99080162APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PE
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING �MIxuswnm..�
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: I D �a 6/ . 1a
/3/ ld -
SANITARY NO. BMITTAL DATE
OWNER'S NAME: ^ 4oS 1'Hp%e,T-��
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BUILDING PERMIT INFO
ONTIIACT, ni:
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V ale. Arg, 5-579--4a3�
°Consultant Fees Paid by Applicant (Initial)
BLDG ELECT„ PLUMB MUCH
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LICENSED CONTRACTOR'S DECLARATION
1 hereby afiina that I am licensed under provisions of Chapter 9 (commencing
th Sccti.n)IXq)of Uivisionlnflhe Business and lsrdessiuns Code. and my license ix
infullforce andeRxt.
8 �QS
License 5-9 Q Lrt.M ( —
Datc I C S Dfi ser
AHCHITEC'TSDECLARATION
I understand my plans shall he used as public reenrds
QTY ELECTRICPERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN
❑ADDITION [I PLUMBING R&PIPE
❑MULTI-0NIT ❑MODIFI MODIFICATION
MODIFICATION
El INTERIOR C3 CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
❑ BATH REMODEUREPAIR (]DEMOLITION
[I OTHER
PERMIT ISSUANCE
APPLIANCES—RESIDENTIAL
PANELS
UPTO2MAMPS
'Pott'-txl
C' -1
Q
x�x O d V
3 F'
Licensed Professional -
OWNER-BUILDER DECLARATION
1 hereby .(Sero that 1 1. exempt farm the Contractor's License Law for the
following reason. (Section ]OJ Boalter, and Professions Cede: Any city ser county
201-I000AMPS
OVER IOf10AMPS
SIGNS ELECTRICAL
W LL
sl
aothat
sr,
which requires a permit m construct, ulan Improve, de I .!, t, of repair any structure
improve. de
pdnno its issuance, Is. requires the epplicam for each Pertninu Eleasigned statpmem
he is licensed pursuant to the proviorm, of the Container's License Lew(Chapter 9
SPECIAL CIRCUITIMISC.
W ..00
d E c y�
X—Yy
yo"
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C
(commencing with Section ]OM)of Division Sof the BtAmessaad Professions Ctdc).,
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section]031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
of more than five hundred dollars(SSMI.
❑1.asowner of the property. or my employees with wages as their role compensation.
TEMP. METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑FOOD SERVICE,
_ PR ENT
'*A/
OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
Sand
uure i.snot intended or offered forsale(Sec.]DM: Business
will do the work, and the vun
Pmfexsions Codec: The Contractor's License Law does not apply to an owner of
OUTLE'T'S-SWITCHES-FIXTURES
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
vale. IL however, the building or improvement is sold within one year of completion, the
NEW RESIDENTIAL ELECT Q PT.
SQ. PT.FLOOR AREA
S/SQ. FT.
T
n ner-huilder will have the burden of passing that he did not build or improve for pur-
1
pose of sale').
❑ 1, as owner of the property, am exclusively ecounting wilt licensed e0auvetors t.
. .
TOTA
omotmm the project (Sec. 7044, Business and Professions Cndep The Contractor's Li-
came l.aw does not apply to an owner of property who build, or Improves thereon,and
QTY. PLUMBING PERMIT FEE
who, ittucts for such pasjecn with ercormactur(s) licmvsed p.... an,In the Coutmcm/s
PERMIT ISSUANCE
AhTF:R - DRAIN &VENT- WATER (EA)
Lantra Law.
rP
I am exempt under Sec. , B 9 P C for this reason
Owner Data
VALUATION
'WORKERS COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
rjuOon dalmmisns:
I he affirm under penalry perjury one of the following
1
STORIES
_
TYPE CONSTRUCTION
r
Ihave and will main tains Cion 37 eof be Lalm, Cod for for WDrkdsceCo.,.-
it w de
wtitmf as provided for by Section 3]M of the LaMrt Cade, for the performance of the
DRAINS - FLOOR. ROOF, AREA, COND.
issued.
lave
FIXTURES-PER'I'RAP
'%
ands illinu man h required by Section
I have and will maintain Worker s Compensation ceofthw Irk for which permit is issued.
J] of the labor C.Jq for the perhrtmanc for whid��t
GAS- IiA.SYSTEM-I INCA OUTLETS
OCG GROUP
APN
a, and ul :tjjhis
C�Workgf' ret eFation Inst soca ca<Pol cy Nl No.: nl's4'T �-{R
bb
GAS -EA, SYSTEM -OVER 4 (EA)
GREASEANDUSTRL WASTE INTERCEPTOR
CERTIFIC TE IF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
l'Dris section need not he completed ifthe Permit is for one hundred dollars IS l Ml
or less.)
GREASETRAP
PIANCHFiCK PP.E
SEWER-SANITARY-STORM EA. 20) IT.
ENERGY FEE
zO
h
a ;
a�
7 Z.
V O
F�
iULenders
y
E" y
Vbuilding
I Tardily that in the peflbrance ofthe work for which his permit is issued. l shall
not employ any person many manner suits to became subjecuo the Workers' Compen-
ApplicLasofCalifomia. Date
ant
WATER HEATER WNENT/ELECTR
GRADING FEE
NOTICE TO APPLICANT: IL after noting this Ccndicate of Exemption, you.umbal
e eubjeco the Workers Compensation isions of the labor Code, you must
becomuprov
fnMwith comply with such Provisions or this permit shall he deemcdo.—ked.
CONSTRUCTION LENDING AGENCY
Ihm ereM1y afiuThan iso construction lending agency for the performance of
the work for which this pemth Is issued (Sec. 3097. Civ. CJ
Ixndefs Name
Address
WATER SYSTEM/1'REATINC
WATER SERVICE
,
SOILS FF.EIs
PAID Dat eceipt x
NEW RESIDENTIAL PLMB. SQ, FT.
TOTAL:
TOTAL:
BUILDIN F
1 certify that I have read this application and state that the above information i.
correct. I agree to comply with ml city and county ordinances and state laws relocation
construction. and hereby authorise representatives ofthis city toenterupan the
QTY. MECHANICAL PERMIT FEE -
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
above-mentioned properly for inspcetlan purposes.
e, indemnify and keep horess the City of Cupeninn against
(We) agree to as, nl
PLUMBING FE
iabilines.judgmems, costs and expenses which may in any wayacme against said City
Inco quenceufthegramingofthispefmit.
ALTER OR ADD TO MECH.
AIR HANDLING UNIT 10.fNCFM)
MECIIANICAL FE
APP :A UNDER. AN AN WILL COMPLY WIT ALL NON-POINT
S R To �3
AIR HANDLING UNIT (OVER I(1,Dp CFM)
CONSTRUCTION TA
Sig t rcof Applican C Imctnr / Date
HA ARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUC17
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,0(10 BTU)
Wrlllhe applicants( future huilding ocrianni mrem handle hazardous material
as defined by the Cupertino Municipal Code, Cheat, 9.12, and the Health and Safety
Code, Section 2553200?
❑Yes
HEATING UNIT (OVER IOLOW BTU)
PAID Dam Receipt
VENTILATION FAN (SINGLE REBID)
BOILER-COMP (3HP OR 1M,BdJ BTU)
Will the applicant or f etre building.Tawas use equipmem or device. which
mit hicarba, air ronmminvme as defined by the Bay Arca Air Quality Management
ij
TK L.
BOILER-COMP (OVER 100,000 BTU)
is
Yes , '�/r7�/'/�J�'," '
AIR CONDITIONER
I have read the hazvdw' s materials requirements under Chapter 6.95 of Nc Culi-
Inealth A, Safi ode, SecdnnM 505.8533 unit 25534. 1 undersand that if the
Gild' oc mamrn I 0 IitismyrcsponsiM1ilitymnotifylheacupant
of r t.l� P I i eofa Ceni c
ll
ISSUANCE DATE
NEW RESIDENTIAL. MECH, SQ. FT,
G
ISSUED By.
TOTAL:
ner or amh00zd m an
OFFICE