S 1489-APPLICANT -TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
HtITNO. 1489
v`
BUILDING PRO11iC'1' IDENTIFICATION
BUILDING ADDRESS:
NO.
APPLICATION SUBMITTAL DATE
fSANITARY
I _
�'C 9 gg'
OWNERSNAME(? PHONE:
�A{VNI _
N'rRACFOR'S NAMED / LIC NO'
N
NIC
❑
CONTROL
ARCHITECT/ENGINFER: LICNO:
F S:
CONTACT: PHONE:
6UILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hemny vllinn that 1 am ,tamed undo, provisions of Chapter 9 (utmmencing
QTY
ELECTRIC PERMIT FEL
JOB DESCRIPTION
with Serino 7000) afluvision 3 crthe Business and Prfiesviluds code, and my license isRESIDENTIAL
is full fume and atmoo 4 il- r'C ^
Liven lass Liatr _(O�I��IIJ Contractor
El SCOWL El KITCHEN REMODEL
El ADDITION El PLUMBING RE -PIPE
El MULTI -UNIT []STRUCTURAL
MODIFICATION N
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECTS DECLARATION
1 understand toy plan. shall he weed vs public reco
PANELS
IIP TO 200 AMPS
❑iNI ERIOR El CHANTY REPAIR
IMPROVEMENT SWIMMING POOLS
[I BATH REMODEIJREPAIR El DEMOLITION
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am eae dept from the Contractor's License Law for the
201-1000AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
following wawa (Section 7031.5, Baroness and Prefesioms Code: Any city or county
❑ OTHER
which requires a permit to co rodeo, alter, imprnee, demolish, or repair any structure,
prior in its issomme,also require the applicant for such pemsit to file a signed statement
SPECIAL CIRCUIT/MISC.
that he is Penwell ....aunt to the provisions sef aha Cro racmr's License Law (Chapter9
TEMP ME TER OR POLE INST.
COMMERCIAL:
(empowering with Section 90X1(pnflJivmime 3of,ha Busimr,,tml Pro, ...nnu Cnde)or
that he is exempt therefmnt and the basis for the alleged tadr,d.on. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section ]HIS by any applicant fore pernit subjects the applicant to a civil penalty of
not inure thin five hroated red..(55fall
❑ I, as owner of the property, or my employees with wages as their Sole c lldwusaiun,
❑TENANT El 17001) SERVICE
IMPROVEMENT
SWI MMING POOL ELEC ERIC
will do the work, and the slrmwra is not intended or offered for sole (Sec. 9094, Business
OTHER
and Professions Code: The Contractors License Law doer not apply to an owner of
OUTLETS -SWITCHES -FIXTURES
Popery who builds or improves thereon, and who does such work himsalf of through
his own employees, provided that such irepnwemente are net intended or offered for
NEW RESIDENTIAL ELECTR SQ FT.
SQ gBOOR AREA
VSQ. Ff,
,.It. If, howevegthc building in improvement issold within one yootofmmpletien,the
owner-huilder will hoe the burden of provin,,h., he meant build or improve for put-
1 1J
pose of salt.).
❑ I, ux owner of the prapeny, con exclusively contmedng with IicenxeJ commemrs mI�
mswm the p Ject (Sec 704Q Business and Professions Code:) Ibt Cnnhumors Li-
se Law does notapply to an owner afpropeny who builds or improves thtreon, and
QTY PLUMBING PERMIT FEE
who contracts for such projects with a commemgs) licensed pursuant m the Commmors
License Law.
❑ I ant exempt under Sce. ,B& P C Far thi,paredr
Yv (\ 1 BVU
rITYUruur�
PERMIT ISSUANCE
ALTER -DRAIN & VENr- WATER DA)
Owner Data
VALUATION
BACK FLOW PROTECT. DEVICE
WORKF.k:SCOMPENSAT10ND1iCIARA'f10N
1 herehy oflirm under penalty of perjury one of the following deelomdans:
DRAINS- FLOOR, ROOF, AREA, COND.STORIES
El I have and will maintain a Certificate of Consent to self -insure for Worker's Cnmpen-
of.d. m provided for by Section 3700 of the Labor Code for the perfroll of the
'TYPE CONS' 1' RUCTION
FIXTURES - PER TRAP
work for which this per is issued.
❑ Hi and will maintain Worker's Compensation Insurance, as refund by Section
3700.Uhc Labor Cndc, fur the pafarprowasfthe work f,whichthie.ecoid it Lmued,
GAS -EA. SYSTEM -I INC. 4 OUTLETS
OCC GROUP
APN
a
44 Warlocks o n hon lnsmmncc carrierand Pricy nn tp
PandPutic
Grrien
GAS-EA,SYS'FEM-OVER4(EA)
FlCA'I'F:OP BXEMPTIUN FRUM WORKERS'
COMPENSAIJON INSURANCH
('fhissurmn need not Be completed pike pe Iran is Baine hundred dollar, (A 00)
or less)
GREASMNDUSTRL WASTE INIIiRCEFTOR
BUILDING DIVISION FEES
GREASE TRAP
PLANCHECK FEE
SEWER -SANITARY- S'TORM HA. 200 Fr.
Ioyany tbminthe afforanypmancenf lheworkfor whichlhto permit isissuCmr,m
not employany person in any manner an as m heeome suhjut to the Worktrs' Cnmpen-
ENERGY FEE
WATER HEATER WAIENTIELECTR
satitn Laws of Culifornia. Data
Applicant
GRADING FEE
NOTICE TO APPLICANT: If, after making hits Cenihcac of Exemplion, you should
become sunjed to the Workers Compensation provisions of the Labor Code, you must
WATER SYSTEM/TREATING
SOILS FEE
forthwith comply with such provision, .,,he, pe real shall he deemed menace.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hereby ORrm that therein sconxwdion leading agency tradeperfrmawOe.f
PAID
Dotc Re ipt#
NEW RESIDENTIAL PLMB. SQ. FT.
the work for which this permit is issued (Seo. 3097, Civ. C.)
Lenders Name
TOTAL:
Lenders Address
TOTAL:
1 unify that I normal this oppleptim. and State that the abovr information is
BUILDING F
tremor, I agmen, comply ,all Army anteriorly ordinances and stale laws relating In
bundle, romans ion, and hereby aulherize na,awnlalives of thin city In emerupan the
QTY. MECHANICAL PERMIT FEE
SEISMIC F . .
abova-mentioned property for inspection purposes.
(We) agree m save, indemnify and keep handles the City 'f Cupertino ngainxt
PERMIT ISSUANCE
ELECT EE
lotbailiea,judgmank,utsts and expenses which mayln any wayacerte against said Ciry
to onsegmenea of the granting of this Permit,
ALTER OR ADD I'O MECH.
PLUMBING 'B
AIR HANDLING UNIT(T'010,000CFM)
MECHANI AL FEE
APPLICANT U DL STANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REG L .ATI( NES.r
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRU IONTAX
Signalur cfA tit o pate
11 IAZ,=BS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING TION FEE
HEATING UNIT (TO 100,00X1 BTU)
Will the p licunt orfulaw building occupant store rehandle hazardous material
as deFlned by d 'upertinn Municipal Code. Chapter 9.12, and the I lenith and Sul'my
Code, Section 25532(a)'?
HEA'T'ING UNIT (OVER H)n,IXth B"IV)
❑Yee Fl No
Will the vppreand or idiom b,dldingnccmponl use equipment or devices which
onll hazardous air wmmmmunb O defined by the Bay Area Air Quality Mtnagentenl
Dean,,?
❑Yes 7 N
PAID
Dnm Rcccipt#
VENPILA'I'ION FAN (SINGLE RGSIU)
BOILER-COMP(3HYOR IOO.OW B'fU)
TOTAL:
BOILER- COMP (OVER leisiI BTU)
AIR CONDITIONER
Ihave actuarial haanrdous mutes,, outmanned, under Chapter 695 of the Cal,
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. PT.
forma Hcalth & Safely Cada Sections 25505, 2.5533 and 25534. I understand shot if the
building doer not currently have a retire,, that it is my responsibility m notify the occupant
ofthen diremema whichntua bane, prior In issuance oda Ceriticote ofOecuponey.
ISSUED BY:
Owner or authorized agent Dam
TOTAL:
OFFICE