30273r
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
o
L)
yI
h
z
PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL.
BUILDING PROJECT' IDENTIFICATION
O
BUILDINGADDRESS:
o y Ate '��. C
SANITARY NO.
APPLICATION SUBMITTAL DATE
-7,2 �
OWN R'S NAME: n A ; HONE: 'ONTRACI'OR'S NAME: LIC NO:
n/1 W
NIC
CONTROLM
❑
ARCH1,UC (ENGINEER: LL£
PHOONE:
ADDRESS:
CONTACE
BUILDING PERMIT INFO
�_f���
S_q/
❑ Consultant Fees Paid by Applicant (Initial)
- B. G ELECT PLUMB MECH
06N ��yVA
g 1
El Cl El
LICENSED CONTRACTOR'S p DECLARATION
1 hereby affirm Nm I vat license) under provisions of Chapter 9 (commencing
QTY. ELECTRIC PERMIT FEE
B DESCRIPTION
with Section]DIRI)ol Divirinnlnf the eusincne and Pmfessinns CnJe, and my license is
in full force and effect
PERMIT ISSUANCP.
RESIDENTIAL:
❑SFDWL E:1 KITCHEN REMODEL
APPLIANCES - RESIDENTIAL
Licease Class Lit.g
Date Contractor
CADDITION El PLUMBING RE -PIPE
❑MULT6UNIT ,O STRUCTURAL
MODIFICATION
ARCHITECT -S DECLARATION
I understand my plans shall he used as public reconls
PANELS
UPT0200AMPS
[:1 INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT
LicemW 1'rofeni... I
201-1000AMPS
OWNER -BUILDER DECLARATION
that I rn exempt s an the CnmrasrCrit License Law fns me
I barleyreason. Any city or county
following rias,.. (Seninn ]031.5, Business and Professions
(Section
REMODEVREPAIR [I DEMOLITION
.
OTHER
OVER IM) AMPS
SIGNS F.L[CfRICAI.
h, m
which requires a permit coaud ,hest improve, demolish, or repair any
SPECIAL CIRCUIT/MISC.
refutes for file urromotartme
s�tohe hemovisio
thatis licensed to the so Contrauch ctors Licens Law (Chapter
that heslcenedfor me Conasmov
TEMP. METER OR POLE INST.
COMMERCIAL:
Sudan
(co of DM,jim 3 ad ProelawsCcd)9
it
the Bminersaption.
mg;exempt Qion
therefrom aan nd the basis vis of
he is m Any of
is exempt therefrom and the basis for the alleges application. Any
❑NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Smanec io l Pennon
Section 7031.3 by any hundred doll for apemdt subjects the epplicanuoecivil penalty of
not more than five hundred dollar (E51n).
wimwa efor mitral. caro oration.
I, as owner of the n ye p y g pc
prose y,aero ri to intended raw offeredforttan Boniness
t will do rework. Corea structure is ami
❑TENANT FOOD SERVICE
IMPROVEMENT
❑0TH R
SWIMMING POOL ELECTRIC
License
and Professions Curie: The Contractor's License law does not apply m an owner of
progeny who build. or improves thereon, and who does such work himself ser through
his own employees, provided that such improvements ore not intended or offered for
sale. If, however the building or improvement is sold within oneyearofcomplctimi the
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTS SQ FT.
SQ.FTFLOORARE•I;
$/SQ. FT.
mer -builder will have the burden of proving that undid not build ter improve for pur-
,se close).
C1 1. aw owner of the progeny, ma exclusively correcting with licensed contractors'.
"
JUL OLs �(I�C
J 26
TOTAL
construct he Project (Sol .]014, Business and Professions Cod.;, The Conttacmrs Li-
v7 6
cense Law does not apply to an owner of property who builds or inpmvesmereun,and
QTY. PLUMBING PERMIT FEE
for such prnjea l,nSlltf uc`gf(s)lici sal pursuant to the Contractor's
ca"((VjS "
whence
(iI)r Vr loutLrt
PERM IT ISSUANCE
License law. ,L'"
Lee,
L em exempt unJer Sec. , Ilk P C phis o
W\lsJ
An I
Owner Dura
ALTER -DRAIN & VENT- WATER IRA)
VALUATION
WORKER'S COMPENSATION DEC RATION
PACK FLOW PROTECT. DEVICE
1 hereby aRirm under penalty of a jury one of me following declarations:
DRAINS- FLOOR, ROOF. AREA. GOND.
'❑ I have and will maintain a Certificate of Consent to self-imme for Worker's Compact-
sanw., as provided for by Section 37M of the labor Code, for the performance of me
STORIES
,
TYPECONSTRUCfION
work for which this permit is issued.
FIXTURES - PER TRAP
I] I have and will maintain Workers Compensation Insurance, as required by Section'
37M of the labor Code, for the performance of the work for which this Permit is issued.
GAS - EA. SYSTEM -I INC. 4 OUTLETS
OCC. GROUP
APN
My Worker's Compensation Insurance carisr and Policy number ase:
Cartier Policy No.:
GAS - E. SYSTEM -OVER 41EA)
GRESE/INDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(This section need not be completed ifthe Permit is for one hundred dollars (S 1110)
or IessJ
GRESETRAP
PENCHECK FEC
I unify that in the performance ofine work for which this permit is issued, )shall
not employ any perm, in any manner so as to become subject the Workers Compen-
SEWER -SANITARY -STORM E. 200 FT.
ENERGY FEP.
WATER HITTER WNENT/ELECTR
GRADING FEE
sari.. Laws of California. Data _
Applicant
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject to the Workds Compensation provisions of the lahar Code, yon must
WATER SYSTEMRRETING
SOILS FEE
fonhwi'b comply with such provisions or this permit shallhdeemed rcvnk<J.
WATER SERVICE
' CONSTRUCT ION LENDING AGENCY
thereby affirm that then is a construction lending agency forthe Performance of
PAID
Date Receipt#
NEW RESIDENTIALPLMB. SQ. FT
Ne work for which Nis plonat is issued (Sec. 3197, Civ, C.)
Lender's Name
TOTAL:
ta'deh Address
certify mat I have reed this application and sure that the above information is
TOTAL:
/�
BUILDING FEE ,#C
QTY. MECHANICAL PERMIT FEE
-
SEISMIC PER
correct l agree to comply with all city and county cra ounces and state laws admin, to
building construction, and hereby authmlee representatives of this city to enter upon the
ahuve-mrnitued property for inspection PuTi
mant
(We) agree to save, indenify keep harmless the City of Cupertino against
PERMIT ISSUANCE
ELECTRIC FEE
ALTERORADDTOMECH.
PLUMBING FEE
IiuMllllcs,judgments,tnsis and expenses which may In any way sumo against said City
in consequence of me standing of mis permit.
AIR HANDLING UNIT (TO 10,000CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 11,0009 CPM)
CONSTRUCTION TAX
Signature .f ApplicantiC.ntracmr Date
EXHAUST HOOD(WIDUC)
HOUSING MITIGATION PER
• HAZARDOUS MATERIALS DISCLOSURE
HITTING UNIT (TU I a,aO afU)
Will the applicant or future building oecupam store or handle hemdous material
as Jeftmed by the Catlett.. Municipal Cale. Chapter 9.12, and the Health ..it Safety
Code, Section 25532(x)"
-
HEATING UNIT (OVER 100,000 BTU)
El Yes ❑No
VENTILATION FAN (SINGLE RBSID)
PAID Date BuetpU
BOILER - COMP (3HP OR Ia,fX108TU)
Will the applicant or future building occupant use equipment or devices which
Lit harardres air communinaab as defined by the Bay Area Air Quality Management
TGTg1; /..,/I
a
BOILER- COMP (OVERRattan BTU)
District?
❑Yes ❑N,
AIR CONDITIONER
I have read the hmarduus matenels requirements under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
(.rota Health & Safety Code, Sur 25505, 25533 and 25534. 1 understand that if the
buildingdow not currently have a tenant, mm it is my responsibility to army the omupvnt
of me rtquirements which must In met prior ro issuance .f s Cenilicate of Cccupuncy.
ISSUED BY;
TOTAL:
Owner or aumonead age,' Date
OFFICE