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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
flU1LDINC PROJECT IDENTIFICATION
29155
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
1236 G/}TAC-/A4 c7,,
OWNER'S NAME: PHONE:
6_ e 4, r,
CONTRACTOR'S NAME: LIC NO:
SIC
❑
CONTROL#
C
CHITECr/ENOINEER:91
ADDRESS:
CONTACT: P ONE:(
BUILDING PERMIT INFO
jig 7_57-5`68F
El Consultant Fees Paid by Applicant (Initial)
,BLDG ELECT PLUMB MECH
,I`�ysl ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
QTY. ELECTRIC PERMIT FEE
- JOB DESCRIPTION
with Section70007ufDivision 3 ofthe Business and Professions Code. and my license is
in full force and effect.
License Class Ln.
Dam Cnmranor
PERMIT ISSUANCE SO
RESIDENTIAL
❑SFDWL ❑KITCHEN REMODEL
[]ADDITION ❑PLUMBING RE -PIPE
❑MULTLUNIT ❑STRUCTURAL
MODIFICATION
APPLIANCES — RESIDENTIAL
ARCHITECTS DECLARATION
I understood my plum shall be used as public records
-
PANELS
UPT0200AMPS
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
ATH REMOUEVREPAIR ❑DEMOLITIOM
11DOTHER
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following remon. (Section 7031.5. Business and Professions Code: Any city or chanty
201. UXXIAMTo
OVER 100(1 AMPS
_
SIGNS ELECTRICAL
which requires a per.,ut m construct, area, improve, demolish, m Tcism, any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Contractors License law (Chapter 9
(commencing with Section 7")of Division 3 of Ne Business and Professions Case)or
TEMP. METER OR POLE INST.
COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
not more than rive hundred dollar, ($50d.
❑ I, us owner of the Property, or my employees with wages us their sole compensation.
will da the work, and the suucmre is.. intended croffcrcd forsele (Sec. 70441 Ilmouss
❑TENANT ❑FOODSERVICE
IMPROVEMENT
❑OTHER
SWIMMING POOL ELECTRIC
faa
Ol1TLET. —SWITCHES—FIXTURES
and Professions; Code: The Contractor's License law does not apply to an owner of
NEW RESIDENTIAL ELECfR SQ IT.
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended m offered for
sale. IL however, the buildint.r improvement is sold within one yearofcurpletiomthe
SQ.FTFLOORAREA
&SQ. IT.
-builder will have the lancer of proving that he did not build or improve for poo
LVEA sale.).
owner of the property, urn exclusively contracting with licensed enOt.t.m to
T
.loud the ,,,jet, Sec. 7044, Business and Professions Codc:) The Contracture U.
nee Law dues not apply to an owner of property, who huilds or improves thereon, and
QTY. PLUMBING PERMIT FEE
,
contracts forsuch projects with a comrectod id lieensed pursuent to Ne Conwcmfs
License law.
❑ Ieme empt undcrSec. 7Y YY,B&PC for[hisomm.
Y" H B
PAI
PERMITISSUANCE
Owner Data
ALTER — DRAIN &VENT—WATER GEA) -
VALUATION
J
9 `
w.h �N �`•/g / 1
YORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty ofperjury, one ofthe following declarations:
to
• BACK FLOW PROTECT. DEVICE:
DRAINS— FLOOR, ROOK AREA, COND.TY
I have and will maintain a Certificate of Consent to self -insure for Workers Campcn-
work forswhich this permit is issuefor by Socum d of the What Cade, for the perfommnce of the
TO as �U ,rex
ECONSTRUCDON
Jry U
FIXTURES —PER TRAP �7 "tea
Lira
1 have and will maintain Workers Compensation Insure.,,., m required by Section
3700ofthe labor Cdde, for the performance afthe work for which this permit is issued.
GAS — EA. SYSTEM -1 INC. 4 OUTLETS
OCC. GROUP
APN
My Worker's Compensation Insurance carrier and Policy number are:
Currie,. Policy N.,
GAS — EA. SYSTEM -OVER 4 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
GREASFANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This line need am he comFleted if the permit is for one hundred dullms($1O)
or less.)
GREASETRAP
PLANCIIECK FEE '
[certify that in the performance ofthe work forwhich this Permit is issued,Ishall
not employ any person in any manner see os te become subjecum the Wmkers' Compen-
SEWER—SANITARY—STORM EA. 201) FC.
ENERGY FEE
endo. Laws ofcalifomia. Data
Applicant
WATER HEATER W/VENT4?LECTR '
GRADING PER
NOTICE TO APPLICANT: If, aper making this Certificate of Exemption, you should
become subject to the Worker's Compensmiun Provisions of the Labor Code, you must
WATER SYSTEMITRRATING
SOILS FEE ,
forthwith comply with such Provisions or this penot shall be thermal revoked.
WATER SERVICE
- -
CONSTRUCTION LENDING AGENCY
I hereby affimr that there is a constmetion lending agency for the performnvicenf
NEW RESIDENTIAL TIME SQ. FL
PAID
Date- Receipt#
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
-
TOTAL:
Lenders Address
BUILDING ME -
I certify that I have read this upplicadnn and state that Ne above information is
correct. l agree an comply with all city and county ordinances and .state laws reining w
building construction, and hereby authorize representatives of this city to enter upon the
QTY, MECHANICAL PERMIT FEE
-
SEISMIC FEE
PERMIT ISSUANCE
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
ELECTRIC FEE
r�
�y
PLUMBING FF.E �V
liabilities,judgments, costs and expenses which may in my way acerae against said City
in consequence of the growing of this Permit.
ALTER OR ADD TO MECH. -
AIR HANDLING UNIT GTO In," CFM)
MECHANICAL ME
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,(0X) CPM)
CONSTRUCTIONTAX
. •
Signature of Appocant(Contmcmr Date
• HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCf)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building Occupant moreor handle harnamu,material
as defined by Ne Cupertino Municipal Code, Chapter 9.12, and the Health and Safety'
Code. Section 25532(x)?
HEATING UNIT (OVER 100,000 BTU)
❑Yes ❑Nu
VENTILATION PAN (SINGLE RESID) -
PAID pate Receipt# -
BOILER —COMP CHP OR 100,000 BTU)
Will the applicant m.futum building occupant use equipment or devices which
emit haimdous air contaminants as defined by the Ray Area Air Quality Management
- TOTAL
BOILER —COMP (OVER 100,W) BTU)
Disuia?
❑Yee ON.
AIR CONDITIONER
I have read the harmdous materials requiremcnu under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
forma Health is Safety Code, Sections 25505.25533 and 25534.1 understand thm if rhe
building does ret currently have a temn4 that it is my responsibility to notify the occupant
t
ofthe requirements which must herm'Poo rmigeuanceofa Certificate of Occupancy.
ISSUED BY:
TOTAL:
Ownerm uth zed agent Dam
OFFICE