S 1248APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
PEtIT NO.
�J 1248
BUILDING PROJECT IDENTIFICATION
-
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATI
A: `
BR'S ME: PHONE:
C NTRACTOR'S NAM LIC NO:
SIC
CONTRO N
A C ITECTIENGINEER: LI NO:
7AJ_
ADDRESS:
❑
CONTACT. PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
ID El E:1LICENSED
CONTRACnderp DECLARATION
1 hereby affirm that 1 am licensee under provisions of Chapter 9 (commencing
QTY ELECTRICPERMIT FEE
LOB DESCRIPTION
withl force ]000)of DlvisinnJufthe Business and Pmfessians Codc, and mylicensa is
Licene Class deHccf
License Class Contr
Date- Contracmr
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
[]ADDITION ❑PLUMBING RE -PIPE
El MULTI -UNIT []STRUCTURAL1
MODIFICATION
PERMIT ISSUANCE
APPLIANCES - RFSIDENTIAI.
ARCHITECTS DECLARATION
undetsmnd my plans shall be used ax public records
PANELS
UP TO 200 AMPS
[:I INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT []SWIMMING POOLS
[D BATH REMODE /REPAIR ❑DEMOLITION
❑ OTHER
Licensed Pro(essiannl
OWNER -BUILDER DECLARATION
I hereby air,,. mat 1 am exempt from [M1e Connector's License Law for the
following reason (Section 7031.5, Business and Professions Cade Any city at county
which requires a permit to construct, alter, improve, demolish, of repair any structure
201-10WAMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
prior to its issuance, also requires the applicant [or such permit o file asigned.stmencm
SPECIAL CIRC UI'T/MISC.
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
TEMP. MET ER OR POLE INST.
COMMERCIAL'
(commencing with Section 9000) of Division 3 ofthe Busines and Profession, Cashbor
that he Is exempt thuermm and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section 7031.5 by any applicant for a permit subjects me applicant o a civil penalty of
not more than five hundred dal lam ($500).
Las ownerofthe propertg or my employees with wages as their sole compensation,
will do the wa,k,.ad the.dmdnrc is not intended oroficred forsalc (SecA044, Business
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
and Professions Ciall The Contractor's License Law does not apply to an owner of
OUTLETS -SWITCHES -FIXTURES
property who builds or improves the re r, and who does such work himself or through
his can emp,aid. provided that such improvements are not intended nr offered for
NEW RESIDENTIAL ELECTR
SQ. FC FLOOR AREA
$/SQ. ET.
sale,fr. however the building or improvement is sold within one year of completion the
mer -milder will have the burden of proving Lai he did not build or improve for put-
poscofsale).
TOTAL
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. ](94, Business and Professions Code:) The Commaor'.s Li-
p
P A
cense Law does not apply In an owner of pmpery who builds or improves [harbor ,and
QTY, PLUMBING PERMIT
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law
lam exempt under Sec. ,B&PCfor thin reason
Ereasonreason.
YM 6
FEB 17 ANS
PERMIT ISSUANCE
ALTER (EA)
F52 F
*Mwrir 2"10146 _Date
VALUATION
Y Uh lrUf Cfl l IVU
} (HR OMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
I hereby ulfiun under penally of perjury one of the following dcclar ,ions:
DRAINS- FLOOR, ROOF, AREA, COND.
❑ I have and will maintain aCriificmc of Consent to self -insure for Worker's Comfort-
cation, as provided for by Sermon 3700 of the Labor Cade, for the performance of the
STORIES
TYPE CONSTRUCFION
work for which this permit is Issued.
FIXTURES - PER TRAP
❑ 1 have and will maintain Worker's Com creation location , as required by Section
3700of the Lnh... Code , fon he P uhnmawrof the work for which this period is issued.
My Workers Compensation Insurance cancer and Policy number are:
GAS - EA. SYSTEM -1 INC.4 OUTLETS
OCC. GROUP
APN
Carries Policy No.:
GAS -EA. SYSI EM-0VER 4 (HA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section real not be coniplmed it the Penni[ is for one hundred dollars($ I So
an less.)
GREASFANDUSTRL WASTE INTERCEPTOR
- BUILDING DIVISION FEES
GREASE TRAP
PLANCHECK FEE
SEWER-SANITARY-S'FORM EA. 200 IT.
I certify that In the Wourmaracefthe work for which this permit is issued, i shall
not employ any person in any manner in as to become subject to the Worker[ Compen-
ENERGY FEE
WATER HEATER WNENT/ELECTR
action Laws of California. Date
Applicant
GRADING FEE
NOTICE. TO APPLICANT IL after making this Cenifium of Exemption. you should
become subject to the Worker's Comteurestion provisions of the Lobar Code, you must
WATER SYSTEM/TREATING
SOILS FEE
forthwith comply with such previsions or this permit shall be deemed revoked
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hereby offimt that there is a constmction lending agency bar he performance of
PAID
NEW RESIDENTIAL PLAID. SQ, FT.
Date Rural #
the work for which this permit is issued (Sec. 3097, Civ, C.)
Lender's Name
BUILDING FEE
Lender's Address
TOTAL:
1 certify that 1 have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating to
QTY. MECHANICAL PERMIT PEE
building consimctum. and hereby andante repfesenotives orthis city to enter upon the
SEISMIC FTSE
above-mentioned property for inspection purposes.
efy and keep hounlesc the City of Cupertino against
agree to save, indmni
PERMIT ISSUANCE
ELECTRIC FEE(We)
ALTER OR ADD'fO MECII.
PLUMBING FEE
'liabilities,judgments, costs and expenses which may in any way acerae against said City
in consequence of me granting of this peanit. I
AIR HANDLING UNIT ('to 10000 CFM)
MECHANICALITE
�'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIRHANDLINGUNI'1'(OVER10,000CFM)
CONSTRUCTION TAX
e1 ppp
��/+90
EXHAUST HOOD(W/DUCO
Signature u p y nt/ ontra for Date
HAZARDOUS MATERIALS DISCLOSURE
HOUSING MI'liGAi'ION BE
HEATING UNIT (TO 100,000 BTU)
TL
Will the applicant or future building occupant store or handle linadoms material
as defined by the Cuperiro Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(x)'!
HEATING UNIT (OVER 100,000 BTU)
❑Yes ❑No
Will the applicant or future building occupant use equipment of devices which
emit hazardous air comaminants as dented by the Bay Arca Air Quality Management
Dlsmic ?
i]Yas ❑No
PAID
VENTILATION FAN (SINGLE RESID)
Date Receipt
BOILER -COMP UHP OR 100.000 BTU)
TO'T'AL:
BOILER- COMP (OVER 10i BTU)
AIR CONDITIONER
I have riodine hazardous materialsaceulrements mode,Cupmr 695of the Cul,-
ISSUANCE DATE
NEW RESIDEN PIAL MECH. $Q. UE
fomis Health & Safety Cada, Sections 25505, 25533 and 25534. 1 understand [het tithe
building does not currently have a tenant, that It is my responsibility to notify the occupant
of the bNorentem, whl h mus[ homer prior to iaxiono of a Cedifi..IofUse panty.
ISSUED BY,
Owner at unnoticed agent Dole
TOTAL:
OFFICE