S 2950 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECIRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NU. A1'VLICA'1'ION SUBM I'ITAL DA I
OWNER'SNAME: A PHONE: CONTRACTORS NAME: LIC NO:
LN 'a „y N/C COM'ROL#
•ARCHITECDENGINEEE: e LIC NO: ADDRESS: ❑
1s,) GSSIO:iKK Ae�:
CONTACT: P NI$ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MECH
❑ d ❑ ❑
LICENSED CONTRACTORS
under provisions DECLARATION QTY ELECTRIC PERMIT FEE
I Mmby affum that 1 am licensed underailo of Chvprer Y fmnsmencing JOB DESCRIPTION
WOC with Senimn 7(XXO of Division3 of me Buvincss and Professions Code andmylicence is
r-,— in full juice mW ctTem. PERMIT ISSUANCE e RESIDENTIAL
WUU License Class Lic ❑ L [Ia •'+ SFDWKI']'CHEN REMODEL
vFiZW Date Contractor APPLIANCES-RESIDENTIAL ADDITION OPLUMBING REPIPE
p Dm ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT [I STRUCTURAL
z O I understand my plans shall he used as Imbue nvords MODIFICATION
024—FD UPr0200AMPS E3 INTERIOR El CHIMNEY REPAIR
Fly; Lensed Pndessnn°1 20bI0RAMPS IMPROVEMENT SWIMMING POOLS
OWNER-HU1LDHR DECLARXI ION OVER lI1fNIAMPS
XW< P
yy C 6 1 be,hy affirm Thee 1 ren exam t h'nm the Contractors Lieonsn Law for the ❑11AT11 RHMOUGL/Rf;PNR 0 DEMOLITION
W O iL U following reason.(Scrion 7031.5.Business and Pmfcuiors Code:Any city or county - ❑OTHER
W 3 y F SIGNS ELECI'RICAI.
LL O y which requires a permit m comm,, he,improve for, ,demolish,nr,pair any s.uaum
FSA thiormiuismadi pursuant to
heapplicantthe Contrmb arminutileseLawdshaptent SPECIALCIRCUI'VMISC. .
I ��y that he is lkenaed Purevum nr me provisions of the C.ntmdoda License Law(Chapler9
1i1EEOO (commencing with Section 7000)of Divisinn3 mf the Business and l'mfessinns Codc)or TEMP METER OR POLE INST. COMMERCIAL'
IL c that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Wim, Section 71315 by any applicant for a perinir subjects the applumm ,,a civil Kielty of POWER DEVICES C1 NEW BLDG/ADDITION ❑DEMOLITION
1_zra.tromm than pvvyundred dollars($500). ❑TENANT ❑FOOD SERVICE
E=Oa ]1.as oasis @eproperty,or my employees with wagesas theiraale comiseminion. SWIMMING POOL ELECTRIC IMP V' IiNT
e will do the work.and the structure is not intended ormficred for sale(See 7044.Business ❑O"fH
W and Potgo ms Code:no Cnntmetar'a Liceree Lots does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
CC property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements am not inended or offered for NEW RESIDENTIAL ELECTR SO FT.
vale.If,however,the building or improvement is sold within one year mfeempletiun.the 140 .FI'.FL A S/SQ.FT.
.,build.,will have me brmle t of proving that he did not hudd or improve lira pun
�prse of xowne �) �� r
1,a owner of ct See.7property.,B exclusively contracting with licensedThiC cunt,.,a i-
onmraet the project exec.7(144.Business and Pmkssinns code:)This,Convvenn's Li-
whme Law does not apply m an owner mf pnq,n1 who builds mr ltnproves thereon,and QTY PLUMBING PERMIT' 3,-06
o...tracts for such pmjeco with a morsetof(x)licensed p mmunt to the Contractors
License law. PERMIT ISSUANCE
❑ I am exempt under Sec. B h P C for this reason
• Owner
Date A ER-DRAIN&VHN'i'-WA'I'ER(EA)
VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of Perjury one of the following declarations:
❑I have and will maintain a Certilicnm of Cunwm m self-insure for Worker's Cumpco- DRAINS-FLOOR,R(IOF,AREA,C(IND.
Bacon,as provided for by Section 37M of the labor Cole,for the performance of the STORIFIS '1'Y IT CONSTRUCTION
work far which Nis pandit is I...ed. FIXTURES-ITS TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
37M.Hhe Labor Code,arieperlirrmm c.of the work lbf which this permit o.issued GAS-EA.SYSTEM-I INC.4 OU'I'LETS OCG GROUP ANN
My Worker's Compensation Insurance carrier and Policy number am:
Carrier, Policy Na: GAS-EA.SYSTEM OVER 4 HDO
T
CERIFICATE 017 EXEMPTION FROM WOR KT:RS'
COMPENSATION INSURANCE GRIiASFIINUUSTRL WASTE IN'I ERCEPI'OR
(The,fir d recd nm bccompleted if the permit is former,hundred dollars is Ioff BUILDING DI VISION FEES
or leu.) GHIiASE TRAY PLANCNEC
Toy i,that in the performance ofthe work for which tots the Workers
isers Cote shall
SEWI3R_yANITARY-STORM Ii A.20X1 FT. "'
ZactemployLaw co cidisanin aDY manners,as nr become suhjem.r the Worked.'Cumpen- E1tGY Ei
mtionlaws of Calimmiv.Date
7 O A Ikam WATER HEATER WNIiNT/ELIICIR
,� Pp GRADING FEii
aN NOTICE by APP LICANTIL Cor,sakingthis Cisions of of Hxemptiodquashould WATER SYS'I'17MUTREAT'ING
; hecome.comp y the Workers Coopensat is provisions of the Lured yoke,you must ITV P
0. Q forthwith comply with such previsions or this permit shall be deenseJ revoked. Wq'IT3R SERVICE
CONSTRUCTION].ENDING AGENCY' NEW RESIDENTIAL PCMB. SQ,PT PAID
U QI hereby affirm thin mere isaconswaiou lending ogcncyf.t the penuournce of ])ate vedA#
he work fair which mix .it is issued(Sec.3097.Civ,CJ B V
U Lenders Name By
-
U AJdrces TUDAL: TOTAL
F6. 1 certify that I have mad this appllcamis and seem that the shove mfonnadon is BUILDING ITE
to correct.I agree to comply aim all city amt county ordinances andstare laws relating to QTY. MECHANICAL PERMIT FEE
C_t Z building conmrucima.andhembyuutherre represcnmtivesoftiis city mentor upon the SEISMIC FEE
shove-nentioned prolwrty for inspection patpnces.
(Wc)agree to save.indemnify and keep hamdcss the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE -
Iiabilities.judgments.costs and expenses which may in any a ay seems,against said City ALTER OR ADD TO MECH.in .sequence of the granting of this pemrit. PLUMBING
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Alit IIANULI NO UNIT TDO I0.SXI CPM)
SOURCEREG", 10 MECHANI LPIiE
AIR HANDLING UNIT(OVER 10.010 CFM) CONSTRUCT NTAX
rmiurcul ApP¢rnUCntmetor Dam EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MH GATION FEE
Will the applicant orlmure building occupant store or handle haeatdousma,nal HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 255320)? HVIiIiAI1NO UNI'((OVER 100,000111 Or
p Yes L7ivm LATION FAN SIPAID
NTISINGLE ftl!SID)
Will the applicant or future building occupant use equipment or devices which Date Receipt#
emit M1murdeas air containments as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR hiring BTU)
District? T L:
❑Yet N. BOILER-CUMP(OVEH 100.fMX1 FTG
I have mad the ha,,amnus internists requi,nsems under Chapter 695 of the Call- AIR CONDIIR)NER
DATE
fomia Halm&Safety CoSani.m 25505,25533 and 25534.I umk¢mnd mISSUANCEar if the NEW RESIDENTIAL.MECH. SQ.FC
of
nsimsnots hichhavemm�amfiortoismyrexofaCenificrnotifYthcpancy.
nl the rcquir� x. belch amat hc�_nn Pnonaiceumme.fa CerritiCate of Occupancy.
set onzciXalit Date TOTAL: ISSUE?D BY:
OFFICE