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PPUCANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING. MECHANICAL
BUILDING. PROJECT IDENTIFICATION
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PERMIT NO,ssa O ^ O a�
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BUILDINGADDRESS:
Ove
SA TA NO.
APPLICATION SUBMI'1-JAL DATE
OWNS SNA E' PHONE:
CONTRACTOR'SNAME:� Ills LIC NO'. /
NIC
❑
CONTROI.II
\RC TECr/ENGINEER: LIC NO:
ADDRESS:
ere
CONTACT: PHONE:
BUILDING PIiRMIT INFO
BLDG ELECT PLUMB MECH
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CON'TRACTOR'S DECLARATION
I herehy of roe that 1 am licensed under pmwlaloos of Chapter 9 h,co mendng
ELECTRIC PERMIT FEE
JOB DESCRIPTION
RMIT ISSUANCE
with Section 70301uf Division 3of the Busirmalod Pmfcssioms Code, and my license is
in full force and effect 6 6? /
J License Qluy Liap
Data ion Contractor
j ARCHITECTS DECLARATION-
1 understand my plans shall he over! as public records
R SIFF�IS'
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING R&PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
❑ BATH REMODEUREPAIR ❑DEMOLITION
❑ OTHE
PLIANCES-RFSIDE"AL
NELS
'ro 2IXIAMPS
1201-1000AMPS
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am cseapt from the Conlmcmrs License Law for the
1 fallowing museum. (Section 7031.5, Business and Professions Code: Any city or county
ER 10110 AMPS
SIGNS ELECTRICAL
j which textiles it permit to construct, alter, improve, demolish, or repair any structure
poorm it, issuance, aksorequirea Ne applicant for such pc—ince file o signed statement
that he is licensed pursuant In the pfovtsions of the Comlmetor'r License Law (Chapter 9
SPECIAL CIRCWT/MISC.
tr
COMMERCIAL:
(commencing with Section 7") of Division 3 of the Business and Professions Code)or
that he is exempt therefrom tied the hasis for the alleged exemption. Any violation of
Section 7031.5 by any epplilmal fora peril subjects the lipplicnal-to a civil penalty of
TEMP. METER OR POLE INST.
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑'TENANT ❑ FOOD SERVICE
POWER DEVICES
not more Nan live hundred dollars (8303).
01, as owner ofthe property, or my employees with wages as their sale compensation.
will do the work, and the structure ismaccorded clattered forsale (Sec. 7044. Business
and Professions Code: The Contractors License Law does not apply to an owner of
IMPROVEMENT
❑OTHER
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECfR SQ Irl'.
preparty who builds or improves Increase, vat who docs such work himself or through
his own employees, Provided that sun improvements are not intended or offered for
Is
sale. If,however, the building at improvement is sold ithin one year of completion,
. FT OOR ARBA
LSQ. I1'.
owner -builder will have the burden of proving that he did not build at improve far par.
pox a so)ed.
d mountains
❑ 1, as owner of the property, am exclusively contracting with licenumountmountainsm
c t the project (Sec. 7044, Business ..it Professions Cade) The Commercial's Li-
censoLaw does not 1pplym an owner of prapany who builds or improw,damm. and
S -
f r/
fp
TOTAL:
QTY. PLUMBING PERMIT FEE
who emeracls for such projects with a conbuctims) licensed proconsul the Gmmucrors
License law.
❑ 1 am exempt under Sec. , B & PC Tennis reason
PERMIT ISSUANCE Q
ALTER -DRAIN & VENT -WATER (IiA7
VALUATION
Data
Owner
WORKERS COMPENSATION DECLARATION
BACK PLOW PROTECT. DEVICE.
I nand w ill mai under penalty to perjury one of the followingor Worker s Cor
(have and will mainlnina Certificate of Consenttofor Worker's Ccmpen-
DRAINS -FLOOR, ROOF, ARE A.COND,
STORIES
'1'YI'E CONS'fRl1CTlOt
action, as provided for by Section 37M of toe Labor Cade, for the tied announce of the
work for which Nis permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as requireal by Section
3700afaoelabm Ceell the pact—ante of Ne .,it for whichthis Peril is issued
OCOGROUP
APN
FIXTURES -PER TRAP O
GAS - EA. SYSTEM -I INC, 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (CA)
My Worker's ora rami Insure a cwricr tied Policy n T g
Carver. Policy NO.:
CERTIFICATE OF EXEMPTION FROM WO KER'
COMPENSATION INSURANCE
GREASF/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE TRAP
PLANCHECK FEE
F:NF.RGY TEF.
(This section aced not becompleed ifthe Permit is Talar hundreddollse,(SIIX))
err less.)
I modify that in the performl of the work for which this Permit is issued, I shall
not employ any person in any owner so as to become subject m the Workers' Co.,.-
SEWER - SANITARY - STORM EA. 200 FT.
WATER HEATER WNENTMLE.CI'R
—WATER
L saian laws of California. Date
O Applicant 1
GRADING FEE
N NLY CII TO APPLICANT: If, after making this Cer ificale of Exemption, you should
became subject to the Womes Compensation Provisions of the Labor Cade, you must
ry forthwilhcamply with such provisions or this pe -it shell he deemed rcvokeJ.
SYS'TEM/fREATINO
SOILS IEE
WATER SERVICE KJI 30
7PAID
z CONSTRUCTION LENDING AGENCY
Q (hereby alfa- that nem is a contraction lending agency for the Pcrfo—ante of
. the work for which this permit is Issued (Sec. 3097, Civ. C.7
Dam ceeipt k
NEW RESIDENTIAL PLMB, SQ. FI'.
TOTAL:
TOL
Lender's Name
U Larder's Address
information
BUILDING FEE
1 certify IIIat I hove read this application and saute Na the above is
casrccL lvgrecmcompI withal) city and county ordinances and slam laws relating to
huildiagccrsmueian,and hereby aathodic lcptesentatives of Nis city to enter upon ane
QTY MECHANICAL PERMIT PEA 1
SEISMIC FEE
above-mentioned pmpeny, for inspection purposes.
(We) agree to sue, indemnify and keep harmless the City of Cupertino against
liabilities ,informal, .,isand expenses which may in any way came nfforatsaid City
I. consequence of the gr ting oImes pe—it.
APPLICANT EI LANDS D WILL COMPLY WITH ALL NON -POINT
OURCE AT NS.
3Q
,(g D
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
CIEIi
MG FEE O
AIR HANDLING UNIT (TO 11,1X10 CFM) (`
MEgj0(CAL LEE
AIR HANDLING UNIT(OVER 10,000 CFM7
CONSTRUCTION TAX
EXHAUST FLOOD (W/DUC J
HOUSING MITIGATION FEE
Sigtor co pPl an✓Cot ctor Dam
na
HAZARDOUS MA RIALS DISCLOSURE
Will the applicant or future building occupant more or handle haaardous mntenal
HEATING UNIT G70 100,1010 B' I' U)
s defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
Code, Section 25532LJU
HEATING UNIT (OVER 110,000 BTU)
VENTILATION PAN (SINGLE RESID)
❑Yes ON.
PAID Q
Dae Receipt%
BOILER -COMP (3HPOR 100,00011TU)
Will the applicant or future building occupant use equipineat or devices which
mit hazxrdons air contaminants as defined by the Bay Area Air Quality Management
TO A
BOILER -COMP (OVER 100,000 BTU)
District?
❑Yes []No
AIR CONDITIONER
ISSUANCE DATE
fi
I have read the huradcasnuterialsrexuiremenLs under Chapter 6.95 of the Cali-
Tadd. Haahh sk fiery ado, Sc ions 25505, 25533 tied 25SJ4. I undersand that if We
NEW RESIDENTIAL MECH. SQ. PT.
building doe. tlyhmnant,ahati ismyresponsibiliryln motif the occupant
u
10 0
of there tic me ssuance, ofa Cenificat o cy.
ISSUED PY: `^ �� '2
TOTAL:
Game recd.gentDbor
OFFICE