31227 APPLICANTTO FILL IN INFORMATION WITH_IN'RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO '' - BUILDING-ELECTRICAL PERMITNO `
« BUILDING DIVISION, ,APPLICATION/PERMIT PLUMBING-MECHANICAL O 'I n
BUILDING PROJECT IDENTIFICATION J1 L
BUILDING ADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
620 . G`!2/I? �/ J4,X� �
OWNER'S - _ - PHONE CONTRACTOR'S NAME: LIC NO: -
N/C CONTROLM
ARCHITEC'UENGINEEW a , PNOI+`� YGM9. ��RPSS:- �� ..�, � - 1
CONTACT: PHONE: -
n BUILDING PERMIT INFO
❑-Consultant Fees Paid bY Applicant licant Initial a 'BLDG •ELECT_., PLUMB MECH
LICENSED CONTRACTOR S DECLARATION t❑_ Y
I hereby firm that I am
lied d p 'mi rte f Chapter 9(commencing QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1y�OZ ith Seco TIDO) fD' i..3ofthe Bus sand Profession Cade and,.
licuneis - 'RESIDENTIAL,F W m full force end effect - +'PERMIT ISSUANCE. ,'r
�UU License Class ZQ L # S OSFI WL •E]KITCHENREMODEL
F1..ZZW Date C ntrsctor - APPLIANCES-RESIDENTIAL ''ADDITION• +'
t/a<G - El PLUMBING RE-PIPE
RCHITELTSDECiON PANELS s 1IMULTI-UNIT ❑STRUCTURAL
ZO 3 I understand my pl - hallbet used as public
records `
OZC , f UP TO 205 AMPS.` 'u i MODIFICATION
F Line d Prof .nal ❑INTERIOR ❑CHIMNEY REPAIR
" 2011nW AMPS 's IMPROVEMENT:I
OWNER-BUILDERmptfrom
m the Com ION OVER 1000 AMPS . ❑BATH REMOD REPAIR DEMOLITION
W Q. I h by affirm that 11. Business
from th Committees s L n e city
for the
I.OyU folio g,cess
(Section]OJIS Bu ns dP teas Code Any ty rcounty• SIGNS ELECTRICAL GTHER r0
f.W yaE" which re4 permit t n wit ah r pro e demolish.h r r P y structure - OTJ—
y:.l piton 't s also requires'he applicant far such Pemtitt file.sg d statement SPECIAL CIRCUIT/MISC'
qe 9+ ihath Ilcensed purso ou th p 1. soP Ilia CommuorsL Lu (Cbapter9 ) O
QO (cmmnenang with Section 701fifD"nom 3 oflhe Business dPr Pass Code)or
'TEMP.METER OR POLE INST. COMMERCIAL'r' ;' �.
,6 p❑,o f� that be is exempt therefrom and the basis for the alleged axe pll n Any violation of _
tizll �• Section]031 5 b an a licant for u ❑NEW BLDG/ADDITION ❑DEMOLITION
y y, pp permit subjects the applicant civil penalty f - POWER DEVICES El TENANT ' ❑FOOD SERVICE
F, not I as ownethanr
fee t h gropendred ty,or my sap - •+IMPROVEMENT
C ❑1,as owner of the property, is employ with wages as their(Sec.
compensation,Bust -SWIMMING POOL ELECTRIC '
will dothe work
ns and the t wre'snotmte dud nff'doe.s of apply 7044 Business []OTHER,
S and Ply who
Code improves
o nt ereo Lndw L •does work hi toll owner of OUTLETS-SWITCHES-FlXTURES
.. property who bu Ids or p es th- n.and who does such work himself or through �
his own employees Provided that such'improvememx are not intended or offered for NEW RESIDENTIALE TR SQ FTS
aid.If,however,the buildingor improvement is sold within aro!
P Ye completion,the SQ.FT.FLOOR AREA_ .7,� $/$Q.FT.
owne budder will have the bollen of prov g thathe Jid not build or mprove for par-
d.
❑I e;sowner of
erof thepr party am exclusively contracting withlicensed conto TOTAL: N
construct Ili pmject(Sea 7044 B Hess and Professions Coda)The Contractors Li—
cr.La d of apply to owner of property h builds orimproves thereon,and QTY PLUMBING PERMIT FEE t IYJp� $� error
who tract f. suchp juin th ontract OI sed pursuant th Comments YYVP�IPA 2 RECn
'License Law -
❑I em exempt under Sec' B&P C f this reason PERMIT ISSUANCE '�
VII u `
Owner Date ALTER DRAM&VENT WATERIeAL. - VAL A
WORKERS COMPENSATION DECLARATION
. Ihereb affirm under h ofperjury of declarations: BACK FLOW PROTECT DEVICE .
y Ce yo ofCor ane. g
❑Ihave and will tnaimainaCert Bcateof Consent to sal(insure for Workers Cooper- DRAINS-FLOOR,ROOF,AREA,COND.• STORIES ..TYPE CONSTRUCTION
cation,as provided for by Sadion 3]00 of the Labor Code,for the performance of the r
k for which this permit is issaml' ' FIXTURES-PER TRAP 1
yc�i have and will maintain Worker's Compensation Insurance,as required by Sectimar _
'i]OO of the Labor Code,for the Performance of the work for which this permit is issued, GAS-EA.SYSTEMd INC40UTLETS OCO GROUP ' APN
My Worker's C m ei tion Insumn e c ter and Policy n
Cartier: Policy No.:( GAS-EA:SYSTEM-OVER 4(EA) ..
r/0.1;1{ 1EX PTION FROM WOR4.ERS'
COMPENSATION INSURANCE - GREASE/INDUSTRLWASTE INTERCEPTOR+
,(This section need not becomple[ed ifihepeimit is for onehundreddollars($100) r BUILDING DIVISION FEES
lose) GREASETRAP - .{
PLANCHECK FEE
fatuity thinmhe perfimmaa�mryp.rnm an
work for whchiM1t theperWorkis ers
C..P.- SEWER-SANITARY-STORM EA.200 FT
nut employ any pe n in any manner so ns to become subject m the W rkers Compen- r ENERGY FEE
Z, stili Lows fCWifomla Data
OQ A - - WATER HEATER WNENTBLECTR GRADING FEE
Applicant
NOTICE TO APPLICANT If,after making this Certifcarn of Esemp imi you should '
a^� beemeasuheatm Ne Workers Compensation WATER SYSTEM/TREATING i
1 p provisions of the Labor Cale,you must SOILS FEE
{l: fonhwi,h comply with such Precision s tar this permit shall be deemed awaked. WATER SERVICE -
Qr Q -
D
CONSTRUCTION NEW RESNENTIAL PLMB.' SQ.FT. PAID Date Receipt If
V Q workTher
which thi th permit
rets c Irv. ole ding agency fnr the peB.nnance of
LL !•� the work far which this permit is issued(Sec.3097,Civ.CJ
Lender's Nome '
L) Lender's Address - - l' - TAL:
[„kl
LL + •i certify that I have mad this application and state thin TOTAL:ilia above information is BbILDING FE 1'
Iti tn correct.I agree to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
G ,7�. building construction,and hereby amhorizercpresemntivesofthis city meaterupon the SEISMIC FE
above-mentioned Property for inspection purposes.
`(We)agree to save,indemnifyand keep harmless the Cit fCo g PERMITISSUANCE +
P y. peninoe ainm' .ELECTRIC FEE
liabilitier,judgmems,casts and expenses which may in any way eccmu against said City ALTER OR ADD TO MECH.
in consequence of the graming of this permit. - PLUMBING FIE
APPLTC T UNI ERSTANOS AN WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
SOU EG TION MECHANICAL .61 07=
_ Q AIR HANDLING UNIT(OVER 10,0!10 CFM) CONSTRUCTIO TAX i
rel Ap as antranm Date / EXHAUST HOOD,(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE - HOUSING MITIG TION FEE
'Will the upplicam or future building occupant store orhandle hazardous material / HEATING UNIT(TO IW,000 HTU) '
as defined by the Cupertino Municipal Code;Chapter 9.12,and the Health and Safety
Rsde ion 255J2(e)^ ....�/////� - .y I HEATING UNIT(OVER I OO,000 BTU) - t .
us VENTILATION PAN(SINGLE RBSID) PAID -
Will the applicant or future building occupant use equipment or devices which - Dale'- Receipt k
`• emit hazardous air concomitants as defined by the Bay Area Air Quality Management BOILER'-COMP UHP OR 100,000 BTU) .•.
District?, S d 1 TOTAL:
❑Yes BOILER-COMP(OVER LOO,"BTU).
AIR CONDITIONER
1 have read the hazardous materials req 's under Chapter 6 95 of the Cali- s - ISSUANCE DATE. j
forria Health&Safety Code,Sections 25505 25533 d 25514 I understand that if me NEW RESIDENTIAL MECH. ' SQ.FT.
building does not currently have a tenant,that ti ray responsibility m notify the,cecupant
of the coquirearnamt,which most be.1 prio,1.i,wam.of.Certfcto of Occupancy.
OwnTy or euthonzed.gent Dine h � , TOTAL f .'
_ Issued eY.
OFFICE