29213C
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APPLICANTTO FILL IN INFORMATION WITHIN,RED LINES - USE BALLPOINT PEN ONLY - -
CITY OF CUPERTINO - s „ ,. BUILDING - ELECTRICAL_
PERMIT NO.
'BUILDING DIVISION " APPLICATION/PERMIT-PLUMBIrvG. MECRANIi;AI.
- BUILDING PROJECT IDP.NTIFICATION
'. 213
tr ' 2 9 9
BUILDING ADDRESS:
.222 r e� 's,.
SANITARY NO.
APPLICATION SUBMITTAL DATE
-Z 6 .
OW RNAME: ONE,
�--
C TRACTOR'SNA LIC NO:
/
NIC
El-
_
CONTROL# "
ARCxITE /ENGI EER: + LIC NO.'
A R
'CONTACT': PHONE:' 1BUILDING
PERMITINFO
❑, Consultant Pees Paid by Applicant (Initial)
BLDG ELECT PLUM MECH '•
' 'I LICE SEDC. TRACTO $DECLARATION+ -
• I hereby"affirm that 1 am licensed under provisions of Chapter 9 (commencing
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
avith Seen.. 7").T7").ThAmm. 3 dithe Insinessand o o Coo dmylica,a,i,
infullforceunit c
V
Lia eCl a - 2—LIc #
Out /- Conuado
., - -
PERMIT ISSUANCE t .i
RESIDENTIAL: " t -
OSFDWL - I ❑ KITCHEN REMODEL
El ADDITION - El PLUMBING RE -PIPE
APPLIANCES—RESIDENTIAL
r^ - HITECTSDECL RATI
.'• lunderdanit my plans shall be used as public me Js
[I MULTI -UNIT ❑STRUCTURAL
MODIFICATION '•
PANELS f,
.'•
- -
UPT02MAMPS -
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT,
Licensed Pr f aumpal -
201-IOWAMPS
OWNER-BUILDERDECLARATION.•
1 hereby affirm th t 1 exemmptpt frfr the Contrncmrs License taw for the
Mllowing reason (Soctiom 7031.5, Business snit Professions Cede: Any city or county
[I BATHREMODEUREPAIR [I DEMOLITION
❑ OTHER
OVER IWO AMPS' - -
-
SIGNS ELECTRICAL,'
which requires a permit to construct, alter, improve, demolish; or repair any stmctore
"
prior to its issuance, also requires the applicant for such permitm fileasigned statement
SPECIAL CIRCUIT/MISC
that he is licensed pursuant to the provisions ofthe Convectors License Law (Chapter 9
TEMP. METER OR POLE IN
COMMERCIAL:
(.ommencimg with Sadion90W)of Divlsloo3 of the Business entl Professions CoJe)or
that he is exempt domfmm and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Scetk m9031.5 by any applicant fora permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ I. as civialftbe properly, or my employers with wagesas their sole compmsatmm;
Jo the week, and theswdum is not intended proffered fo... to (Sea ]044, Business
"
[]TENANT El FOOD SERVICE
.IMPROVEMENTwill
❑ OTHER
SWIMMING POOL ELECTRI
OUTLETS—SWITCHES-FIXT -S
r.
and Professions Code�The Contractors License Law, dos not apply to an'owwr of
eny who builds or phwes thereon, and who does such work himself or through
propim
his own employees, provided that such improvements are are not intended or offered for
sole.ILhowever, the buildingm improvementis sold within oneyearofeempletion,the'
- -
NEW RESIDENTIAL ELECT',a''-
-
V`SQ.
Pf. FLOOR AREA
$/SQ. FT.
-
owner -builder wi.
will have the burden of proving that he did not build or improve fur pun-
❑ I, as owner of the progeny, am exclusively contracting with licensed contractors m
N9AR 19
TOTAL:
construct the project (S. 7f . Business and Professions Code:) The Contractnds Li-
t �� 961
cense Law does not apply to an owner of properly who builds or improves thereon, and
QTY. PLUMBING PERMIT FEE
who contracts for such projectawiN acrannetimVIkenscdpurseanttotha Contractors
License Law.' ' 1
.& P C for thisreason
L31 an exe ilei$ B
'C��T Ur (gV �4.9I
"
' -
PERMIT ISSUANCE - -
ALTER — DRAIN & VENT — WATER (FA)
OwnerDa¢
WORKERS COMPENSATIO DECLARATION
_ VALUATION ''•
BACK FLOW PROTECT DEVICE
11 e y of im under penalty of perjury one of the following declamations:
'DRAINS— FLOOR, ROOF, AREA, COND. +f"
I hoamal will maintain a CeniBwteof Cm,nnosellmsure for Workers Co i n-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
STORIES
TYPE CONSTRUCTION
FIXTURES—PERTRAP
work for which this permit is issued
❑ I have and will maintain Wmrkees'Compensation rnsumnea, as required by Section
'
3700ofthe Lab C afortin,,formance of the work for which thio permitis issued.
My Warker'e oft sorra n ITPolicy u
Cartier, icyN
GAS, EA. SYSTEM -1 INC. 4 OUTLETS
- OCC. GROUP -
!i l
APNI, '
-GAS —EA. SYSTEM -OVER 4(EA)+
CERTI ATE OF EXEMPTION FROM WORKERS"
COMPENSATION INSURANCE
J not be completedifdmpermlt is Tomas hundred dollars(SIM),,,
or less.)
I ramifythatink the ceofthe work for which thisPermit issued Ishall
lion any
GREASOINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GR
GREASE TRAP q
PI.A,NCHECK FEE
SEWER-SANITARY—STORM EA. 20 FT.
FEE r
ENERNG
�peyrty
�^' /S g����r�ubj.cu J
ntemploy
vithin APPIiv
.. ✓�� -
WATER HEATER WNENT/ELECTR
CRAD FEE' I.
'1a
NOTICE APPLICANT If, iter making this Cernfcate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Cede, you must
WATER SYSTENITTREATING
-
SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked.
WATER SERVICE -
NEW RESIDENTIAL PLMB. ' SQ. FT.
CONSTRUCTION LENDING AGENCY '
I hereby affirm that ill= is a conswetion lending agency for the performance of
PAID
Date Receipt# A
-
,be work for which this permit Is Issued (See. 30)9, Civ, C.)
.Lender's Name
.,
"
.TOTAL: -
'Lerider'sAddress -
TOTAL:
a"
BUILDING FEE -
I certify that 1 have read this application and slate that the above infermmion is
tc,oecL l agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby authorize representatives of This city to enter upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE' -
PERMIT ISSUANCE 1
ELECTRIC HE
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of C.penino .,.last
liabilities,judgments, costs and expenses which may in any way accrue agar nst said City
in consequence of the granting of this permit
ALTERORADDTOMECIL
PLUMBING FEE s
AIR HANDLING UNIT (TD 10,600 CFM)ti
MECHAN/CAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS:• t
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
'Signature of AFfshunUCentractor - IDate
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST, HOOD OVMUCT) 'HOUSING
-
MITIGATION FEE
HEATING UNIT (TO Hit,000 BTU) ..
_
'kill the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the HFalm and Safety
Code.Sectkmn 532Ed?t.
i
•'
-
HEATING UNIT MVERI(IOpoO BTU)
❑Yea ❑No"
' s
Will Nee applicant or future building t use equipment or devices which
pp g pun Alva
emit hazardous air contaminants as defined by the gay Area Art Quabty Management
Qu
DistnatE' Na
❑- -
❑Yes /
-
PAID
,Date„ Recetp� N
VENTILATION FAN(SINGLE RESID)
BOILER— COMP(MP OR 100,000 BTU).
C6
l _ •TOTAL.,
BOILER COMP (OVER IOILWO BTU),
- ii t
'. 'AIR CONDITIONER r
1 have read thehamrdmps materials requirements under Chapin, 6.95 of the Cali
4. -„ ISSUANC TE
NEW RESIDENTIAL SUCH, SQ. FT.
,forma Health & Safety Code, Sections 25505, 25533 and 25534. I understand Nat if Ne
building does not currently haven tenant that it is my responsibility to notify the scutum',.
of Na requircmems which must be mu p�ormissuanee ofe Cerlifiente of Occupancy.-•
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ISSUED BY:
-
TOTAL:
Owner or authmrizeda enc' - - - Uare
g 5
OFFICE