S 1702I11120I ICANT Ifn FII I IN INFfTRMATIfTN WITHIN RFO 1-1NES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDwc- ELECT 'RICA],
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. -MECHANICAL
- BUILDING PROJECT IDb1N'TIFICA'FION
PENT NO. q �o^
1 L
BUILDING ADDRESS:
c 6 It
SANITARY NO.
APPLICATION SDtlMI'ITAL DATE
�(? `til
OWNER'I NAME: PHONE:
ARCHI'1"ECr/ENGINEER: JD LL LIC NO:
COMA ORS NAME: LIC NO',
ADDItFSS. ^ 16// l vC
S dill //T/
NIC
❑
COMROLM
[/
CON ACT: PHONE:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
[v ❑ ❑ ❑
re s X397 Asia
❑ Consultant Fees Paid by Applicant (Initial)
QTY ELECTRIC PERMIT FEE
LICENSED CONTRAC E R'S DECLARATION
I hereby affirm that 1 ant licensed under previsions of chapter 9 (commencing
with Section 7000) of Division 3 ofthe Business and professions Code. and my acenmka
with
in full foreeand effece_a 9 ,390359
License Cls Lic.M
Date Z�A—Contrnemr
JOB DESCRIPTION
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑ PLUMBING R&PIPE
❑ MULTI -UNIT ❑STRUCTURAL
Mt7j11FICATION
[I INTERIOR IMNEY REPAIk
IMPROVEMENT ❑SWIMMING POOLS
[I BATH REMODF,IIREPAIR [D DEMOLITION
❑OTHER
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECTS DECLARATION
I mulcrmand mm y,lashall be used as public rearmds
PANELS
UPT0200AMPS
Licensed Professional
OWNER -BUILDER DECLARATIONOVER
1 hereby affirm that I am exempt from the Contractors Licence Law for the
following reason.(Section 7031.5, Business and Professions Code: Any city or county
201-1000AMPS
11NX1AMI'S
SIGNS ELECTRICAL
which requires a permit to construct, alter, improve, demolish, or repair any swcmm
prior to its issuance, also requitry the applicant for such .at to file asigncdslate vol
that he is licensed pursuant to the provisions ofthe Contmcmrs License Law (Chapter 9
j (commencing with Section 7000) of Division 3 ofthe Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
SPECIAL CIRCUIT/MISC.
TEMR METER OR POLE INST.
E
:W BLIXi/ADDITION E3 DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty or
of more than five hundred dollars (S500ap
❑ I, as owner ofthe property, or my employees with wages as their sole compensation,
ale (Set. Business
cture is not ended mottered for hW
will do the work, and the stmint
POWER DEVICES
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
OTHER
SWIMMING POOL ELEC R
and Professions Code: The Contractors 1-icense Law does not apply to an owner Of
OUT 'LIDS - SWITCHES -F
pmpcny who builds or impmvcs therein, end who does such work 1 —1. or through
his own employees, provided that such improvements are not intended or offered for
sale.If. howevcn the buildin,aurprovement issold withinanc year ofmmplmion,the
NEW RESIDENTIAL ELECTR Fr.
SQ. Fr. FLOOR AREA
VSQ. FT.
W
wnerhuilder will have the burden of proving that he did not build or improve for pur-
pou oLsalef.
❑ I, as owner of the limped, am exclusively contracting with licensed contractors to
TOTAL:
nnsWct the project (Sec. 9(94, Business and Professions Coda:) The Contrumor's LI-
nseLaw does not apply toanowner f proped, whin builds or improves thereon, and
QTY. PLUMBING PERMIT
who contracts for such projects with a enntrachood licrnsed pursuant to the Contractors
PERMIT ISSUANCE
License Law.
❑ 1 am exempt out, Sec. , B & P C for this niton
Owner Date
COMPENSATION DECLARATION
WORER
ALTER - DRAIN & VENT- WATER (EA)
BACK PLOW 1'N(yl'F.CT. DDEVICE1Bm
VALUATI(IN
1 hereby ut unKder pcwlty nl perjury one of the following Jedaration.c.
I p
STORIES
TYPE CONSTRUCTION
❑m,as andwill main by eCion 370of he Labor Coaceoforthe Wnoerece of the
. tion, as Provided Baby Section 371M1 of the WM1nr Code, for the perfurtnancc of the
w rwhich this pemtai is issued,
DRAINS -FL(X)R,RWP.AREA. COND.
FIXTURES - PER TRAP
I I have and will maintain Worker's Compensation he w Insurance, h requited by Section
3]LYl of the lsMr Code, fur the performance of he work for which this permit is iswM,
GAS - LA. SYS 1LM-I INC. 4OUTLETS
OCC GROUP
APN
My Work Cnmpvnsauon nd Policy oumlxx
rye a auri
Cartier\1-i i��t =u YnOlioY Ntyr�'V -1�Dy6�
GAS-IiA. SVS'I'IiM-0VRR4(EA)
ATION INN FROM WORKERS'
ERTIRC COMPENSATION
COMPENSATION INSURANCE
GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DTVI. ON FE -ES
(This section need nm be complcmdll the permit is tbnine hundred dollars is 100)
or lest)
I certify that in the peformancenf the work forwhich this permit is isued.l shall
not employ any person in any manner sa as to lucnme subject to the Walken' Cinmpen-
' Orion lows of California. Date
Applicant
GREASE TRAP
PLANCHECK FEE
••
SEWER-SANITARY-S'IDRM1 241
ENERGY FEE
WATER IIEATIiR W/VHN'IIECEC'I'R Q
GRADING I:Tai '
NOTICE TO APPLICANT. IL a@r making this Cenircme of Exemption, you should
became subject to the Workers Compenxation provisions of the Labor Code, you must
pvislnnsm this pcmatshill he deemed revoked
forthwith comply with suchro
WATER SYSTEM/rREAI'IN
WA7 L•R S[RVICE s ssP
SOILS FEE
CONSTRUCTION LENDING AGENCY
I hemby nlRrm that there is a cn emotion lending agency for the performance of
the work for which this permit is issued (Seo. 3097. Civ. CJ
Lenders Name -
PAID Da Receipt a
NEW RESIDENTIAL PLM$
'TOTAL:
TOTAL'
J Lender's Address
BUILDING FEE
1 certify Ohm 1 have read this application and state that the above iammwdm is
correct, I agree to comply With all city and county ordinances and state laws relating to
building construction, and hereby amMrize reptesentativer of this city m cater upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE:
P17RMIT ISSUANCE
ELECTRIC FEE
nbnv -r entioned property or inspection puzposes
(We) agree to save, indemnify and keep amen less the City of Cupertino against
PLUMBING FEL
habilities,judgme ts, costs and expenses which mayinaay wayaccme against said City
in , ICANnce NOERSIf the A NDng of this Permit.
SOUREREULATIONANDS ANI)WILL COMPLY W11'H ALL NON -POINT
SOURCE REGULATIONS.
ALTER OR ADD TO MECH.
AIH{IANDLIN[i UNIT I'1"OIQOIk1CFM)
MliCfiANICAL FEE
Alk HANDLING UNIT (OVER I0,(00CIT1)
CONSTRUCTION TAX
Signulnre of A,,1a,m/Cmdmcmr Data
EXHAUST HOOD(W/DUCT)
HOUSING ME rIGAT10N FEE
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the applicant or furore building occupant store or handle haralous material
as defined by the Cupertino Municipal Cole, Chapter 9.12, and the Health and Safety
Code, Seen.. 25532(a)^
HENT ING UNI "P (OVER 10,00) If RB
VENTILATION FAN (SINGLE RESIDE
❑Ves ❑No
PAID
Dae Receipt
Will the applicant or future bit neeupunt ass eyulpmem art devices which
emit havmdous air contaminants as defined by the Bay Arca Air Quality Management
BOILER-COMP(3HP (1R 1001,00g1 B'TU)
TOT
District]
E] Yes F1 No
BOILER -COMP (OVER 100.000 BTU)
AIRCONDHIONER
/ ISSUANCE DATE
I have rad the luvnrdous materials requirements under Clingier 6,95 of the Cali-
NEW RESIDENTIAL MECH. SQ. FT.
Tome Health & Safety Code, Sections 25505, 25533 and 255.14. I understand that if the
b 1
building does not curendy have a hmnn6 that it is my respm,drlit, m notify the occupant
of the requtrearents which must be, met prior to issuance of a Certificate of Occupancy.
/^1
ISSUED BY:
TOTAL:
Owner or authorized agent Date
OFFICE