30123APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE. BALL POINT PEN ONLY
CITY OF CUPERTINO '` - BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
-I BUILDING PROJECT IDENTIFICATION
PERMIT NO. a �w
o 1 -3
30123
BUILDING ADDRESS'. - -
SANITARY NO.
APPLICATION SUBMITTAL DATE
5 AI04 ) T-,
.LcL6
OWN'R'S NAME:'r -` PHONE: -
l
CONTRACTOR'S NAME' LIC NO:
10-y P—T 6 Tli[.ueS%
'NIC
❑
CONTROL It'
ARCHITECrUENGINEER: LIC NO:
ADDRESS'. -
CONTACT: -
BUILDING PERMIT INFO
�--P]HONE:
2?— u'
❑ Consultant Fees Paid by Applicant(Initial)
- BLDG ELECT PLUMB 'MECH
l� OM i S 7-0 1
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION •'
I hereby affirm that 1 am licensed under provisions of chapter 9 (commencing
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
with Seen..700tpof Division 3afthe Business end Professions Cade,aodmylicenseis
I. full farce and effect.
/ 4
PERMIT ISSUANCEI
RESIDENTIAL:
❑SFDWL `OKITCHFN REMODEL
APPLIANCES -RESIDENTIAL
License Class' Lic. #
Date Cantra�r�. nb^H YNw
E] ADDITION ElPLUMBDIG RE -PIPE
❑MULTI -UNIT ❑ STRUCTURAL
MODIFICATION
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
PANELS
UP TO 200 AMPS
❑INTERIOR CHIMNEY REPAIR
IMPROVEMENT
Licensed Professional
201-1000AMPS -
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any City or county,
,BATH REMODEIBEPAIR C1 DEMOLITION
-
El OTHER
OVER 1000 AMPS -
SIGNS ELECTRICAL
which requires a permit m compact, for, improve, demolish, or repair any stmcture
-
prior to its issuance, also requires the applicant for such permit to file a signedsmtement
SPECIAL CIRCUIT/MISC.
met he is licensed pursuant to the provisions of the Commences License Law (Chapter 9
TEMP. METER OR POLE TNST.
COMMERCIAL:
(commencing with Section 7000) of Division 3 of the Business and Pmfessions Code) or
that he is exempt Omrefrom and the basis for the alleged exemption. Any violation of
El BLDG/ADDITION DEMOLITION
POWERDEVICES
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not moie than five hundred dollars($500).
1, as owner of the property'mr my employees with wages as their sole compensation,
will do the work, and the structure is not intended oroffered fersale (See, 71004, Business
❑TENANT ❑FOODSERVICE
'IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
and Professions Code: The Connector's License Law does not apply to an owner of
OUTLETS - SWITCHES - FIXTURES
property who builds or improves thereon, and who does such work himself or through
his own employees, pmvided that su firraprovements are not intended or offered for
sale. If, however the building or improvement is said within one yenraf a,mpletion. the
NEW RESIDENTIAL ELECTR
SQ. FT. FLOOR AREA
VSQ. FT.
-
owner- builder will have the burden of proving that he did not build or improve fur Pur4;��
pose of sale.). I-
❑ 1, as owner of the property am exclusively comment, with licensed controemrs to
onstmm the project (Sec. 7044. Business and Professions Code.) no Contractor's Li-'
�-p
C-
-
TOTAL:
nse Law does not apply to an owner of property who build- m improves theme., and
QTY. PLUMBING PERMIT
'
who contracts for such projects with a commemr(s) licensed pursuant to Ne Contractors
License Law.
- ❑ f am exempt under See. ,B& P C for this reason,V
JUL'J
JUO1296'
9'
PERMIT ISSUANCE
Owner Date
ALTER -DRAIN & VENT -WATER (EA)
W�!P VALUATION'
1 P t'UPL,l l Hvy
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
I textural will maintain. Certificate MConsentta self -tenure for Worker's Cnmpen-
soden, as provided for by Section 3700 of the Labor Cade, for the pcaf moanto of the
DRAINS- FLOOR, ROOF, AREA, COND.
STORIES
TYPE CONSTRUCTION
work for which this permit is issued. s
FIXTURES -PER TRAP
I
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
'
37W ofthe Labor Code, for the performance of the work for which this permit is issued.
GAS -EA. SYSTEM -I INC. 4 OUTLETS'
_ OCCGROUP
APN
My Worker Compensatlo finconce'srie tropic and Policy �(
Cramer: TG iLNV Policy No.: V
_ •,
GAS-EA.SYSTEMOVER4(EAj `
CERTIFICATE. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASEIINDUSTRL WASTE INTERCEPTOR
BUILDING ONISION FEES
(This mcdnn need not becomplmWlDhe pervildsforona hundred dollars ($IW)
or less.)
GREASETRAP
PLANCHECK FEE
I cenilY that to the performance ofthe work for which this permit is issued, l shall
not employ any person in any man......... become suhject to the Workers' Compen-
SEWER - SANITARY - STORM EA. 200 Fp.
ENERGY PEE
action Laws of Califarnim Date
Applicant
WATER HEATER W/VENT/ELECTR
GRADING FEE '
NOTICE TO APPLICANT: If, after making this Certificate of Exemptiomyou should
become subject m the Worker's Compensation provisions of the Labor Code, you most
WATER SYSTEM/TREATING
SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked'
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I lssued(ec.30lending agency for the performance nf.
NEW RESIDENTIAL PLME. SQ. FT.
PAID-
Dale Receipt#
-
forhthipermit i (Su. 3099, Co. CJ
- -
LEm enderkforwhichtfiispermitlaissued
Lender's Name
-
-' TOTAL:
Lender's Address
"z1 TOTAL:
BUILDING FEE
I terrify that I have read this application and state that the above information is
QTY. MECHANICAL PERMIT FEE
correct, I agree to comply with all city and county ordinances and state laws relating to
building commodes, and hereby aothodzerepr,cou.tivesofthis city to enter upon the
SEISMIC FEE
ISSUANCE
ELECTRIC FEE `
above-mentioned property for inspection purposes. -PERMIT
(We) some m save, indemnify and keep harmless the City of Cupertino against
ALTER OR ADD TO ME CH.
-
PLUMBING FEE
liabilities judgment and expenses which may in any way active against said City
it nseyuenee the ntingofthispermit.
AIR HANDLING UNI 'T(TO 10,0010 CFM)
MECHANICAL FEE
APPLICAN N ST 'AND WILL COMPLY WITH ALL NON=POINT
SOURCE G ATI
AIR HANDLING UNIT (EVER 10,000 CFM)_
CONSTRUCTIONTAX ;
„
Si rc ofApplc met Date
- RD S MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE -
HEATING UNIT TO 100,000 BTU)
Will th ¢ants o ure building occupant space or handle hazardous materiel
as defined by the Caliendo. Municipal Code, Chapter 9.12, and the Health and Safety
Code, Sectio. 25532(a)? -
-
HEATING UNIT (OVER 100,000 BTU)
❑yes ON.
PAID
Date Receipt#
IVENTILATION FAN (SINGLE RESID)
BOILER -COMP (3HP OR 1 W,IIW BTU)
Will the applicant or future building occupant use equlpoent or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
BOILER- COME (OVER 100,000 RTU)
District? •-
❑Yes " ❑No
-
AIR CONDITIONER
1 have read the hazardous materials requirements under Chapter 6.95 ofthe Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. PT.
forma Health & Safety Cede, Sections 25505, 25533 ad 25534. I understand Nat if the
building does not cutrcmly have a tenant, Our it is my msponeibility t. notify the occupant
ofthe requirements which must fe met prior to issuance of a Cenific 1, of Occupancy:'
-
ISSUED
TOTAL: .,
Owner or authorized agent Date
OFFICE _ ,