S 0405uru eon t u¢e - nnE BALL D(MNT DEN (1031 V
nrru�nnr ry rrra. u. uv v ............. ......... ..�� �..._� ___ _..__. _..-.. —.- _--_-
CITY OF CUPERTINO HBILIHNG - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL.
BUILDING, PROJECT IDENTIFICATION
PERMIT NO.
S 0405
V
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATI
OWNER'S NAME: PHONE:
CO ACTOR'S NAME: LIC NO:
t C—eeeG • �1� -4
NIC
❑
CONTROL#
ARCHITECT(ENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MELD
❑ Consultant Fecs Paid by Applicant(Initial)
LICENSED CONTRACTORS DECLARATIONQTy
9 mmeneing
th1 aC, .ed under pnwizions nr chapternm
I hereby .termat m li
ELECTRIC PERMIT FEE
-
JOB DESCRIPTION
PERMIT ISSUANCE
with Sosdua900(BO(DiVlsma 3 ofthe Businessaml Profezzlons Code. and my license i.
in full foreeaed Tec
License I ss Lic. # u 7"' �6..L't� `
Date Contrenor L ll.. �'�•-' -
ARCHITECTS DECLARATION
I un mnJ my plans shall be used as c rc
p.
RESIDENTIAL:
❑SFUWL ❑ KITCHEN REMODEL
❑ADDITION El PLUMBING LPIPE
[I MUTT[ -UNIT []STRUCTURAL
MODIFICATION
HIMNEYREPAIR
❑INTERIOR IN
IMPROVEMENT � WIMMING POOLS
C3 BATH REMODEIJREPAIR El DEMOLITION
❑ OTHER
'
APPI-LANCES-RFS1UIiNT1AL
PANELS
UPT0200AMP5
Li-cenensed omessionai �
1 OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Cmdmcho, License Law in,, the
t following .... (Section 9031.5. Business and Professions Code: Any city Or county
201-IUIM)AMI'S
OVER Into AMPS
SIGNS ELECTRICAL.
iwhich requires a permit to cnmtruct, alter, improve, demolish. or repair any structure
prior n in anchocgalsn requires the applicant Tmstch permum flea sigaccistatement
that he is licensed pursuant to the provisions ofthe Contractors License Law (Chapter 9
(commencing with Section 7000)of Division 3 ofthe Businessmid Prnfesoonz COde)or
that he is exempt therefrom and the busts fnr the alleged exemption. Any Ontario. of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500L
C O 1. as owner ofthe property, or my employees with wages as their sole compensation,
will do the wofk, and the structure I,.., intend,dmraRered for sale (St 704 L Business
a and Professions Code: The Corbusier, License Law does out apply n an ovner of
SPECIAL CIRCUITNISC.
TEMP. METER OR POLE INST.
COMMERCIAL' t
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVLiNPy`I'1A
❑OTHER Y �-D
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLEI S- SWITCHES -FIXTURES
SQ F L A
�'`
' IV f, i'
-
E/SQ. 17.
property who builds or improves thereon, and who does such work himself or through
his own employ.., provided that much improvements arc not intended or offered for
sale. If, however, the building or improvement is sold within one yc-of completion, the
owner -builder will have the burden of proving that he did not build or impmvc for put-
Lose of sale.).�ur`�I�NO
Ej I, as Owner Of the property, a exclusively contracting with licensed contractors to
mnNuct the projen (Sec. ]1Wq Business and Professions Code:) The Contractor. Li-
cense Law does not apply m an owner of property who builds or improves thereon, and
NEW RESIDENTIAL ELECTR SQ Fr.
PLUMBING PERM FEE
QTY,UPERMITISSUANCE
who contracts for such projects with a continental licensed pursuant the Contractors
License law.
I am exempt under Sec. ,B& P C forthis reasonAIN&VENT-WATER
UANCE❑
(EA)
1 VAhi
`WORKERSCOtyof
Uate
Owner
DECLARATION
NNOTECT. DEVICE
pennon
1 hereby affirm under penalty of perjury one of the following Jeclarmions:❑ Ihaas and will maintain.
of Comenvo Workers Camper-
i.
LOOR. R00P,ARFiA,COND.
STORIES
TYPE CONSTRULTIO
m.37me
Cod for the
as provided fnr mi Ss issu 39IX1 of the IaMt Cede, fnr the performance Of the
fnr which this permit i. i
-
-NCR TRAP1
YSTEM-I ING40UTLEfS
orW.
M I hove and will maintain Work<r's COmpenwti.n Insumna, us requited M1y Semi.nrwhichdo"armitisissued
OCC. GROUP
APN
YSTEM-OVER 4 EA)
My Wm 9(gCf�pryTys�ylpn arace �� aPolicy NoYtruMc arc r
MyCarWr47a►iC 7iV
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
OREASETRAP
PLANCIIECK FE E
IiNERGV FEE
Trisacelmomesma becuraretW ifthe permit is foresee hundmddellws(51IX0
or les'.)
I certify that in the Performance ofthe work for which this permit in issued, Ishan
not employ any Person in any manner so as m hcatoe subj.no the Workers' Compcn.
SEWER - SANITARY - STORM EA. 210 FT.
WATER HEATER WN12NTIELEM
WATER SYSTEM?REAggNG
GRADING FEE
SOILS IEE
sotto. laws of California. Dom
Applicant
n NOTICE TO APPLICANT: IL after making this Cendicate of Exemption, yew should
become subject to the Worker's Compensation Provisions of the Labor Code, you must
yforthwith or this shall No deemed revoked.
WATI7R SERVICE
Comply with such Provisions permit
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency fie the performance of
the work for which this Permit is issued (Sec 309]. Civ. C.)
Date Rcrei #I
B. SQ. FT.PAID
'TOTAL:
Lender's Name
Addmss
certify that 1 have must this application and state that the above information isO correct. l agree to comply with all city and county ordinances and state taws 111.1111, toAL
Construction, and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
wayeccroeagainst,sinCityCII.
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1, NON -POINT
TOTAL:Lender's
BUI
PERMIT FEEbuilding
=TOMECIL
ELECTIC FEE
PLUMBING FEE
AIR HANDLING UNIT (TO 10,010 CFM)
MSCI IANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,00) CFM)
CONSTRUCTION TAX
Signature of Applicant/Commetor Data
HAZARDOUS MATERIALS DISCLOSURE
Will theupplicam- future huildialo,c-lam store., handle huninooz material
as defined by the Cupertino Municipal Cede, Chapter 9.12, and the Health and Safety
Cale, Section 25532(a)P
EXHAUST FOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO Iffl.00 RTU)
HEATING UNIT (OVER 101.0011 BTU)
VENTILATION FAN (SINGLE R178 ID)
❑Yes ON.
PAID
Date Receipt M
Will the applicant -future building Occupant use equipment or device, which
mit hazardous air cunmmime nts as defined by the Bay Arca Air Quality Management
BOILER -COMP UIRPOR 10Qa0 BTU)
TOTAL:
BOILER - COMP (OVER IIXk1100 BTU)
District?
E) VC, [I No
AIRCONDITIONER
ISSUANCE DATE
I have read the hazardous materials mouitements under Chapter 6.95 of Its, Cali-
NEW RESIDENTIAL MI CH. SQ. Pr.
fomin Health & Safety Code, Sections 25505, 25533 and 25534. 1 melcoutnd Nut if the
b IJ g n currently haveituamnt. union res coolility fn notify the. capon,
of, he hi st he once. CenifcaF flScuracy.
7
��
TOTAL:
ISSUED BY:
U n thotvad agent Dan,
OFFICE