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CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONMERMIT PLUMBING - MECHANICAL
BUILDING PROJECTF IDENTIFICATION
1'E IT NO
1393
BUILDINGADDRFSS:
21 &J5_0 CAO wM8Vs A Leff CVp�RTtNDI0tN 1(4
SANITARY NO
APPLICA'1'IONSURMITTACDA'IE
PHONF.�L_ / O
O ER'S NAMF:�4T�
I:45
COM'RAC'f 'rig
r�
12
N/C
CORI ROT.
7 L /�Lv
_ kgO 7 1
H 7
❑
A CHITEC'UENGINFER: LIC NO
A 4RFI �. JC
Yto it orc< (r�1470,6
9 7✓ i L
CONTACT: 0 kJ PJ PHONE: `
J
5 0 �./ 2es i 260
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB ME❑CH
L�
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm mm 1 am licensed under provisions of Chapter 9 (commencing
with Seetimn70%fcfDiv lsinn3 ormp Bminessand Pmfeanionc Codo,andmy license is
in full force and effect.
License Class Lia.#
Date comma.,
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL;
❑SFOWL [_1 KITCHEN REMODEL
❑ADDITION �LUMBING RE -PIPE
❑MULTIUNIT ❑STRUCTURAL
CHIMNEY RE N
El INTERIOR ❑CHIMNIiY REPAIR
IMPROVEMENT 0SWIMMING POOLS
PHRMI'f ISSUANCE
APPLIANCES - RESIDENTIAL.
ARCHITECTS DECLARATION
I understand my plans shall W used as public recoNs -
PANELS
UP T02fN1AMPS
Licensed Professional
201-10MAMPS
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contmcons License Law for the
l following resod. (Section 7031.5. Business and Professions Cada Any city or county
which requires a Perini[ to constmet, alter, improve, demolish, or repair any structure
ipflkamu, isnmmcc.alanrequires[heupplicum fnrsueb perm,in file asignedsmi,mem
tbm he is licensed purwam m he prio,,k m of lire Contractor's License Law (Chapet 9
(commencing with Sttlinn]0W1of Division 3 clue Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Scdino7031.5 by anyappllcan[for a permit subjects the applicant la a civil penalty n(
n I mom [bun live hundred data, ($5M).
I, m owner of the property, or my employees with wages as their sole compensation,
will do the wok,md thesaucmre isnot imrmaximolTertd f sidelSm.70,W.Businesz
BATH REMO ?IJREPAIR ❑DEMOLI ON
RF
OTIILR A
R
IM ,A V
OVER HNID AMPS
SIGNS ELFC75ICAL
SPECIALCIRCOHUMISC.
TUMP. MUTER OR POLE INST.
COMMERCIAL:
0NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
and Professions Cede: The Contractor's Liccow law does no[ apply to an owner of
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELF.C: R SQ FT
property who huilds or improves thereon. and who does such work himself or momgh
his nun empinyms, Presided ma[ such imprncameras arc not intended nr offered for
sale. If, hmvevev me building or impravemem ismld within one year of complain., the
SQ. FT. FLDOR#RFA
LSQ. !'T.
comes -budder will have the burden of placing that he did not build or improve for put.
ener of the property, am exclusively contracting with licensed contractorsm
P p I D
A
TOTAL:
msvnm me Project (Sec. 7044, Business and Professions Gde:) The Comm arses Li-
w Law Joie no[apply [o an nwnernfpropeny who builds or improves thereon, and
n
B�Ae 9={ AIM41
QTY PLU rPERMIT RLE
"a...mcu orsoca pr teats wanawnwe[orcs)bcensw nursawnemucomrttmor's
I��RR wlv MIW O
PERMIT ISSUA E
License Law.
lion in rSec. .R&PCRvthis u
CITY I 11-11-r
ALTER—BRAIN — A (EA)
VALUATION
net Dalefie
BACK FLOW PR(HEG . - li
W( 1MPENS1A'1/ 07 DECLARATION
I hereby a(liror t� �Jer lrenally of per)yfy one of me following Jedam[ions:
STORIED
TYPI3 CONSTRUCTION
❑ Ihaveand will main ( a Certificate of Consent toself-inaure for Workers Comped-
mlinn, as Provided far by Section 37W of the Letum Cede, far the . e ....mance of the
work for which this permit is issued.
DRAINS— FLOOR, ROOF• AR.A
FIXTURES — PER TRAP
❑ 1 have and will maintain Workeex Compensation Insurance, as required by Selina
30W of the Labor Code,forthe performance of the work for which this pemri[is issued.
OCC. GROUP
wPN
GAS— RA. SYS TEM (INCA OUTLETS
GAS — GA. SYSTEM OVER 4(17A)
My Workers Compensation Insurance canner and Policy number arc:
Career: Policy No.:
GREASFIINDUSTRL WASTE INTERCEPTOR
CERTIFICATE. OI' EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(This section decd not he completed if the permit is for one hundreddoltars(SIM)
nr IcssJ
GREASETRAP
PLANCfiECK FEE
SEWHR—SANITARY—STORM EA, 20) P1'.
ENERGY FEE
I acidly mal in the perfammacof the walk for whlehmispeunit l.s issued,(shall
[o become subject to the Workers' Compen-
not employ any person in any manner so as eco
WATER HEATER WNENT/ELECTR
GRADING FEE
' talion Laws of California. Date
Applicant
j NOTICE TO APPLICANT IL after making this Cerincmn of Exemption, you should
' become subject the Workers Compensation provisions of the Labor Cede, you must
WATER SYSTEM?REM IND
SOILS FEE
forthwith comply with such provisions or this Permit shall W deemed revoked.
WATER SERVICE
' CONSTRUCTION LENDING A017NCY
Ihm,by affirm that there is a concuuctinn lendiagegency fonhc parmmaneeof
he work far which this permit is issued (Sec. 3097. Civ. C.1
Lender's Nunn
PAID
Rec tpt
Date xx
NEW RESIDENTIAL PLMB. SQ. TE.
OT
qu 'X000NSn=OTAX
'I OTAL'
Lenders Address
PGIi
I cenify ma[ 1 have read this application unit style fl m the vNice information is
correct. I agree to comply with all city and county ordinances and state laws mining to
building conswc[inn. and hereby authorize representatives of this city to enter upon the
alcove-nnmioned p,,,,,ty far inapenion purpascx.
(We) agree to save, indemnify and keep ham less the City or Cupertino against
QTY. MECHANICAL PERMIT FEE
PERMIT' ISSUANCE
EG
rill
EE
liabililicsjudgments. costs and expenses which may in anyway zccmeagainslmid City
in asequence of the granting of this permit.
ALTER OR ADD TO MECH.
PIR HANDLING UNI '1'(TO III,INN)CFM)
A ITE
APPLICANT UND17RSTANDS AND WILT. COMPLY WITH ALI, NUN -POINT
SOURCE EGULATI NS.
%� 1.3 9d
AIR HANDLING UNIT (OVER 10." CFM)
IIO TAXAppllen
'evil ate
5Xt{AUS'! HOOD (WIDUCP)
ITIG ION FET?
HA 'MATERIAL' ISCLOSURF
Win heapplican[ r future butoccupant store or handle harutdous mncrial
HFA'I'INO UNIT(TU IW,tNNl B9'I1)
as defined by the Cupeni o Municipal Code, Chapter Y.12, and the Health and Salary
Code, Seaham 25532(m?
HEATING UNIT (OVER 1011.01X0 B'I'U)
VENTILATION JANISINGLERESID)
❑Yes ❑No
PAID
Date Receipt#
Will the applicant or future building occupant use equipment or devices which
inax as defined by the Bay Area Air Quality Management
it air cnmamm
emhazardous
BOILER—COMP (3HP OR 100,10) PTU)
TOTAL:
Otstncfl
❑Yes ON.
BOILER —COMP (OVER IfN41NN) BTU)
AIR CONDITIONER
ISSUANCE DATE
I have read the hurardoux materials reppomats under Chapter 6.95 of the Cali-
NEW RGSIDENTIAL MSCIL SQ. FT.
crsnd that if the
manila Health & Safety Code, Sections 255115, 25533 and 25534. 1 undm
building docs act currently have a tenant, that it is my mspensibility to madly me occupant
of me requirements which must he met prior to issuance of a Cenname of Occupapry.
ISSUED BY:
I TOTAL:
Owner or audida red agent Date
OFFICE