30662aO
C
kPPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO , BUILDING -ELECTRICAL.
BUILDING DIVISION APPLICATIOWPERMIT PLUMBING - MECHANICAL
CONTACT:
PHONE:
NAME:
LIC
❑ Consultant Fees Paid by Applicant (Initial)
_ = Z 1 heaby affirm Nm 1 am licensed under pmvisions of Chapter 9 (co==ming
;�' Op with Section]IKK) of Division 3 offs, Business and Professions Cade, and my license is
in full rase and ellen.
UF License Class Lie. k
GDam Contractor
I.ARCH] TECTS DECLARATION
p � Z4 1 understand my plans shall M ..itm public retards
Z
4 � C Licensed Professional
Y OWNER -BUILDER DECLARATION
WN 1 hereby affum that 1 am exempt from the Commm
cr's License Law for the
3 6 444V... following reason. (Section 7031.5, Business and Professions Code: Any city or caumy
= y which requires a permit m consumer, alter, improve, demolish, or repair any stmcwm
sprior to its issuance, also requires Nnniuo file e applicant for such pea signal statement
} shot he is licensed pcommumte provisions of the Contractors license Low (Chapter 9
apo (cammencing wit Section 7")of Division 3 of to Business and Profacsions Code)or
y that he is exempt therefrom and the basin for to alleged exemption. Any violation of
4X1.. m Section ]031.5 by any applicant ter a permit mbjxts the applicant m a civil penalty of
1„ not mom than Eve hundred dollars ($50T.
p I, as owner ofthe property, or my employees with wages as their sole compensadon.
will do the work, and the stmcome is not intended orolTcred for sale (Sec. ]OLI, Business
and Professions Code: The Counselors Litems law does not apply to on owner of
a" 3 properly who builds or improves Lemon, and who does such work himself or trough
his own employees, provided that such improvements are nal intended or offered for
sale. If however, the building or improvenfent n sold within one year of completion, the
ownerbuilder will have the burden of pmving That he did not build or improve for per-
' you of side.).
❑ 1, as owner aide property, am exclusively contracting wit licensed contmemrs to
compact the project (Sec. 7044, Business and Professions Cada:) The Cnntrannr's Li-
tter¢ Law does not apply to an owner ofpmperty who builds in improves thereon,and QTY.
who compacts for such projects wit ao ntract r(&) licensed pursuant to the Contractors
License Law.
❑lam axe funder Sec. ,B& P C for this reason
Owner Dace —
WORKE COMPENSATIOND rLARATION
I hereby affirm under penalty of perjury one d dm following dedamdons:
[ have and us IT maintain a Certifcae of Co xzat to self-insum for Workers Compete-
' section, as provided for by Section 3700 of the Labor Cole, for the perfo.,a of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which his pemtit is issued.
My Warkcrn Compensation Insurance carrier pad Policy number a2:
Comer: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section mad ant be, completed if the pemdt is for one hundred dal lass (S)00)
or less.)
1 certify, that in the performance office work for which this permit is issued, I shall
oat employ any person in any manner so as,, rernme subject lo The WalletsCompen-
O ration Laws of California. Data '
Applicant
NOTICE TO APPLICANT. IL atter making This CerOffcam of Exemption, you should
f'n become subject to the Workers Compensation provisions of the Labor Code, you must
WfoMwith comply with such provisions or this permit shall be deemed revoked.
Q
CONSTRUCTION LENDING AGENCY
V 0 I hereby which
that Nero issued( (See
loo lending agency for to performance of
(1r U the work for which this permit is issued (Sec. JtN], Civ, CJ
Q V Lenders Name _
W Lender's Address
1 certify that 1 have read Nix
application and stale and the above information is
V) correct, l agree m comply with all city and county ordinances and state laws relating m QTY
V Z building consumnion, end hereby euthodu repreunmtives of tis city reenter upon rhe
uhuve-mentioned property for inspection purposes.
(We) agree m rave: indemnify end keep hurmleas to City of CUMrllm against
liabilities, judgments, costs and expenses
m
which may in any way ace against said City
in masequence of to granting of this Famous,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
HAZARDOUS MATERIALS DISCLOSURE
Will do applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
Cade, Section 25532(0?
❑Yes ON.
L1 Will the applicant or future building occupant use equipment or devices which
h.as,ons air commitm ms as defined by the Bay Area Air Quality Management
District?
❑Yes Fl No
1 have read the hasalloue materiels requirement under Chapter 6.95 of the Cali -
made Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that if the
holding does not wmmdy have a tenant, that it is my responsibility u many to occupant
of to requirements which must be mel prior to Issuance of a Certifirnm of Occupancy.
ELECTRIC PERMIT I FEE
PERMIT ISSUANCE
APPLIANCES- RESIDENTIAL
PANIi1S
UP TO 20E AMPS
OVER 1000AMPS
SIGNS ELECTRICAL
TEMP. MER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLET S - S W ITC I1E5 -FIXTURES
NEW RESIDENTIAL ELECTR SQ Ff.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER- DRAIN & VENT- WATER IEA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF. AREA, CONI.
FIXTURES - PER TRAP
GAS -EA. SYSTEM -1 INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EAT
GREASMNDUSIRL WASTE INTERCEPTOR
GREASCU AP
SEWER -SANITARY-STORM RA. 200 FT.
WATER HEATER W/VENDELECUt
WATER SYSTEM /TREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. ET.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO I0,001) CEM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(WIDUCP)
HEATING UNIT (TO 1110,000 BTU)
HEATING UNIT(OVER EXT" BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (JHP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. ET.
OFFICE
JOB DESCRIPTION -
SANITARY NO.
APPLICATIC
❑ADDITIONajar
0 PLUMBING REPIPE
❑MULTI -UNIT
NIC
SEISMIC FEE
CON'
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
BUILDING PERMIT
BLOC
ELECT MEN
❑
❑ ❑
JOB DESCRIPTION -
W1.
I
/, O KITCHEN REMODEL
❑ADDITIONajar
0 PLUMBING REPIPE
❑MULTI -UNIT
IJ ❑STRUCRAL
N
SEISMIC FEE
' MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
❑BOTH REMODEUREPAIR [I DEMOLITION
COMMERCIAL:
❑NEWBLECIADDITION 0DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ. ET. R#R eRF, D LSQ. Pf.
DEC 113199
SII Y Lor uurrn111
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
raw
Dam Receipt#
TOTAL:
BUILDING FEE
FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt#
TOTAL:
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PENONLY
CITY OF CUPERTINO 'BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PING PROJECTBING - IDENTIFICATION
BUILUINT: PROJECT IDENTIFICATION
PERMIT NO. A
'2 y83IVB8
-
JIPILDD�INGAADDRESS
SANITARY NO.
DA
APPLICATION SUBMITTAL TE
(�
• 4 4 y
.03 V V UNIT# LOTH
I ^—k-.��
l
N S NAME: PHONE:
CO ACTOR'SjjVAME: a LIC NO:
V-bYL C
NIC
❑
CONTROL#
ARCHITECT/ENGINEER: LION
ADDRESS:
CONTACT: PHONE:
QTY, ELECTRIC PERMIT AEE
BUILDING PERMIT INFO
LDG EPLUMB MECH
❑ ❑
PERMIT ISSUANCE
1
LICENSED CONTRACTOR'S DECLARATION
Thereby of Division 3 ofthnsedinss =it rifesio Chapter and mmecense wish
f Division 3 of the Business and Professions Code. and my license is in
Section '/(10ud
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
pgrygfS
full e
effen'
Clas
License Class
License
UPT0200AMPS
-
Dam Connote
Conn
- 1000 AMPS
D
ARCHITECYSDECLARATION
1 undenwnd my plans shall be used as public records.
SQ. FT. FLOOR AREA
S/SQ. PT.
OVER I000AMPS
OVER
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm that 1 an exempt from the Co License Lues for the
following massa. (Batton m3 L5, Business and cions Co
Code: Any city or county
TEMP. METER OR PoLE INST.
which requires permit reconstruct, alter, improve, demolish,
improve, demolish, repair any structure
- -
n cs he ch file signed statement
POWER DEVICES
in.hoits s]fee.aacdolso imat,, Copermm's Lice
the provisions of the thentmemrs and Poe Law (Chapter
the p.. Want of the
font he is ncing w th Section
9(commencing with Section 1000)of Division 3of the Business and Professions Code)
SWIMMING POOL ELECTRIC
- VALUATION
or that he is exempt herefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicantto a civil penalty of
OUTLETS - SWITCHES - FIXTURES
not room than five hundred dollars ($500).
❑ I,asownerofthe property, ormyemployeeswithwegesestheirsolecompensauon.
NEW RESIDENTIALELECB_SQ, FT.
- STORIES
TYPE CONSTRUCTION
will dothe work, andfi esnncture is not intended proffered forsale (Sec. 70,14, Business
and Professions Code: The Contractors License Law docs not apply to an owner of
property whobuilds.r improves thereon, and whodoessuchwork himselfmthroughhis
ownemployees, providedthat such improvements stent intendedorofferedforsale. If,
OCC GROUP
REB. UNITS
however, the building or improvement is sold within one year of completion, the owner-
"
builder will have the burden of proving that he did not build or improve for purpose of
ale.}
❑ I, as ownerof the property, am exclusivelyconnecting with licensedmmrnetors to
QTY. - PLUMBING PERMIT PEE
FLOOD ZONE
APN ,.
consumer the project (Se.. 7044, Business and Professions Code:) The Contractor's
License Law does not apply to on owner of property who builds mintprovesthereon.and
PERMIT ISSUANCE
who contracts forsuch projects with a communal licensed paramount re the Contractor's
License Law.
ALTER-DRAIN&VENT-WAT (EA
FEE SUMMARY
❑ 1 am exempt under Sec. , B & P C for this reason
gpCK FLOW PROTECf.OEVIC
OUTBID FEES
SANITARY Y N
RECEIPT N
Owner Date
DRAINS - FLOOR, RUDE, ARE D,
WORKMAN COMPENSATION DECLARATION
❑ Ihereby affirm that l have a certifieam ofconseat m self -insure, or a oertifieate of
Workers'Compenmtion Insurance or a certified copy thereof (Sec. 3801, Lab C.) which
,.vera all employee's under this permit. '
Policy is
SCHOOLTAX Y N
RECEIPTN
FIXTURES - PER TRAP
PARK FEE Y N
RCCEIPT #
GAS - EA. SYSTEM -I INC. 4 0UTLF.T
\
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
MANCI IECK FEE
❑ Certified copy Is hereby broached.
GREASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
This section need not be completed if the permit is for one hundred dollen 011 W)
or less.)
WATER HEATER WNENT/BLECTR
I cenifytbct inthe performance ofth, work for whichthis permit is issued, l shall
not employ any person in any, manner so as to become subject re the Workers'
PAID
WATER SYSTEMTREATING
Compensation Laws of Califomia. Date
Dam Receipt If
Applicant -
NOTICETOAPPLICANT:If,aRer making this Certificate ofexemption, you should
NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE 11�es"
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I herehy.M. that there iso construction lending agency births performance of
the work for which this permit is issued (Sec, 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
`
QTY. �' MECHANICAL PERMIT FEE
PLUMBING FEE
Lenders Name
Lender's Address
I ceflify that I have read this application and e,am that the above information is
correct. l agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
buildingconstruction, and hereby authorize representatives ofthis city to enter upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCDONTAX
(We) agree m Bove, indemnify and keep hornless the City of Cupertino against
liabilities,judgments, costs andexpenses which may in any way accrue against said City
AIR HANDLING UNIT(TO IOJXq CFM)
AIR HANDLING UNIT (OVER IO,WOCFM)
in emoSili at, he granting of this permit.
Signamrs of A,IiexrVCmumc;p1 Data
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt it
HEATING UNIT (OVER 100,000 BTU)
TOTAL
Will the applicant or future boilding occupant score or handle hamrdous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
VENTILATION PAN (SINGLE RESID)
Code, Section 25532(a)P
❑ Yes ❑ No
ISSUANCE DATE
Will theepplicaatorfumre buildingoccupaat useequipmenmrdevices whichemit
hazardous an contaminants as defined by the Bay Area Air Quality Management
�. District?
BOILER - COMP (3HP OR 100,000 BTU)
PA
e
BOILER - COMP(OVER 100.000 BTU)
NEW RESIDENTIAL MECH. SQ. FT.
❑ yes ❑ No
t
J
1 have read the hazardous materials requirements under Chapter 6.95 of the
I understand thin
California Health & Safety Code, Sections 25505, 25533 and responsibility
et it my responsibility tonaify the
occupanthe tof gdoes not cents which have a
occupant of the rcgoirememe which must be met prior to issuance of a Certificate of
Occupancy,
/412
1i
ISSUED BY:
Owner s emhorized agent Date
TOTAL:
OFFICE