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CITY OF CUPERTINO BUILDING. ELECPRICAL
RUI 0.IN (VISION APPLICATION/IaF.RMIT PLUMnIrvc - Mb:CHANICnI,
BUILDING PROJECT IUEMI'IFICATIUN
P'
WILLING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
4 c
OWNER'S NAME: PHONE:
C RACfOR'S NAME: LIC NO:
$rJt?' 1 S IO %S�OIG4
N/C
❑
CONTROL#
RC :CT/ENGI HER LIC NU:
DI 155:
d Ti
CONTACT: \ PHONE:
Gl l S tetg'� Tarr' _ ��� 1
-
❑ Consultant Fees Paid by Applicant (initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECt
QTY
ELECTRICPERMIT
__ _
m.' FEE
LICENSED CONTRACTORS DECLARATION
1 hcrcby off rte Thar 1 am licensed under proviunns of Chapter 9 (enmmenc ng
widXacflr7fK1p.fDmah 3c fthe BUSinessa dPmfesaom Code ndmylcenseis
n fall fnrsamd cffc , Sb(o�
' Licens t Lag «�' - ,Z�giC
Dam COmlDECL mot_- r-, —r—
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑KIICI IEN REMODEL
❑ADDITION PLUMBING RFiPIPE
❑MULTFUNIT ❑STRUCTURAL
MODIFICATION
❑IMPROVk ❑SW CHIMNEY
MING PREPAIR
OL
IMPROVEMENT SWIMMING I'fIO1S
❑13ATII REM EVRBPAIR ❑DEMOLITION
�07,xPR t (LQ( h.(2. ElG$�.
P13RMI1' ISSDANCIi
APPLIANCES- RESIDENTIAL
ARCHITECTse DECLARATION
undemtand my plans shall he used us public rreoMS
PANELS -
-
UPTONNIAMPS
j Licensed Professional
OWNHR.BUILDER DECLARATION
1 hereby affirm that I not exempt from the Contractor's License I.nw for the
201- 1000AMPS
OVER,1000AMPS
Following reason. (Section 7031.5, Business and Professions Cole: Any city or county
SIGNS ELECTRICAL
c-m-I T 1
j which requires a permit to construct, alter, improve, demolish, or repair any suucorc
prirrm its issuance, also requires the applicant forsrch permit o Me a signed statement
- that he is llesnsed pursaanuotheprovisimnafrhe Cnntracors License Law (Chapter 9
(commencing with Section 7") of Division 3 oftbe Business and Professions CMe) or
L 'bar he is exempt thercfmm and the basis far the alleged exemption. Any violation of
Section 9131.5 byany appliant Err a permit subjects the applicant In a civil IF cnaltyaf
not more than five hundred dollars (5500).
Las owner of the property, or my employees with wages as their sole compensation,
will do the work, and the orucmty is not intended or offered for sale (Sec. 70,14, Business
a uad Professions Code: Gin. Cumna ar's Lieense law does not apply to an owner of
SPECIALCIRCUII'IMISC.
TEMP. MITER OR POLE INST.
COMMERCIAL,
❑ NEW BLDG /ADDITION ❑ DEMOLITION
❑ TEXAN T' [I FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS- SWITCI TES - FIX"
NEW RISIDENTIAI. T:LECT Q PI'.
popery who builds or improves thereon, and who does such work himself nr though
his own employees, provided that such improvements are not intended or offered for
sale if, however the building or improvement is sold withinome year ofeumpleuon ,the
SQ. IT. FLOOR AREA
8 /SU. FT
ownerfimider will have the burden of among that he did not build or improve for put.
1
TALL
Q
you of sa1rJ.
❑ 1, as owner of the property, am exclusively contracting with licensed rearucmn m
QTY; PLUMBING PERMIT
FEE,
construct the poject (Sea 7!144. Business and Professions Code:)'I'h. —aa. ors came Law does not apply to an owner of property who builds or roproves Ithemon, and
who contracts for such projects with a contractor(s) licensed pmar ard to the Contractors
PERMIT ISSUANCE
License Law.
❑ Iam exempt under Sec: ,II& P C for this reason
ALTER - TRAIN & VENT - WATER (EA)
VALUATION
Owner Doe
D
WORKER'S COMPENSATION DICCLARAI']ON
BACK FLOW PROTECT. DEVICE
1 hereby alllrm under penalty of perjury one (if the following declarations:
TB S
TYPE CONSTRUCTION
❑ I have and will maintain aCciifictte of Consent to self -insure for Worker's Compcm
DRAINS - FLOOR. ROOF, AREA, COND,
cation, as provided for by Section 37M of the Lahr Code, for the performance of the
work for which this permit is iswmd.
:C01R1
FIXTURES - PER'TRAP
❑ 1 have and will maintain Worker's Compensation Insurance, us required by Section
3700ofthe Labor Cade, brtheperfrrmmce ofthework forwhich this permit is issued.
GAS -EA. SYSTEM -1 INC.4 OUTLETS
. UP
�APN OyN
2
GAS -EA. SYSTEM -OVER 4 WA)
My Wonkyy C�gnye ti 1 once artier and Policy nuWcVjegls'7/1MO+
Carrier A k nIC% Policy Na: ll//�3��''1IYY VVYYAALLJJ
GREASIIINDUSTRI. WASTE INTERCEPTOR
CERTIFICATE Olt EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION Ilil!S
(Thissectionaadnotbe completed iOhe permit is forene hundred dollars ($lop
art lemJ �
ORGSE'I'RAP
PhANCIICCK PEE
SEWER - SANITARY -STORM EA. 2W IT.
ENERGY RiF.
Icenil thminthe onmanceFFtithe wo forwhl lithos rmitis issued, ]shall
not employ an person in y manner P e Workers
WATER UPA'I'ER W /VENT/ELECfR
GRADING hlili
smion Lawsn into iu. am
i Applicim
NOTICE T' A LI A :If. eBCr making @i rap non. n Id
Feature suhj fib c Worker's Campensmi m " c, you must
WATBRSYS'TE1,UTREATING
.gOI1S lili`n\ `� '1
'y forthwith comply with such provisions or lik,amnit Shull be created revoked.
WATER SURVICE
v
rY1s
RID
NEW RESIDENTIAL PLMB. SQ. FE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
thn work tort which this permit is issued (Sec. 3097, Civ. Cr _
Lender's Name
U tl
TOTAL:
TOTAL:
.
QTY, MECIIANICALPIERMIT
FEE'
Landers Address
ILDING FEE
a 1 cmify that 1 have mad this epdivelicn and slam Oat the.hove information is
O correct. I.,me to cmuply verb .11 cityand county ordinances and stem laws relating to
S il$MIC EEI
huilding comoretiog and herehy authome representutives of this city m error uqm the
PERMIT ISSUANCE
lil.IiCPRIC ITT.
above-man Toned property for incpation purposes.
(We) agree m save, indemnify and keep harmless the City of Cupcnino against
PLUMBING FEE
lithilitic,judgmerns, comsand expenses which may many waymemeagaimteaid City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT
SOURCE REGULATIONS.
ALTER OR ADD *10 MECH.
AIR HANDLING UNIT (TO 1(1,OX0 CFM) -
MECHANICAL THE
AIR HANDLING UNIT (OVER IB,(NIBCPM)
CONSTRUCTION TAX
Signammof ApplictrUComrecmi Data
EXHAUST HOOD(W/DUCO
HOUSING MITIGATION FEE
HAZARDOUS MA'I'17RIALS DISCLOSURE
Will the applicant or future building occupant %lure orhandlehazankno material
HEATING UNIT ('1'01(X1,001 ID U)
as defined by the Cupertino Municipal Cole, Chapter 9.12, and the Health and Safety
Code, Section 25532(07
(MATING UNIT (OVEN I(NLO() BTU)
VENTILATION PAN (SINGLE RESID)
❑Yea JNn
PAID
_-
Dmc Rccei t p
Will the applicant or future building urinated use equipment or devices which
emit hma us nin all nndammams as def { by the Bay Area Air Quality Management
BOILER -COMP (3xP OR 101,010 BTU)
BOILER -COMP (OVER 10!1,(X10 BTII)
District?
❑ Yes No
AIRCONHITIONER
Ihavcre the huxardnuv mmcrialxm quiremcma under Chapter 6.95 a1'Ihe Call-
fomia H hh & afcty Cole, Seniors 2550,5. 25533 and 25534. 1 unfler l.d that if the
building vs no currently have a tenant, that is my rtx ildr ter ythc cupmt
ISSUANCEDATE
NEW RLSIDENTIAI, MECH. SQ. FT.
of them me B which most be met pri ice of a Con tram [Oren
L
ISSUED BY:
- TOTAL:
Ow or thorized. um
OFFICE