99110093APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY TJ/ I I I IVO I
OFFICE
CITY OF CUPERTINO BUILDING -ELECTRICAL
PERMIT NO. r
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING- MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BIU1ILDINLGGADDRFSS:/1 11
SANITARY NO.
PLICATION SUBMITTALgUATE
C
fS`ML `PHONE:
Lt 2 111 '5111'.10
CONTR`ACTOR'S NAME: x LIC NO:
NIC
❑
CONTROL p
CHITECTICNGINEER: LIC NO:
ADDNF:SS:
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
ee BLDG ELECT PLUME MECH
❑ ❑ 4 ❑
CCZ
��
IVFU
rU'
°pyZW
) n z
Q
W U
d
' 4 y
70Jprior
3p.
LICENSED CONTRACTOR'S DECLARATION
I hereby alTtrm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 ofmc Business and Professions Code, and my license is
in full force and effect.
Date Class Lick
Dam ContractorDECLARATION
Ory ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL,
❑SFUWL [I KITCHEN REMODEL
❑ADDI770N ❑PLUMBING RE -PIPE
[]MULTI -UNIT El STRUCTURAL
MODIFICATION
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT I-] SWIMMING POOLS
u
❑BATH RF DF1 PAZ ❑ DEMOLITTN
❑OTH R 1 `mad, � V'1
1
1gn 1G gf I
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
ON
OWNER -BUILDER DECLARATION Contractors
1 heathy .(Seat that 11. exempt from the Cssams is Limnse Law for the
fallowing reason. (Section ] um Business and Professions Cade: Any city or county
repair arty swnurc
which requircx n permit re camwat, alter, improve, de permit t file
miu issuance, also requires the applicant for such permino fileasigned statement
that he is licensed pursuant to me provisions ofthe Contractor's License Law (Chapter 9
PANELS
UP TO 200 AMPS
281-1000AMPS
OVER IBfg1 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
)<2
p+
(commcncin mSectiun]000)of Division3of the Business and Professions Codc r
gwi )n
that he is exempt themfmm and the basis for the alleged exemption. Any violation ofde?z❑
TEMP. METER OR POLE INST.
COMMERCIAL'
NEW BLDG/ADDITION ❑ DEMOLITION
n 0.
-z>
+ 6
LF=+e
p eo
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
nm more than five hundred dollars ($500),
Q1, as owner mime property, or my employees with wages as their sole compensation,
will do the work. and me street= is not intended proffered for sale (Sm. 7044. Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, pmvidW that such improvements arc not intended or offered for
sale. If, however me building or improvement is sold within one year of completion, the
POWER DEVICES
ANT ❑ FOOD SERVICE
MOVEMENT
❑ THER
SWIMMING POOL ELECT RIC
OUTLETS - SWITCHES- FlXTURFS
NEW RESIDENTIAL ELECTR SQ FT.
SQ. FT. FLOOR AREA
$/SQ. FT.
mer -!wilder will have the burden of graving that he did not build or improve for Pur-
pose of sale.),
neI
Ppwr of me property, am exclusively contracting with licensed contractors to
�}/�6nss
TOTAL:
a.. the project (Sec. 701 Business and Professions Code:) The Contmcbm" Li-
move
QTY, PLUMBING PERMIT FEE
who convucm for such projects with v comramor(n) licensed pursuant to the Contractor's
ISSUANCE
License LetterPERMIT
❑lame mIn ndc ,`. .B&PC for this reason
ALTER - DRAIN & VENT - WATER IFA)
VALUATION
wneDate
WORKER'S COMPENSATION DECLARATION
'I
,
BACK FLOW PROTECT. DEVICE
OP
hereby affirm m under penalty ns:
perjury one of the folloinsure for decWorker's
STORIES
TYPE CONSTRUCTION
to Worker's Comp the
❑Ihave and wills for bynaCion 37 m of the 1 -mor
Section 3] W of the Lubar Code, for the performance of the
moon, as provided for Code, for the
DRAINS - FLOOR, ROOF. AREA, COND.
mi
work for which this peroral is issued.
FIXTURES -PER TRAP
❑Ihave and will maintain he erfos Compensation Insurance, which required by Section
me labor Code,fon thsuranc (numbame: permit is issued,
GAS -G.SYSTEM-1 INC. 40IffLEfS
OCC. GROUP
/ APtarj�
GAS - EA. SYSTEM -OVER 4(EA)
MyOof cancer and Poork
My Worker's Compensation Insurance carrier andPolicyNcy number are:
Cartier: Policy No.:
'/C ....77
GREASFIINUUSTRL WASTE INTERCEPTOR
CERTIFICATE. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(Th,,exithamedism be completed ifthe perm, is intone haddreddallars($IW)
nr less,)
GREASETRAP
PLANCHECK FEE
SEWER -SANITARY -STORM FA. 200 FT.
ENERGY FEE
I comity that in me performance ofine work for which this permit is issued, I shall
Wo employ any pawn in mymaane, so as m become subjecuo the Worker%Compen-
WATER HEATER WNENT/ELECPR
GRADING FEE
Q Z
z o
VI
F
nation Laws of C.1ifarniti. Date
Applicant
NOTICE TO APPLICANT: IL after making this Cenificate of Exemption, you should
become subject o the Winimes Com,msat ion provisions of the labor Code. you must
forthwith comply with such provisions or this permit shall M deemed revoked.
WATER SYSTEMCFREATING
WATER SERVICE
SOILS FEE
NEW RESIDENTIAL PLMB. SQ. FT.
a Q
.�1. Z
L) O
u' F
WI<ndefs
y
mF.c VJ
UZ
CONSTRUCTION LENDING AGENCY
L hereby affimadim men, iso conswetionlandin,ii,mey forthe performance of
the work for which this permit is issued (Sec. 3097, Cie U)
Lender's Name
PAID
Date Reccipt k
TOTAL:
TOTAL:
Address
BUILDING FEE
1 cmify that 1 have read this application and sm a that me above information is
correct. l agree to comply with all city and county ordinances and state laws relating to
huilding cousnalma,and herebyautherizereprewroolimsof this city to maotipmthe
QTY. MECHANICAL PERMIT FEE
SEISMIC HE
PERMIT ISSUANCE
ELECTRIC FEE
shove -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless me City of Cupertino against
PLUMBING FEE
liabilities,judgments, costs and expenses which may in any way acerae against said City
in consequence of the imaging of this permit.
ALTERORADDTOMECH.
AIR HANDLING UNI'1'(TO 10,000 CFM)
MECHANICAL FE F.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT
SOL ER GI TIO
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
�Sigdladurc I' AFluenni/Cnnraaor Date
HAZARDOUS MATERIAIS DISCLOSURE
EXHAUST HOOD OVIDUCT) -
HOUSING MITIGATION FEE
HEATING UNIT(TO 100,000 BTU)
Will the applicant or future Wilding occupant some or handle loaushos material
as defined by the Cupertino Municipal Code, Chapter 9. 12, and me Health and Safety
Code, Si 25532(ayl
IIEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RFSID)
C] Yes ❑No
PAID DamRuei # Ip
Will the applicant or future building cammot use equipment or devices which
coil haaindnos air em andiction as defined by the Bay Area Air Quality Management
BOILER -COMP (3HP OR 100,1100 BTU)
T
BOILER -COMP (OVER IOdy" BTU)
District,
❑Yes ❑Nn
AIR CONDITIONER
I have read the hazardous materials reyuiremems under Chapter 6.95 of me Cali-
ISSUANCE D�q/�`C
NEW RESIDENTIAL MECH. SQ. FT.�T
fomia Health & Safety Code. Sadat. 25505, 25533 and 25534. I ..dent. that if me
/ /
bumly have a mrmrlL mag it ix my responsibility to nmify me occupant
oftm� W.I.?,airs emsw m hot emegp' no issuance uta Certificate nl Qcupancy.
or autbodzed agent rWYA a Date
ISSUED BY:
TOTAL:
OFFICE