Loading...
S 1875 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PF. IT NO BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL . 1875 _ BUILDING PROJECT IDENTIFICATION BU LDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE l0q .)-4- N 4L4►3EY 4U& Ct P &9-tirro CA (sol _ OWNER'S AMS^ PH NE: CO TRACT_O/R'S NAME I O LIC NO' �' *Sl _L.3- 1aiak� OK1 4b8946-33$a (Z ry p3 3g N/C CONTROLh AI CHITLCf/ENG11yyssER: LI NO: ADDRESS'. ^ El K 1'f�N X91 Fo- O br +t- iialh w c.H CONTACT: - PHONI+ r BUILDING PERMIT INFO 1 ^ /—'�/�^ T ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION 1 hereby affirm that 1 um IieensW under provisions of Chvpler 9(commencing TWQ00 wiW Section 90f10j of Division3ufihe Busmen...and Professions Code.and, lieenseps O l PERMIT ISSUANCE - RESIDENTIAL, L fu use ClanA efface. rte/ QUV Licence Clu Lie.st / d CSFDWL ❑KITCHEN REMODEL h<L Dalc�Comrncmr APPLIANCES-RESIDENTIAL CADDITION C1 PLUMBING REPIPE IITECPS DECLARATION PANELS ❑MULTI-UNIT El STRUCTURAL Z0,0 I mtdeamad my phre shall be used as pohlic re s MODIFICATION OZ^1 uP T0211(IAMPS ❑INTERIOR ❑CHIMNEY REPAIR ly Licenced Professional 201-IMOAMPS IMPROVEMENT CG j -BUILDER DECLARATION 'C SWIMMING POOLS p� C4 6 1 hereby uflir that ebur 1 no exempt from the Camenor's License Law for the OVER 1000 AMPS ❑BATH REMODELIREPAIR DEMOLITION X O W U following reason.(Section 90315,Business and Professions Calc:Any city or county SIGNS ELECTRICAL C OTHER W W k1 y which requires a peril leo construct,altar,ibtprem,demolish,or repair any sr uchme prior m its issuance,also regniesthe applicant for such permit m file a signed statement SPEC IAL CIRCUIT/MISC. ,M J�e �� y. 'hot he isIpaused pursarm,,the pmvihons clubs,Comraeoe,Fireme Law(Chapter 9 pQ�� 00 (commencing with Section 7000)of Division 3 of[lie Business and Professions Code)or 'TEM P.M ETLR OR POLE INST. COMMERCIAL: G y o eC that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION iYCI 4y Station 7031.5 by any applicant fora permit subjects the applicant to a civil penally of POWER DEVICES not me than five handled dollars(&500). El El or C=< I,as owner mf the IMPROVEMENT C2C2 O ❑ the,trchmeis mym incraeecwithcated as talei(Sea7ompensatces SWIMMING POOL ELECTRIC F will do the wcom and,Had Container, License Law doesnotCasale(Sec.9044,Business C OTHER tal3� and Prof hobs Code:The Conmacoce License Law does not apply to vn mwnou of OUTLETS-SWITCHES-PI S SS properly who builds pr vided es thereon,and veto doessuchn work himself onMongh . has own employees,e provided Ihal each improvements are not intended or offered for NEW RESIDPNTIAI.P.IH?CT SQ FT. sale Bl however,Whave the burden odpro int is sold did non wild or improveaor,the SQ.FT.FLOOR AREA S/SQ.F1'. owaeof wddu will have the burden of proving that Ito did not build or improve for pur- pose of sale.). ❑ 1,as owner of the property,ran exclusively contracting with licensed C Connector's to cause La]hees arm (See.Oan owner and Professions Ca le i The Connector'sdd ncelnwdoeersuch ply rawn with a cufpmperty who sedprsds or improves Contractor QTY. PLUMBING PERMIT EP, who contracts for such projects with a emmecmr(c)licensed pursuant to We Comracnrz s License Law. PERMIT ISSUANCE E]I ran exempt under Sec. ,B&P C for this rearon Owner Data ALTER-DRAIN&VENT-WATER(EA) VALUATION • WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE D © O 1 hereby affirm Linda penalty of perjury one of the billowing dadmations ❑Ihvve nntl will mvmleinaCertificnm ofConsem mate][-ineure for Worker's Compen- DRAINS-FLOOR,ROOF,AREAL,COND. STORIES TYPE CONSTRUCTION ration,ac provided for by Section 37W)of the Labe Gale,for the performance of the work for which this permit is issued, FIXTURES-PER TRAP I have and will maintain Worker's Compensation Insurance,as required by Section 3900 of the Labor Code,for the performance of the work far which this paMt is issued. GAS-EA.SYS'rew-I INC.4 OUTLETS OCC,GROUP APN My Worker.Compensation Insurance carper anLIP oly n m er n Carper: Policy Nm.:� GAS-EA.SYSTEM-OVER4(EA) CERTIFICATE OF EXEMPTION FRO 1 WORKERS' COMPENSATION INSURANCE GREASE INDUSTRL WASTF.INTERCEPTOR BUILDING DIVISION FEES(This.ection need nm he complied if WepemulisRuma, undreddolmaISI0o) or IessJ GR SASH TRAP PLANCHECK FEE 1 certify that in the performance of the work for which this permit is issued,1 shall Zenot mploy any Parsn my mariner so ash)become subject to the Workers'Compact- SEWER-SANITARY-STORM EA.200 PL ENERGY FEE ration Laws as ate T/ O r WATER HEATER WNENF.LECTR r O Applicant o n tom- 5 AUINC FEE Taj] NOTICE TO AP :1, a n g it,, enioaaaa o1'hzemmmin,you should WATER SYSTEM(TREATING SOILS PPF. become sub' a the Worker's Compensation provision,of the Labor Code,you must _ Gil ry forthwith mply with such provisions or permit shall be deemed revoked. WATER SERVICE `It s I ... Q CONSTRUCDONLENDING ngAGENCY agony NEW RESIDENTIAL PLMB. SQ,PT PAID O I far by affirm whih(hithmtboreissued ea.30lending agency for perfmnnvneeof Dt ReceiplM W H the work for which Wig permit is issued(Sec.309),Ci,CJ O U Lender's Name TOTAL. Ixnder a Address TOTAL: / .� Wy 1 eenee that 1 have read the application y o slate that the shove information as BUILDING PF. U Q i h correct.]agree m comply with all city and county ordinances and state laws relining no QTY. MECHANICAL PERMIT FEE C.7 ,'� building cnsweion.and hereby authorize representatives ofthis city to enter upon the SEISMIC P above-tnanlioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC F liabilities,judgments,costs and expenses which may in any way accme against said City ALTER OR ADDTO MECH. PLUMBING FE in ormf the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'1'(TO IQUW CFM) SOURCE REGULATIONS. MECHANICAL FEE AIR HANDLING UNI'F(OVER 10,UW CFM) CONSTRUCT ION TAX Signnmre or Applic amracmr - ❑uta EXHAUST HOOD(W/DUCT) HOUSING MITIGATION Fl3P, AZARDOUS MATERIALS DISCLOSURE Will applicant or fume bupldpngrnecupirm,ram mr handle h...Mo.,material HEATING UNIT(TO 100,000 BTU) as defined by the Cupertino Mun CPul Code.Chapter 9.12,and the Health and Safety Coda,Section 2592(x)" ±HEATING UNIT(OVP,R 100,00)BTU) E]Yet ❑No ENTILATION FAN(SINGLE RESID) PAID Date Receipt k Will the applicant or[roue building maupvnt use dampmem or device.which g01LERCOMP(3TIP OR IU(I,IXXI RTU) emit hazard - mux air contaminants as defined by the Bay Arca Air Quality Management TOTAL: Dirlticl? ❑Yes No BOILER-COME(OVER 100,000 BT 0) I have rrnd the named...materials damammcna under Chapter 695 of the Cala- AIR CONDITIONER $ NCE D E forma Health At Safely Code,Sections 25585,25533 and 25534.1 understand Wal if the NEW RESIDENTIAL MECH. SQ.FT. building does not currently have v tenant,that it is my responsibility to notify the occupant of ohm requirements which most he mel prior to issuance ora Cetlillcam of OccuWnay. Owner or authorized agent Unto TOTAL: ISSUED BY: I "9�` OFFICE