30676APPLICANTTO FILL IN INFORMATION WIT14IN RED LINES - DSE BALL POINT PEN ONLV -
CITY OIFCUPERTINO BUILDING -ELECTRICAL'
PERMIT NO. 30676
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
j, '
BUILDINGADDRESS: -. t,
SANITARY NO.
APPLICATION SUBMITTAL DATE
240 15-7-6
OWNERS NAME: - PHONE:
I--aA �:' TOM �..L�N./Oli�
C'O1NTRACTOR'S NAME: ,. LIC NO:
R.yU3SL. a qCz s (p�`( q
NIC
❑
CONTROL# _
CHITECT/ENGINEER; LIC NO:
ADDRESS: - -
CONTACT: - PHONE:
- - -
BUILDING PERMIT INFO
❑Consultant Fees Paidby Applicant(initial)
'BLDG ELECT PLUMB-" MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION ..
with Section]fXNI)of Division7ofthe Business and Professions Code, andmyliumse is
in full force and erf��CCt.
License C1ass c �z'0 Lw. # (o�st66PS 4
Contra
PERMIT ISSUANCE t
'
RESIDENTIAL:
❑ SEDWC El KITCHEN REMODEL
❑ADDITION (]PLUMBING RE -PIPE
[IMULTI-UNIT', ❑ STRUCTURAL
MODIFICATION
-
DENTAL
ARCHITECT'S DECLARATION ,-
1 understand my plans shall he used as public records f
-
PANELS
UPTO 2W AMPS
F1 INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT
License)Professional
DOWNER
201-1000AMPS -
-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
❑BATH REMOOEUREPAIR L1 DEMOLITION
❑ OTHER
pyER 10(IOAMPS -
SIGNS ELECTRICAL
which requires a permit m conswct, site,, improve, demolish, or repair say suuctam
SPECIAL CTRCUIT/MISC. t
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuantto the provisions of the Contractor's License Law (Chapter 9
TEMP. METER OR POLE INST.
-
COMMERCIAL:
(commencing with Section ]000) of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars
❑ I, us owner of the property, ar my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. ]044, Business
POWER DEVICES
,
[I TENANT "�PgDD SERVICE
IMPROVEMENT
[] OTHER
SWIMMING POOLELECfpk
OUTLETS —SWITCHES —FIXTUR
I
and Professions Code: The Conlmclurs License Law dues not apply 'lo an owner of
,
Property who builds or improves thereon, and who does such work himself or through
his awn employees, provided that such improvements aro not intended or offered for
sale. If, however the building or improvement is sold within one year ofcompl"mm,the
nsobuilder will have the burden of proving that he did not build or improve for put-
posenfsale.).
NEW RESIDENTIAL ELECTR IT.
SQ:FTFLOORAREA
PA
$/SQ. Fz
-
F]1, as owner of the property, am exclusively contracting with licensed contractors to
N I p
conswct the project (Sec. 7044, Business and Professions Code:) The Contmetm's Li-
OA
cense Law does not apply to an owner of property who builds or improves thereon, and
QTY. PLUMBING PERMIT
C.
who contracts for such projects with a comandri(s) licensed pursuant to the Contractor's.
License law.-
❑lam exempt under Sec.' ',B& P C for this reason
t v/
C�T,y
1
PERMIT ISSUANCE
Owner Date
ALTER — DRAIN & VENT — WATER (EA)
nun
4yyzdT�
BACK FLOW PROTECT DEVICE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
P
DRAINS— FLOOR, ROOF. AREA, COED.
I have and will maintain a Certificate of Consent m self -insure for Worker's Compen-
saner, as provided for by Section 37M of the Labor Cede, for the perfutmaace of the
for which this permit is issued.
ST6RIESW TYPE CONSTRUCTION
FIXTURES -PER TRAP
I'I have and will maintain Worker's Compensation' Insurance, as required by Section
{/
7FIs
]7011 ofthe Labor Code, for the performance ofthe work for which this Permit is issued
My Wor �Crynpen, nlnsnrance currier and Policyn ore:
Policy Ne.:
CERTIFICATEOFEXEMPIONFROMWORKERS'COMPENSATION INSURANCE
GAS— G. SYSTEM- I INC. 4 OUTLETS -
OCCGRA0WAPN
v
` up out- -
GAS—EA. SYSTEM-OVER4(EA)
GREASERNDUSTRL WASTE INTERCEPTOR
BUB.DING DIVISION FEES
(This sediun need not be completed lithe permit is for one hundred dollars (EI W)
or less.)
- 'GREASE TRAP
PLANCHECK FEE -
Ioyanyperotheanyinperformance ofthe beemnork which this perthe Wit ,ke.'C..pssued, I sll
not employ any person in any manner so as m become subject to the Workers' Compen-
SEWER—SANITARY—STORM EA. 200 FT.
ENERGY FEE
-
sation Laws of California. Date
Applicant
WATER HEATER WNENTMLEC R
GRADING FEE
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you most
WATER SYSTEI&TREATING
SOIfS FEE
forthwith comply with such provisions or this permit shall be deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY'
I hereby affirm Nat there is a conshuctiun lending agency for the performance of
NEW RESIDENTIAL PUMP. SQ. ET,
PAID
Date Receipt 4„
tho work for which this permit Is issued (Sec. 3097, Cl, CJ
Lender'sName
-
TOTAL
LGlderA
TOTAL:
-
that I have read this application and state that the above information is
I certifyrify that
BUILDING FEE
'
QTY, MECHANICAL PERMIT FEE
SEISMIC FEE
correct. I 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
PERMIT ISSUANCE"
ELECTRIC FE8
above-mentioned property for inspection purpose.. -I
(lye) agree to save, indemnify and keep harmless the City of Cupertino against
ALTER OR ADD TO MECH.
PLUMBING FEE
liabilities,judgments, costs end expenses which may in any way accrue against said City
in consequence of the granting of this permit.
AIR HANDLING UNIT (TO IO,WO CFM)
MECHANICAL FEE
f�
APPLIC T DERSTANDS•AND WILL COMPLY WITH ALL NON -POINT.
SOURCE X TIONS.'/
AIR HANDLING UNIT(OVER 10,00) CFM)
CONSTRUCTION TAX
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
raacmrDole
ARDOUS MATERIALS DISCLOSUREor
Signntur \71m)?
' HEATING UNIT OH IW,000 BTU)
future building oreapantstore or handle hazardous material
in Municipal Code, Chapter 9.12, add the Health and Safety
" -
HEATING UNIT (OVER MR" BTI])
LJ Yes - ❑No' -
LJYe
.,
PAID
1
VENTILATION FAN (SINGLE RESID)
Date Receipt#
-
BOILER— COME CHP OR 100,000 BTU),-
Will the applicant or future building occupant use equipment or devices which
,mit hazardous air contaminants as defined by the Bay Area Air Quality Management
District? I'
❑Yes' FIN.',
TOTAL:
-
BOILER — COME (OVER IWW ,BBTU7•
AIR CONDITIONERe
1 .
nous materials requirements undo Chapter 695 of th
y 1 have read the hazN Cali-
i ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. ET.
brain Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if tEc
building does not currently have a tenant, that it is my responsibility to notify the occupant
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
ISSUED BY:
`I
Owner or suthorizedager,t. Dale
OFFICE