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. PI.
(iftei
requirements musavet
of the requirements which must rte met peon. issuance of a Certificate of Occupancy.
be met prior
ISSUEDBY: L `J
Owner or authorized agent Date
TOTAL: O
OFFICE