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CITY OF CUPERTINO BUILDING - BLECTRICAI. PERMIT NO. ,� n
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL.cnf���O/ / O
BUILDING PROJRCT IDENTIFICATION •��V (O!O
BUILDING ADORES: SANITARY NO, APPLICATION SUBMI'I']AL DATE
t14 -2-'T cHCCL DQE BARc��o�Jq G,z�9
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO: NIC CONTROL
� Jed vv R`LILNO: 6 gys2
CHO'ECf/F.NGINEER: LIC NO: ADDRESS: ❑
Ad v% c."2 -r3 -f6
CONTACT PHONE: BUILDING PERMIT INFO
fST ❑ Consultant Fees Paid by Applicant (Initial) BLDG ELECT PLUMB MEECCHH
IJ � � [?-
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEF.
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing JOB DESCRIPTION
with Section TW(Rof Division 3n(theBminess and Pmfessiom Code. cod my license is PERMIT ISSUANCE 3r '�
in full force and effect. SFDWL [I KITCHEN REMODEL
License Class 1-m.g APPLIANCES -RESIDENTIAL. ❑ADDITION [:1 PLUMBING RE -PIPE
Date Gmtmemr
ARCHITECTS DECLARATION PANELS ❑MULTI -UNIT MODIFICATION
I understand my plans shall od used as public records
UP T021x1AMl'S ❑INTERIOR [I CHIMNEY REPAIR
Licensed Professional 201 -lap AMPS IMPROVEMENT []SWIMMING POOLS
OWNER -BUILDER DECLARATION OVER IOWAMPS ❑ BATH REMODELIREPAIR (]DEMOLITION
I hereby affirm that 1 am exempt from the Contraaois License law for the ❑ OTHER
following reason. (Section 7031.5, Business nod Proficomm Code: Any city or county SIGNS ELECTRICAL
which , u m, a permit to constmct, alter. improve, demolish, or repair any stmdure
prior to its issuance. also requires the applicant far such Permit to rile a signed statement SPECIALCIRCUITIMISC. L
that he islietrund pursuant lathe provisionsoftha Cmdraumes License Law l Chapmr9 COMMERCIAL:
(commencingwith Secdon�000)of Dismon3ofthe Inomeasand Pmmosions Cod0or TEMP. METER OR POLE INST.
that he is exempt therefrom and the basis for the alleged exemption. Any violation of NRWRBLEMENT, TLON'�Ca TION
Section 91131.5 by any applicant for a permit suhjects the applicant to a civil penaltyof POWER DEVICES 9TENANT.fA\ a0FLI1 VI(
not more than five hundred dollars (f500). n�IMPROVF.MENTs
L os owner ofthe properly. or my employees with wages as their sales,or'.mlion, SWIMMING POOL ELECTRIC fIOTHER
will do are work, and the stmcmre is not intended or offered for sale(See70,G. Business D
and 1'mfeedions Code: The Comtmcmrs License law does not apply m an comer of OUTLETS - SWITCHES - FIXTURES
DIJ UE CV 2
property who builds ar improves thereon, and who does such work himself or through
his mon employees, provided that such improvements ore not intended or offered far NEW RESIDENTIAL ELECTR SQ FT. SQ IT FLOOR AREA SISQ. FT.
sale. IL however, the building or impmvemem is sold within one yemofcompletion.the /� r
owner -builder will have the burden of poising that he did nut build or improve for par- r Q
poscofsale.). TOTAL: By--------'--
❑ I, as owner of the props", um exclusively contracting with licensed comracmm m h
constmct the project (Sec. 104J, Business cod Prufesawns Cnde:) The Cartmel a$ Li- d
stun Law docs Out apply to an owner of Properly who builds or impnwes thereon, road QTY. PLUMBING PERMIT FEE
who conwets frosuch projects with a commetor(s) licensed Pursuant to the Contractor's p
License Law. PERMIT ISSUANCE 3 S
❑Inmexempt under Sec. ,B&PClmmisaoson
ALTER - DRAT & V T ATER (EA) VALUATION Q . A
Owner Date
WORKER'S COMPENSATION DECLARATION BACKFLOW ROTE .0 ICE ���J 00o
1 1 hereby aRnn under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent m self-insum for Worker's Compen- DRAINS -FLOOR, ROOF AREA CO STORIES TYPE CONSI'RUC'I'IOD
section, as provided far by Section 37M of the Lobo, Code, for as performance of Ne
work for which this pemrit is issued. FIXTURES -PER TRAP C� ��
❑ I have unit will maintain Worker's Compensation Inwrmce, as required by Section GAS -PA. SYSTEM -1 INC. J OUTLETS
3101afthe labor Cess. far the perfommnecof the work for which this peord is issueJ. OCC. GROUT' APN
My Worker's Compensation lnsurunce carrier and Policy number are:
Cardec Policy No.: GAS-F.A.SYSTF.M-OVER4(F.A)
CERTIFICATE OF EXEMPTION MGM WORKERS' GREASIDINDUSTRL WASTE INTERCEPTOR
COMPENSAGON INSURANCE BUILDING DIVISION FRES
(This section need not berompleted if the permit is forome hundred dollars (3100) GREASHTRAP. �0819d
or IcssJ PLANCIIECK FEE
I certify Nm in the performance of the work for which this permit is issued, I shall SI;WEB- SANITARY -STORM LA. 200 FT. ENERGY not employ any petro in any manner so as to become subject to the Workers' Compen- ENERGY FEE
,� action Laws of Calil'un . hate WATER HEATER WNEKWELEC9'R GRADING FEE
O Applicant
rNi
NO] ICE TO APPLICANT: If, after making this C'milrote of Exenhplion, you should NATER SYSTHMITREATING SOILS FEE
' become subject to the Wmkels Compensation pmvioinis of the Labor Code, you must
Qfolosithcomply with such prooidmumOnthis pennitshe][bcdcemedresukcd. WATER SERVICE �oty
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ. FT. PAID 1
I hereby affirm that them is a construction lending agency for the performance of Umte Reaiptp
the work far which this pemhit is issued (Sec. 3091, Civ. C.) TOTAL: 61
UEnlace, Name
Lender's Address 'TOTAL. '��,z
W
AGDI IrJUMTTn LII I IN INanaNIATlnN WIT141M FIFO LINES - USE BALL POINT PEN ONLY
to
I certify that I have read this application and e sure that thabove infmmmlon is
ommi.1agree mcomplywithall city mrdcountymmummesand stunlaws mlatito,,
building concoction. and thereby maintain mpeasentatives of this city to enter upon the
BUILDING FEE
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
" above-mentioned property far!ospection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities.judgments, costs and espenus which may in any way accrue against said City
PERMIT ISSUANCE
ELECTRIC FEE Z2, 'L
ALTERORADDTOMECH.
PLUMBING FEE PZ2.21
in consequence of Ne So ming of this permit.
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNI3'(T0 Of" CPM)
�s
MECHANICAL ME Z/ �
SOURCE REGULATIONS
AIR HANDLING UNI ('(OVER 10.000CFM)
CONSTRUCTION TAX
Stgnamre ol'Applorn/Comractor Dote
HAZARDOUS MATERIALS DISCLOSURE
Willtheupplicard nr furore building meupan,trocur handle hemNaus material
as defined by the Cartoon Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(0)?
EXHAUST HOOD GVMUCT)
i HOUSING MITIGATION FEE 7�
HEATING UNIT TO 100,001 KITH
NOTING UNIT (OYER 10[I,(p0 BTU)
VENTILATION FAN(SINGLE RESIDE
❑Yes ED NO
PAID
Data Receipt p
Will the applicant or furore building occupanl use equipment or devices which
hit hamrdnus air Onati imams as defined by the Bay Area Air Quality Management
BOILER -COMP (3HP OR Ifp,INp if rut
TOTAL:
BOILER -COMP (OVER 100,000 BTU)
Laurie?
D Yes ❑Nn
AIR CONDITIONER
ISSUANCE DATE.
I have read the hsrardaus makriels requimmenn under Chapter 6.95 of the Cali-
NEW RESIDENTIAL MECH. SQ. PT.
fomiu Health & Safmy Code, Suctions 25505, 25533 and 25534. 1 understand but if the
Ip y
building does not currently have a tenant, that it is my responsihil!ty to rally the Occupant
of the requirements which must he met prior m issuance of a Certificate of Occupancy.
B,.. --,To -
ISSOED BY:�To It
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TOTAL:ZZ�s zj
Owner or authorized agent Date
OFFICE
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