30842APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PERMITNO. 30842
] O H
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL.
J �T L
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
O ER'S NAME: PHONE:
SLG 2 -o o
CONTRACTOR'S NAME: LIC NO:
NIG
❑
,�ROL# -
>�C ` l
ETEQ GI FLI NO:
ADDRESS:
'ARC
&r- FHHONNE:
_
VV
C NTACT/V` }}p
�! Gd+� L q" ( 2,� — 0 700
❑ Consaltant Fees Paid by Applicant (Initial)
BUILDING PERMIT (INFO
BLDG E PLUMB -MECH
LICENSED CONTRACTOR'S DEC LAR ION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION -
with Section 70W) of Division J of the Business and Professions Code. and my license is
in full force and effect.
License Class Lic.te
Date Contractor
PERMIT ISSUANCE
RESIDENTIAL:
❑SFDWL [IKREMODEL
UM13IN
❑ADDITION' A Pi 1 ❑PLMBWG'RE-PIPE
❑MULTI -UNIT ❑STRUCTURAL
- MODIFICATION
❑I CHIMNEY REPAIR
IMPR(NBIpERT4 (V��,�°y(JJ�
APPLIANCES - RESIDENTIAL
ARCHITECTS DECLARATION
1 understand my plans shall he used as public records
PANELS 4
V
UPT0WAMPSS
Licensed Professional
20L1(KKIAMPS
OWNER -BUILDER DECLARATION
I hereby i fflfm that 1 sat exempt from the Cmarmaors License Law for the
B T ODEVRF.P% LJDF.MOLITION
OVER 1110D AMPS
SIGNS F.LF.CTRICAL
fallowing rcns.r. (Section 7031.5, Business and Professions Cale: Any city or county
which requirea permit to construct, Ater, improve, demolish, or repair any structure
SPECIALC CINCUI'r/MISC
-
prior to its issuance. also requires the applicant for such Permit file a signed statement
tbat he is licensed pursuant to the pravision.s of the Contractors License Law (Chapter 9
TEMP. METER PRPOLE INST.
COMMERCIAL:
(commencing wiN$ermn 7000) of Division 3 f,h, Business and Profeasions Cade) or
t�. hour exempt therefrom and tho basis for the alleged exemption. Any smImm. of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
S.ainn 7031.5 by any applicant for a permit subject the applicant as a civil penalty of
t mom than five hundred dolleas(SSW).
❑1. as owner ofthe prapeny, or my employees with wages as their sole compensation,
will do the work, and the saucwm is not intendedoroltered for sale (See, 7044, Business
and Professions Codi The Cort License law doves not apply to an owner of
-NAM' ❑FOODSERVICE
m IMPROVEMENT
❑ OTHER
SWIMMING RIC
OUTLETS -SWIT H- ES Q
property who builds or improves tbermn, and ro
who does such work himself or thugh
his own employees, provided that such improvement are not intended or named for
sale. If,however, the building., improvement is sold within one year of complemion.the
caner -builder will have the burden of proving that he did not build or improve for put -O
as I W FSIDENTI E R SQ Ef.
SQ. FT. FLOOR AREA
ESQ. FT.
pose ofsaleJ.
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
consumer the prdject (Sm. 704W, Business and Professions Code:) The Commcmrs Li.
'
cense Law dans mnapplyto vt ow.m.fproperty, who buildsor improves thrown,und
QTY, PLUMBING PERMIT FEE
whommocts for such projects with a contracmKs) IicensW pursuant m the Cnntfoaorx
PERMIT ISSUANCE
License taw
❑ ,B&PCfo this re's.
Ownm IffECIOMa Dote
ALTER- DRAIN & VENT -WATER (EA
VALUATION
BACK FLOW PROTECT, DEVICE
VWDROERSCOMPENSATIO DECL RATION
6 G6
mks
Ihereby affirm under penalty of perjury one of the following declarations:
1
URAINS-FLOOR, ROOF, AREA. COND. l
❑Ihave and will maintain aCertifcatmfConsem to self -in sure for Workers ComPen-
section, as provided for by Section 3100 of the Labor Cole, for the performance of the
STORIES
TYPE CONSTRUCTION
work for which this permit is issued.
TXTURES - PER TRAP
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3100 ofthe Labor Code, for the performance ofthe work for which this permit is issued.
GAS - EA. SYSTEM- I INC. 4 OUTLETS
OCC. GROUP
APN
My Workers Compensation Insurance comer and Policy number me:
Cartier: Policy No:
GAS- EA. SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREAS MNDUSTRL WASTE INTERCEPTOR
BUIL ISI ON PEPS
GREASF,TRAP
(This section need not be completed if the permit is for one hundred dollars(51W)
or less)
Loy anytbat in the performance asanbekfor subjectch 1. permit isissued.
orop ll
not employ any person in any manner w ns m become subject t. the Workcn' Cnmpcn-
PLANCHECK FE ,
ENERGY FEE r
SEWER -SANITARY -STORM EA. 200 FT.
WATER HEATER WNEM/ELECTR
section Laws of C.f lmorm. Data
Applicant
GRADING FEE
NOTICE TO APPLICANT. If. miter making this Ceniftcme of Bxemption, you should
"me subject to the Workers Compenmtion provisions of the Labor CMe, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
WATER SYSTL'MIIREATING
WATER SERVICE
-
SOILS FEE
CONSTRUCTION LENDING AGENCY
amcy fonheperforom is'
I hereby ofrmthat there is. construction lendinggo
NEW RESIDENTIAL PLMB. SQ, Er.
PAID
Date Iicce't
mire work for which this permit is issued (Sec. 3091. Civ. Cj
Lenders Name
TOTAL:
Lender's Address
TOTAL:
-
BUILDING FEE ra,
I certify fl m I have read this application and state Nw Ne above information is
QTY. MECHANICAL PERMIT FEE
�•
SEISMIC FE Lk 1.
correct l agree to comply with all city and county ordinances and stem laws relating m
building consweian, and herehy authorize rcpresenmtives of this city to enter upon the
PERMIT ISSUANCE
ELELTRI
above-mentioned property for inspection f u Tows
(We) agree m save, indemnify and keep hm ,leas the City .f Cupertino against
liabilities,judgments,cosBmdexpenses which may in any way accrue against said City
in consequence of the granting of this permit.
ALTER OR ADDkEZMECH.
PLUM FEE
AIR HANDLING UNI 0,000 CPM)
APPLICANT UN ERS'EANDS AN WILL COMPLY WITH LL NON -POINT
SOUR TI S.
MECHA (CALM
AIR HANDLING UNIT (OV 10,Oo0C
CONSTRUCTION AX
AAJ3
IiXHAUST HOOD (W/D
HOUSING MITI TION FEE
�
igmm�rco sec Com tet am
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO AWO BTU)
Will theapplastat m future building occupant alone or handle hazardous material
as defined by the Cupertino Municipal CMe, Chapter 9.12, and the Health and Safety
Code. Section 25532(x)7
HEATING UNIT(/ ER IWXW BTU)
❑Yex ❑No
Will the applicant future building occupant equipment or devices which
emit hazardous air contaminants as Defined by the Bayy A Area Air Qualify Management
District? Yes 17 No
PAID
Unte Receipt
VENTILATION N(SINGLE RESID)
BOILER - COMP (JHPOR IW,OW BTU)
IOTA
BOILER- COMP (OVER 1 W,WO BTU)
AIR CONDITIONER
/1h ave reed the hezmJous rnatcriAs requirements under Chapter 6 9 of rhe Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. PI'.
ria Health & Solely Code, Sections 25505, 25533 and 25534. 1 understand that if the
huildin of orantl ve a tenant• tis my responsibility to notifythe «cuport
of to hi test etp'rta issuantt ofe Certify sof Oc panty.
wrier acdaL1,111 I 16irrifie
,
iSSUEUBY:
L
r 1 117 OFFICE