31299'. APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY L'N"IsisIr - •' "' - '
CITY OF CUPERTINO /', BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT'- ''.'.PLUMBING-MF.exArvICAL
BUILDING PROJECT IDENTIFICATION
-' PERMTT NO:
,, 1,3299,
.
BUILDING ADDRESS: . - -
SANITARY NO.
APPLICATION SUBMITTAL DATE
X08.03 Gan 'o!r Ufs�u�r, G�*u%rio S7s 06
,1 ��
`O'
OWNER'S NAME: /J - PHONE:
V (lJ 0. Z S .% —*
ONTRACI R'SN ME: - LIC NO:
N/C
I'' '❑
-CONTROL tt
_.
ARCHITECT/ENGINEER: LIC NO. +
Jv ]
r� ` ��/
CONTACT. PHONE:
- - -
BUILDING PERMIT INFO
Gtr QO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG - ELECT ,- PLU B ME(;H
❑ � /L]f](VI
Dd'Z
�r400
W�
222p W
Z j m
O,^L„-'.Ox
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M1
F
LICENSED CONTRACTORS DECLARATION
I h by ffrm m e l l ed d p f Chapin 9 (d mine cing'
bh5 i ]000) fD a3ofthe Business and Pr fesamn Code, -d mylce se
in fullforce and effect.
LictrucCloss Lie.# -
Dam' Contractor
f2TY. ELECTRIC PERMIT FEE
: .. JOB DESCRIPTION -
r
SFDWL pKTCHEN REMODEL
ADDITION ' El PLUMBING RE -PIPE
L1 MULTI -UNIT EISTRUCTURAL
'. . MODIFICATION
❑ CHIMNEY REPAIR'
�1 PROVEMENT
`
3THREMODEUREPAIR,-❑DEMOLITION
J -
OTHER -
s
PERMITISSUAE
NC ", li
APPLIANCES=RESIDENTIAL❑
ARCHITECT'S DECLARATION,
1 dersiend my plans shall be used us puhlic records-
_ _ -' _ 1.
PANELS
UP TO 200 AMPS,. I..bINTERIORR
Licesed Professonal -
OWNERBUILDERDECLARATIO&
hereby affirm that I am exempt f tit the C t cmc s License Law f the��'D
'follo g reason. (Soctimi 7031.5. Business d Provocations Code Any city or county
201-1000AMPS
OVERdfMYJAMPS .'
SIGNS ELECTRICAL
p.
which ream res n permit u, construct. site , improve d oormikh or mepmr any wcame
that he is licensed pursu a theprovisions of Contractor L' L (Chapter 9-
Met to its issuarce.'also requires the applicant for such Permit to file a signed statementPNEWRESIDENfIALEL7E�R
IRCUG"NUSG. a,
'-
_
(rnmmenc ng with Sect n]000)orDivision3of the Bpvness dP fCde)orER
that he tc exempt therefromand the basis for the alleged exemption. Any vmlafon of
OR POL IS
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Sect ]01156y y ppltf p nsuM1lects the epplicann 'I pe by fVICES
n i thanfih d dd ll ($500)
a wit rofine pr p rty yi ployees wnhwagesa th is lee mpensalon,
Il do th k dthe st t re sit t meadedaroffered for 1 (S .]044 B .
f ..❑
TENANT ❑FOOD SERVICE
IMPROVEMENT,I
,[]OTHER
_
POOL ELECTRIC,
ad Prf C d Th C t t License Law does t pply t ofSWITCHES-FIXTURESpaspeny
h 6 Id p N d who docssuch w rk hs n. If through his wit n pl yc s pr "d d th t h mp t s are not tended or m ffered forENTIACELEC
If h e er the bu Id ng o mp ovement i Id "thini y f l ion theFJ.OppOR
budder will have the burden of proving that he did not build or impasse for pur
R SQ PT.sale
AREA
V
$ISQ. FT.owner
'n
pose rsele)
E] 1, f theproperty, lust lycontracting with licensed contractors to
'
T'
T
i
construct the p jet (Sas 7044 Business and Profession, Cade) The Commerce, Li-
censeLaw does not apply to an owner of property who builds or improve, moo oe, and
Q9Y. PLUMBING PERMIT FHE Si
,r
-
who contracts for such projects th outractood licensed parmum to the Commemes
License low.
l am exempt under Sec. ,B& P C for thisreasnn
,In
LurCl'�NO )
PERMITISSUANCE
ALTER - DRAIN &VENT-WATER(EA)
Owner Date11
VALUATION
1
WORKER'S COMPENSATION DECLARATION
I hereby affirm under peeelty of perjury one of are following declarations:
BACK FLOW PROTECT. DEVICE
'
❑ I have and will maintain a Certif6ate'of Consent to self -insure for Workees Compen-
stand, as provided for by Section 3701 of the Labor Code, for the performance of the
DRAINS- FLOOR; ROOF, AREA, COND.
a STORIES
TY PE CONSTRUCTION
-
-
work for which this permit is issuedFIXTURES-PER
R TRAP
-
❑ I have and will maintain Writer's Compensation Insumnce, as required by Section
'v
fthe Labor Code, a performance ofthe work for which this permit is issued.
GAS- EA. SYSTEM-] INC. 4 OUTLETS -
OCC.GROUP'
- APN
y Ware in .It sum are carrier and Policy number are:
Cartier: Policy Nr.:
,..
-
-
GAS - EA. SYSTEM -OVER 4 (EA) p.
1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
y
GREASEQNWSTRL WASTE INTERCEPTOR f
-
BUILDING DIVISION FEES
(This section neednd be completed ifthe permit is frrnnehundred dollars($100)
roles,.) -
OREASETRAP
x'
PLANCHECKFEE H
�O
VJ
a
I certify matin the performance 8fthwork for which thispermit. i. meet, I shall
employ y person m an man so a t b subject th Workers Co.
not east an "y
sarlot Laws of California.Date
Applicant
- - t i -
SEWER- SANITARY STORM EA. 200 F, f.
-
ENERGY FLE
GRADING FEE
WATER HEATERW/VENT/ELECTR
NOTICE TO APPLICANT If. R km th C n fume of Exemption, you should
B
become subject the W pi C P< t provisions of Ne Labor Code, you must
WATER SYSTEM(IREATING -
- - _ ,
SOILS FEE
L7J
7,z
' U'
W
U
0.
forthwith comply with uch pins inns or permit shall be deemed necked.
ONLENDMGAGENCY s
., CONSTRUCTION w
1 hereby affirm that thereen is is aa ronscuon lending ,gen y forthe pertovnance of
the k for which this permit is Issued (Sec 3097, Civ. C.)
Lender a Name - f
WATER,SERVICE
'PAID t etcei #' l ^
_
-
NEW RESIDENTIAL PCMB. SQ. FT.
v.. -
",
v -
TOTAL •, i,,
, �'
Lenders Address
TOTAL:
BUILDING FEE
I nobly that 1 h d this city an fon and tat thin the above information s
r up n 1.the
coned (agree [o comply with II rty and prey natives es and stare la enter
building construction, and hereby authorize presentative of thismtymenmruponthe
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
ti [A
e.) �
PERMITISSUANCE
ELECTRIC FEY. A
above-mentioned property for inspection purposes. -
less the City of Cupertino against
'' (We) agree to save, indemnify and keep harmpe
PLUMBIN EE
iliabilities,judgments,
costs and expenses which may in any way accrue against said City
nsegpeuce of the gm 'ng of this permit.
ALTERORADDTOMECH:,, i
_
- AIR HANDLING UNIT ITO to," CFM)
MECHANICAL 8
APPLICANT UNDERS NOS AND' WILL COMPLY WITH ALL NON -POINT
C
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTIO TAX
Signamrebf Applicant/Convector, Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
- -
HOUSING MITIG ION FEE )'
.
HEATING UNIT (TO Rattail) BTU)
Will thepplivilime, f tura building occupant amour handle huiardoos material
as defined by the Cupertino Municipal Code, Chapter 9,12, and the Heahh and Safety
Crude, Settled 2557261)'f
❑Yea [:IN. -
-
1
HEATING UNIT (OVER 100,000 BTU)
-
PAID =
Date accents #
VENTILATION FAN (SINGLE RRSID) -'
BOILER - COMP(3HP OR 100,000 BTU)
Will Weepplie i future building goc occupant use equptit or devices which
' '
lity Manogemene'
ardous air contaminants as defidW.by the Bey Area Air Quality
emit hazte Q
_ TOTAL:
BOILER - COMP (OVER 100,0110 BTU) +,
District?
❑Yes. n [IN.
,i
AIR CONDITIONER
-1 have read the hazardous materials requirements under Chapter 6.95 of time Cali-
=
ISS ANCE DATE,
NEW RESIDENTIAL MECH: I SQ FTS
'.
forma Health & Safety Code, Sections 25505 25533 and 25534. I understand that if the
building does not currently have a tenant thatl" my responsibility to roily the occupant
of Nerequirementa which most be met poor en is,muce of a CenlBrstc of Ocbuponey.
•'r
'ISSUED BY:
Owner or authorized agent Dale,
,. i' OFFICE -