30026APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE SALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO. 30026
] O O L V
J
$UILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
20 IbUn RD a
—tb-n6
:R'S AME PHON -
C TRA R'S NAME: LIC—NO:
NIC
CONTROL
❑
1R I .CTBN T• R: '�� LIC O: -
ADDRESS:
COrA
�l PHONE:
BUILDING PERMIT INFO
W* :5T mi
mi
2 •
❑ Consultant Fees Paid by Applicant (Initial)
GO ELECTPLUpfB MECH
LICENSED CONTRACTOR'S DECLARATION
1 hereby Winn that I am licensed under provisions of Chapter 9 (commencing
Section 7001) of Division 3 of the Business and Professions Code. and my license is
nt full fame and effect.
Llttnu Class Lia M
Date Contractor
QTY ELECTRIC PERMIT FEE
xN
F.,
f�
47
y
❑
W
raj
i U
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL C3 KITCHEN REMODEL
❑ADDITION [I PLUMBING R&PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑ INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEIIRF.PAIR [I DEMOLITION
❑OTHER;
• �O.
PERMIT ISSUANCE ?
APPLIANCES -RESIDENTIAL
ARCHITECT'S DECLARATION
I understand my plans sM1al be used ax public amendsPANELS
I'TO 200 AMPS
Licensed Protean onnl
DECLARATION Contr ON
Oat lam exILDERempt
1 hereby affirm that 11. exempt from the esmractorLicense law far Ne
following ren n permit to h,or Core: air an or county
It rtquirex a pcmm to constmn, aline improv$ demolish, or rebair any swan
7onstr t, alter, Improve. demolish,
]01-1000 AMPS
OVER IWIIAMPS'
SIGNS ELECTRICAL
1P.SPECIAL CIRCUIT/MISC.
10
p{
V•
i y
I�❑Lothe
Prior to its issuance, also reyuius the applicant for such permit fila.m'nedstme n
Net he is licensed pursuant m Ne provisions of the Canwc,olx Wcenu Taw (Chapter
(cmhmencing with Seaton lumoof Division 3o fine Basinamium Nofeaeions Cnde)or
Nat he is exempt therefrom and the binds for the Illegal exemption. Any violation of
Section 7031.5 hyany appllcam far. panni, .object, the upplicanuo a civil pe..try of
not more than five hundred dollars ($5110).
owner k, the the may,mmyentployeeswiNwageaas rtheirsole compensation,
will dathewims and the LndW mraffichad y a. Business
TEMP. METER OR POLE INST.
Q NEW BLDG/ADDITION' ❑ DEMOLITION
,t
W w ANT' I :I I"Ch 1 TTVl.'� FOOD SERVICE
MPROVEMENT
[-]OTHER
-
POWER DEVICI'S
SWIMMING POOLELECTRIC
he C.eistets
and v,dca mlapplmic
to
Code: The Cmntmereo License Lues Nets not apply tomlf owner n
LPTS-S HES-FIXTURES
..
artywhob
progeny who builds or improves thereon, and who does such work himself or through
-'
his awn building that such b arc not intended or offered for
NEW RF. IAL F.LECfR SQ FT.
SQ. fT.FLUOR AREA
s. 7yy
4 Ci
`^' GG
5/SQ. FT.
however,
ulc.iLhowever. Ne building orimprovementismlJ withinone year of completion, the
mentis old w
mwner-builder will have the burden of proving that he did not build or improve far par-
poseof sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
..a' Ne project (Sec. 7044. Business and Professions CedeU The Corn.....
cense Law does not apply to an owner of property who builds or improves thereon, and
QTY. PLUMBING PERMIT FEE
whocoatmets for such projects wiN a commemr(s) licensed purmanuo Ne Conaactor'a
License Law.
❑ Iamexemptunder Sec, ,B&PCfor Nis Ramo
PERMIT ISSUANCE
ALTER - DRAIN & VENT -WATCH HSA)
Owner Data
VALUATION
//s
�
Mot
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT DEVICE
1 hereby of ion under Penalty of perjury one of Ne following declarations:
0 -
DRAINS- FLOOR, ROOF, AREA. COND,
❑ I have and will mountain. Cetificateof Consem to velf-itsm. for Workers Compete
section. as provided for by Section 37W of the Labor Code, for the performance of the
STORIES
TYPE CONSTRUCTION
work for which this permit is issued.
FIXTURES -PER TRAP
Fl have and will maintain Workers Compensation Insurance, as required by Section
3700.f the Labor Code, fore pedmmtance of Ne work for which this permit is issued.
M Workers Cy�^^ tion Insurance curtier and Ynlic nyp ryy,�
Caromr. s7 Policy No.: \ 1� STI fatI
GAS- E.A. SYSTEM. I INCA OUTLETS
OCOGROUP
APN
V, GAS- EA. SYSTEM -OVER 4(EA)
CER'DFlCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This motion ..it not be completed if the permit is Rome hundred dollars is 10)
or less)
GRHASWINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FENS
GREASETRAP
PLANCHECK FEE
z
0
I certify that in Ne performance of the work for which this permit is issued. )shall
not employ tiny barman in any manner so as o become subject to the Workers' Campers-
motion Laws of California. Date
Applicant '
SEWER -SANITARY -STORM EA. 2(p FT.
ENERGY HE,
WATER HI7ATER W/VENT/ELECTR
GRADING FEE
NOTICE TO APPLICANT: If, after making this Cmifeate of Exembtiom, you should
become subject to the Workers Compensation provisions of the labor Code, you muse
forthwith comply with such provisions or this permit shallh deemed revoked.
WATER SYSTEM,TREATING
WATER SERVICE
Q
SOILS FEE
NEW RESIDENTIAL PLM B. SQ. IT.
CONSTRUCTION LENDING AGENCY
len ding age,my foreperfor,mntt of
thi Nerete issued
PAID
Dare Receiplp
f•'
U
WJ
workwhich Sac. 30
Le work for which this permit is issued (Sec. 3(147, Civ. C.)
Lender's Name
TOTAL:
Isndern Address0.
BUILDING FEE
1 artily Nat I have read Nis .,Umion and store that do,mavc information is
IA
Z
correct. l agree to comply with ail city and county ordinances andstate laws relating to
building construction, and hereby auhcrice representatives of this city to enter upon the
QTY, MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE O
ELECTRIC FEE
aaove-mentioned property for inspection purposes.
(We) agree m save, indemnify and keep hanNess the City of Cupertino ngainsr
liabilities,judgments, costs and expenses which may in anyway accme against raidaity
caasequenceofthegmndngof Nispemit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
S CE REGULATIONS.
PIETER OR ADD TO MECH. �^
PLUMPING FEE
AIR HANDLING UNIT (TO 10,0010 CFM)r1
-
MECHANICAL FEE L f
ALR HANDLING UNIT(OVER10,000 CFM)
CONSTRUCTIONTAX
ANAV7
EXHAUST HOOD UVIDUCD
HOUSING MITIGATION FEE
mu of Applicant/ ctor Date
a
' H WUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
William applicant rare building occupant store or handle hazardous material
as defined by he Cupertino Municipal Code, Chapter 9.12. and the Health and Safely
Code, Section 25532(a)R
-7—
HEATING UNIT (OVER 100,000 BTU)
❑Yes C] No
Will the applicant or future building occupant use equipment or devices which
hazardous air contaminants as defined by the Buy Areaa Air r Quality Management
Dnmet^
❑ Yes ❑ No
PAID
Data Receiplhazardcontaminantsemit
VENTILATION FAN (SINGLE RESIU)
BOILER - COMP (3HP OR 100,000 BTU)
TOTAL
BOILER -COMP (OVER 100.0 BTU)
001
AIR CONDITIONER
I have read the huzmdous materials raparcments under Chapter 6.95 of the Cali
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. IT,
fond. Health & Solely Code. Sections 25505, 25533 and 25554.1 umdenmnd Nat if the
building does not currently have a tenant that i, is my Rapomibility to modify the comment
of Ne requirements which man Na at priono iseuanee mf a CeuiOcate of Occupancy.
�
TD F
ISSUED BY:
Owner cr authorized agent Data
OFFICE