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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
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BUILDING - ELECTRICAL
PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PE It' NO
1623
BUILDING ADDRESS:
SANITARY NO,
APPLICATION SUBMITTAL DATE
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OWNER'S NAME PHONE:
CONTRAC'TOR'S NAME: LIC NO.
N/C
CON I'ROI, M
❑
v
II ARCHITECT INEFR: LIC NO:
ADDRESS: ` vote—
CONTACT: PHONE:
BUILDING PERMIT INFO
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❑ Conaultaut Pees Paid by'Applican[(Initial)
BLDG ELECT PLUMB MECH
tAl FTf4/� 'rtklY/
LICENSED CON "TRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under previsions of Chapter 9 aommeneing
QTY. ELECTRIC PERMIT
FEE
]OB DESCRIPTION
PERMIT ISSUANCE
SO
with Section 700@ of Division 3 orthe Business and Professions Gnlc, and my license is
in full Porce ands t
License Cl Lic.K 4� �`!�
Dae a Contra amr bT7 Q S
- ARCHITECT'S DECLARATION
I understand my plans shall be used n, public records
RESIDENTIAL,
❑STOWE ❑ KITCHEN REMODEL
]ADDITION [I PLUMBING RE -PIPE
❑ MULTI -UNIT ❑STRUCTURAL
MODIFICATION
APPLIANCES - RESIDENTIAL,
PANELS
UPT02MAMPS
[1 INTERIOR ❑SWCHIMNEY MINGREPAIR
IMPROVEMENT E3DEMOLINGPOOLS
POOL
Licensed Pmfessionul
201-I(k10AMPS
OWNER -BUILDER m Ce Coun ON
I hereby (SaW that I nm exempt from the Conlacmr's License Low Trr the
following reason. (Section 7031.5. BuainesR and Podasinn, Code: Any oily nr umnty
requires a permit to construct, alter, improve, demolish, no repair any structure
[I BATH kEMODCL/REPAIR (] DEMOLITION
❑ OTHER _
OVER IBM AMPS -
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
Prior m as issuance, all. requires flcopplicunt for such permit to Ne a signed statement
that he is licensed pursuantmthe poo ca aofthe Cianolo d, License Law (Chapter 9
(wmmencing with Section 7000)of Division 3arthe Business and profession, Cde)or
TEMP. METER OR POLE INST.
ME IA : 150 kwT
that he is exempt therefrom and the basis for the alleged exemption. Any vioLnlon of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWEk'DEVICES
Section 7(31.5 by any applicant fora penult subjects the applicant to a civil penalty of
not methanfive hundred dollars y employees
roflnd propusgarmyot intended withwages nsal, (Sri. sole 044,Boation,
will dothewons andtheheCore ntisnets License ed i
the work.
rot apply 7044, Business
and Law owner of
Coda: The Contractors s License Law docs not apply
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
[I OTHER
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES -FIXTURES
property who s if
who builds or improves thereon, and who does such work himself or through
disown
disown employees e provided that such improvements arc nm intended or offered for
sale. If, however the building or improvement is sold within one ywrofcompletion, me
NEW RESIDENTIAL ELHCTR SO FT.
.Q. FT. PLOORAREA
$ISQ. Fr.
eolaullder will have me border of proving than he did not buildor improve for per-
pu aofsale).
El 1,asowner of the Seaproperty,TIL am exclusively contracting with licensed cno-aux .-
camera the (Sec. Business and bus The Conneemr9
TOTAL.
r .n
V
es nota t) an Property who ds ori and
wase Law drmroapply nhan mentor.atm
wcesed
QTY. PLUMBING PERMIT
FEE
pursuant
who se Law rte such projects witsowmmctor(s)licensed punuam wdue ennwomrs
witha caricatures
License Law.
❑Ism exempt under Sec. ,B&PCfor this rcason
JJ��
PERMIT ISSUANCE. 5r 6j 0
Owner Data
ALTER -DRAIN&VENT - WATER (EA)
VALUATION
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT DEVICELk
I hereby u0imh under penalty of perjury one of the following declarations:
Ihavr and will mvinwin aCerlifiwtcrf Consent msxlf-insure for Worker's Compen-
satirn, as Trinidad far by Section 37M of the Labor Cwa fur the performunw of me
110
- STORIES TYPE CONSTRUCTION
I
` DRAINS -FLOOR, ROOF, A1577!)
D
work for which this permit Is issued.
FIXTURES - PER TRAP
1 have and will maintain Worker's Compensation Insurance, as required by Sernion
3700ofthe LaborCade, frrtheperformvncerf the work forwhlch tins pormi(is issued.
GAS -EA. SYSTHs1_ QTS
OCC GROUP APN
My Worky:. Comp tion luh{ytnnca cnrriw ind Policy berg
Carzier.hTx !��!- i_ Oisolicybf,:Q;;ZhhO A.
GAS -EA SYSTEM
4(EA Q
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissectienneed not be,amplaed ifflepennit isf on ehondredd.hoo($I00)
nr less)
GREASTINDUSIN
TE INTERCEPTOR
BUILDING DIVISION FEES_
GRHASH'TRAP
-SEWER
PLANCHHCK HE
_
as the Wineissued, 'Con,xshall
Loy any mainthe perforanydiannce ro the as to bekfor subjectch to
not employ any person in any mm�ner so as m become whject to the Wom'kers' Compen-
STORM EA. IDU Ff.
ENERGY FEE
WATER HEATER I t'/ELECUR
satime Laws of California. Date
Applicant m
GRADING FEE
NOI'ICE'TO APPLICANT: If, afar making this Ceirmia , of ExempOon, you should
become subject m the Worker's Compensation provisions of the Labor Coca you must
WATER SYSTEM
SOILS FEE
I
forthwith comply with such provisions or this permit shall be deemol revoked.
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ, Fr.
CONSTRUCTION LENDING AGENCY
I hereby affirm that is awmstmption lending agency for the performance of
PAID
Dna eipt
-
the work for which this permit is issued (Sec 3097, Clv. C.)
-
Lemde,Name
-/TOTAL
Address
TOTAL:
BUILDING FEE
I ecrlfy that I have read this application and stale that the nerve infunnalion is
-
urnwt.I ngrw mwrhhply with ml mty arta commy orainanwx and stem lawn rela0ngm
QTY MECHANICAL PERMIT
FEE
building consumction, and hereby authorize represenwrve.s of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino againstELECTRIC
SEISM IC FEE
PERMIT ISSUANCE
FEE
ALTER OR ADD TO MECH.
PLUMBING FEE
linbllities,jod6ments. vests and expenses which mayor any any acrueogarn, said City
in asequence of the granting of this permit
AIR HANDLING UNIT(TO IgWOCFM)
MECHANICAL HESC�RCE
APPLICANT UNDERSTANDS AND WILL COMPLY WI'DI ALI. NON -POINT
REGULATIONS'
AIR HANDLING UNIT (OVER 10,000CED
CONSTRUCTION TAX
\�IL)i 0� a f� rj ^`
CS
Olale�
Srgnmare of Appleco a uaeror "a
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,00) BTU)
Will the applicant or future building occupant store or handle hazardous manual
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Coda Section 25532(x)7
- ❑Yrs VIN.
HEATING UNIT (OVER 100,000 BI U)
PAID
=
VENTILATION FAN (SINGLE RESID)
Dom ReceiplN
BOILER -COMP QHP OR 100,000 BTU)
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants its defined by the Hay Area Air Quality Management
Ddnu4
s'Yi �
❑Yes No
C
I have mad the hazardous materials requirements under Chapter 6.95 of fire Cali-
vfamla
TOTAL:
4 D
BOILER -COMP (OVER 100,00f1 BTU)
AIR CONDITIONEk ,
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. CE
Hoaph & Safety Gals, Sections 25505, 25533 rod 25534. 1 undehstard that it the
ipding does net cumntly have a tenant, that it is my responsibility mnotify the cecupnnt
ne rg Brits Ahimust be met prior tit issuance of a Cc 'An
/ /
..�
ISSUED BY:
Owns or authorized agent Date
TOTAL:
OFFICE