S 0031' (As
a
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PE"IT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO
BUILDING ADDRESS:
I 03 Co r
SANITARY NO.
AP PLICATION SUBMITTAL DATE
•L-7 4
OWNER'S AM PHO E:
CO RALT R'SNAMF' LIC NO:
NIC
CONTROL#
Hky,
El701546
ARCHITE T/ENGINEER. LIC NO:m I
0 G
ADDRESS
SS f F
f
CONTACT: PHONE:
BUILDING PERMIT INFO '
n J$p-7m--4%
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
KW e—
❑ ❑ ❑
LICENSED CONTRACTOR
code, S DECLARATION
1 hereby affirm that 1 em licensed ander provisions of Chapter 9 (commencing
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE
with Section 70(10) of Division 3 0r' the Businese mad Professions Code, and my license isIDFN
in full foreevad
toe U
eC s
DateContractor
UAL;
CSFDWL C KITCHEN REMODEL
[I ADDITION El PLUMBING RE -PIPE
❑MULTI-UNTf ❑STRUCTURAL .
MODIFICATION
APPLIANCES -RESIDENTIAL
ARCHITECTS pECLA ION
1 undersmnd my plansshall be usedmpubii cords
PANELS
I
UP T0200AMP5
❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional
201-1000 AMPS
IMPROVEMENT ❑ SWIMMING POOLS
OWNER-BUILDERexemptmDECLARATION
I hereby maso aBirtn that 1 am exempt from the Conmestmeme License Law far the
following reason.
9onstr Business and Professions Cade: Any city or county
❑BATH REMODEL PAIR CDF.MOLITION
u�/%AXl
; wH%
OVER 1000 AMPS
SIGNS ELECTRICAL
permit alter, improve, demolish, or repair any shvdar)
which requires a permit la mon:the
r 1
SPECIAL CIRCUIT/MISC. '
o posdawropper
evisionofcion for such Contrarmrs License Law(Chaptr9
that hesliensed prsant tote previsions
that hats licensed pursuant 70th) of Diskirsof the the Business
License Law(Chode)or
rom an )of basis for of the al eged ra cept Pmfeme i Codepsr
that he is ixempwith thSection
that is exempt therefrom and the basic for the tl exemption. Any of
TEMP. METER OR POLE INST.
COMMERCIAL '
C NEW BLDG/ADDITION C DEMOLITION
POWER DEVICES
it penalty
io for a X500) it subjects the npplicantmacis il penahy of
subjects th
Section 9031.5 by any hundred
not more Nan five hundred dollars ($SOB).
' C1, as 0wner0f Ne propeny, or my employees with wages vs their solec0mpensmion,
do the work, and the structure is not Intended or oBered for sale (Sec. 9044, Business
❑TENANT [_1 FOOD SERVICE
IMPROVEMENT
[-]OTHER .
SWIMMING POOL ELECTRIC
and Professions Cade: The Compactors License Low does or apply to im owner of
OUTLETS - SWITCHES - FIXTURES
property who builds or improves thereon, and who does such work himself of through
Icn
'
his own employees, provided that such improvements are not intended or offered for
however, the building or improvement is sold within e year ofromplelion,the
sale. IL on
NEW RESID17WIAL ELECfR SQ PT.
SQ. PT. FLOOR AREA
$/SQ. FT.
owner -builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
P
,
C I, as owner of the propeny, sun exclusively contracting with licensed contractors to
4
consumer the project (Sec 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to son owner of propeny who builds or improves thereon, and
QTY, PLUMBING PERMIT FEE
hoatmate forsuch projects w4h.corracor(s)licensed pursuant to rho Cantmmors
w0n
License Law. -
1 am exempt under Sec. , B & P C for this reason
�1I��
C�� Y
PERMIT ISSUANCE
ALTER- DRAIN & VENT -WATER (EA)
BACK FLOW PROTECT. DEVICE
Owner Dale
ATION
,fOnARATION
t�V
WORKER'S COMPENSATION DECL
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Couper-
cation, as provided for by Section 370H0 of the Labor Code, for the performance of the
DRAINS- FLOOR, ROUP. AREA, COND.
STORIES
TYPE CONSTRUCTION
work for which his permit is issued.
FIXTURES -PER TRAP
1 have and will maintain Worker's Compensation Insurance, as required by Section
37M of the Labor Code, for the performance of the work for which this permit is issued.
GAS - EA. SYSTEM -I INC, 4 OUTLETS
OCC. GROUP
APN
My Wnr pensatmawrsarance ?and Policy a
Carrien��ION NO:-
GAS -EA. SYSTEM -OVER 41EA)
GREASE/INDUSTRL WASTE INTERCEPTOR
EXEMPTION WOkKERS'
CF. TI C COMPENSATION
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(This section need not b, completed ifthe Permit is for ne hundred dollars ($100)
or less) (This
-
PLANCHECK FEE
I reality his in the rierm of the work for which this Permit is issued, l shall
maemployany rsonitanymannerspps�kg�rr¢ subject to the Workers'Compen-
SEWER - SANITARY - STORM EA. 200 ET.
ENERGY FEE
WATER HEATER WNENTIELECTR
GRADING FEE
saber Laws of y(mmi Date e.-11 /Mf/
Applicant
NOTICE TOJAL ICA T: IL a t making this Certificate of Exemptlom you should
bedsore subJ the Workers C n encadon provisions of the Lahnr Code, you must
WATER SYSTEM?REATING
SOILS PEE
forthwithwwith such Trevi or this permhsholl be deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the Performance of
NEW RESIDENTIAL PLMB. SQ, FT.
PAID
Dete ReceiptN
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
TOTAL:
TOTAL
Lender's Address
Is
BUILDING PEE
1 certify that I have read this application and state that the name information
corer, l agree to comply with all city and county ordinances and state laws relating to
building consbactiam and hereby authorize repmseatmives of this city to care, open the
QTY. MECHANICAL PERMIT FEE
SEISMIC PBB
PERMIT ISSUANCE
ELECTRIC FEE
t mance-mentiooed property for inspection purposes.
(We) agree m save, indemnify and keep harmless me City of Cupertino against
ALTER OR ADD TO MECH.
PLUMBING FEE
liabilities, judgments, costs and expenses which may in any way)cane against said City
inconsequence of the granting of this permit.
AIR HANDLING UNIT (TO 10.001 CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS. •
AIR HANDLING UNIT (OVER 10.0000 CFM)
CONSTRUCTION TAX -
Sigaatmreor ApplicaapCmdractor Date
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT CTO 100,000 B' 1' U)
Will the appli..,a, future huilding ssccup., sparser handle hmardnus material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
[I Yes El No
PAID -
pate Receipt9
BOILER - COMP (3HP OR 100,(NN)BTU)
Will the air cont applicant or future building y the B use equipment or Ma as which
Lear hmzard0us air contaminants as defined by the Bay Area Air Quality Management
_
TOTAL:
BOILER -COMP (OVER 100,000 BTU)
DinbimP
L-] Yes F-1 No
'
AIR CONDITIONER
I h tce rend he bamrdons tastednls requirements under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FE
fomia Health & Safety Code. Sections 25505. 25533 and 25534, 1 understand that if Ne,
building does not correctly have a tenant, that it is my mspmsibility to notify the occupant
of Ne requirements which must be met prior o issuance of a Certificate of Occupanry.
ISSUED BY:
TOTAL'
Ownerofauthnriud agent Dam
OFFICE