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CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. ^/� /� /�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL '/9O/1 yN
BUILDING PROJECT IDENTIFICATION L 9J V 6
ILDING ADDRESS:. /O ry
O moi'O�/� SANITARY NO. APPLICATION SUBMITTAL
\DATE
NR'S NAME' E: NT AC RS A x'N
,. N/C CONTROL# I
H /ENGINEER: LIC NO: ESS'. ❑ L
it
CONTACT. -
PHONC: (,�z BUILDING PERMIT INFO
q
! ❑ Consultant Fees Paid b Applicant Initial
Y PP (Initial) LDG ELECT PLUM MECH
LICENSED CONTRACTOR'S ❑• ❑
1 hereby arm that I am licensed uncle p ions of Chapter 9(commencing QTY' MIT FEB SOB DESC
�aO ZO with Section JOIXpor Divam . I
ion3nfthe BuseP ofessinns Code,and my license is
RIPTI
EE++ fand effect. PERMIT ISSUANCE RESIDENTIAL'
m� LicenseClass ' ❑SFDWL `
❑KITCHEN REMODEL
RW Dam Contractor
APPLIANCES-RESIDENTIAL ❑ADDITION. ❑PLUMBING RE-PIPE
[. ARCHITECT'S DECLARATION,' PANELS ❑MULTI-UNIT El STRUCTURAL
C O m K1 understand my plans shall M used as public recent,
O Z OMODIFICATION
UP TO 200 AMPS TERIOR .O CHIMNEY REPAIR
� {zl Lsenxd Professional •. 201-IIMI(JAMPS is IMPROVEMENT
raj Oer I ma cream form
Carnation's
OVER IIXq AMPS 14TH REMODEUREPAIR 0 DEMOLITION
1 hereby affirm that I em exempt from the Cnnlmaer'6 License Law for rhe
{'�'3�j O d U following reason.(Section 9031.5,Business and Professions Code:Any airy or county SIGNS ELECTRICAL ❑OTHER
O Fy which requires a permit m construct,alter,Improve,demolish,or repair any suucmrc'
prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. s
}
that he is licensed pursuant the provisions of the Contractor's License Law(Chapter 9
(commencing with Saturn9W0)ofDivinion 3 more Business and Professions Code) OMM R
q O TEMP.METER OR POLE INST. - -IA
that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
iWC 4N, Section9pJ L5 by any applicant forapermit aubjecm the applicant loacivil penalty of. POWER DEVICES
IILI.......Zp. t more than five hundred dollars($5W). - ❑TENANT ❑FOOD SERVICE
}O ❑ Les owner of the properly,or my employxs with wages as rM1eir sole compensation, SWIMMING POOL ELECTRIC. IMPROVEMENT
GC will ZrIurarile and the ilrucmre is not intended or offered foraale(See.9044,Business ❑OTHER
W i� and Professions Code:The Contracmr's License Lew does not apply m an owner of OUTLETS-SWITCHES-FIXTURES '
�'3.. properly who builds or improves thereon,and who does such work himself or through ..-
his own employees,provided that such,improvements are not intended or offered for NEW RESIDENTIAL ELECT
SQ PT.
saleaf,however the building or improvement is sold within one year ofcompletiestrhe I SQ.FE FLOOR AREA $ISQ.FT.
ownenbro
uilder will have the burden of forcing that he did not build or improve for pur. - S
asowner
pose s
El I;as tweecontracting
t of the pmpeny,am exclusively conv"ni e,with licensed Connector's ntmcmrs ro TOTAL:
construct the project(Sec:o an Business and Professions Codei The esteon, nd p,
Li-
canine Law does not apply to an owner of tenter(who builds or improves thereon,and ,DO \oQ
P QTY. PLUMBING PERMIT FEE $t�
who convects far such projects with aconttactor(e)licensed pursuant the Comra<tor's r VU4'�
License Law. PERMIT ISSUANCE
' [IlamexcmptunderSec.- ,B&PCImNisreason
Owner Dale ALTER-DRAIN&VENT-WATER(EA) t VALUATION
WORKER'S COMPENSATION DECLARATIONt
OrP 1 herermby affiunder penalty of perjury one of the following declarations: FLOW PROTECT.DEVICErions: I.
I have and will maintain.Cenificatum Consent to s,IFm,rm forWerker's Common- DRAINS-FLOOR,ROOF,AREA,COND.
sation,as provided far by Section 39W of the Labor Code,for he performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section '
37W ofrhe Labor Code.for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM=I INC.4 OUTLETS - OCC.GROUP APN
Y
Wor ge sation Insurance ca 'er dPolicy nyptbar /�
Cam_ �1�oliry Nis: J2 2 a1' GAS-EA.SYSTBM-OVER4(BA)
^{-w AQ.I CER IFI EATE ION FROM WORKERS'
- ICC COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
...../////��-� k,eakmieed ambecomplaetl ifthe permit is forces hundred dollars($10r) BUILDING DIVISION FEES
or> GREASETRAP PLANCHBCK FEE
I certify that in the performance ofrhe work far which this panni,is issued,Ishan SEWER-SANITARY-STORM EA.2W PT.
not employ any person in any manernao as m become subject m the Workers'Capital, ENBRGY FEE'
sation Laws of Califomie.Data O O Applicant WATER HEATER WNENTMLECTR
Z r PP - GRADING FEE
r1 In NOTICE TO APPLICANT:If,after making this Campion,of Exemption,you should WATER SYSTEM/TREATING
Au
5 become subject to the Worker's Compensation provisions of the Labor Code;you must jPAD
S FEE
q
forthwith comply with each provisions or this permit shall be deemed revoked. WATER SERVICE CONSTRUCTION LENDING AGENCY NP.W RESIDENTIAL.PLMB. SQ.FT. p'I herebyaffirm Nat there is a conswetion lending agency farina performance ofR<ai t#the work for which this permit is issued(Sec.309].Civ.C.)Leader'a NameLender'sAddress - TOTALI certify that I have read this application and state that the above information isDING FEEcorrect.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEEbuilding conswetion,and hereby authorize representatives ofthis city to enter upon the MIC FEEabove-mentioed property for inspection pmiposes. I '�-PERMIT ISSUANCE(We)agree to save,indemnify and keep harmless the City of Cupertino against TRIC FE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of granting of thle perml,. PLUMBING E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SO REGULATION ^4aaob //'/�'� MECHANI LFEE
,e(a AIR HANDLING UNIT(OVER.IO,IMp CFM).
CONSTRU TION TAX
Stgnameo lien / .mmwmr —Da EXHAUST HOOD(W/DUCE)
HAZARDOUS MAXIALS DISCLOSURE HOUSIN ITIGATION FEE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I Oft"BTU) -
as defined by the Cupertino Municipal'Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? �_ n HEATINGUNIT(OVER IW,000 BTU)
❑Yes E]No
VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which _ Data Receipt# '
vemir hazardous air cOntminam
as as defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR 100,00OBTU)
Distrix? _ TOTA
❑Yes [IN. - BOILER-COME(OVER 101000 BTU)
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE ATE.
fomn Health&Safety Code,Sections 25505,25533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not cutremly have a tenant,that it is my responsibility to notify the occupant
of Ne requirements which must be ma poor to issuance to Conflictive of Occupancy. -
V
Owmer o authorized agent Date TOTAL: ISSUED BY:
OFFICE