31102APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
BUI.DINC.DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL
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❑ Consultant Fees Paid by Applicant (Initial)
1 hereby affirm that I am licensed under provision. of Umpecr m
9 (comencing .
{O0OZO with Secfon]W(o.d Division 3ofthe Business and Profeoiuns Code. and my license is
F u]" in full force and effect.
G"U License Class Lia 0
NZ W Datc Capt...,
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RC14I'IECT'S DEC ATION
ZOnZ If. c yp is I a obs ,
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F ice.9pnorns'ita'eciancei'sa,
ionalOWNER-BUILDER DECLARATION
C W1arfrm that I am exempt from the Contractors License Law for the
3mgra. (Station ]031.5, Businessand ProfessionsCode: Anycity memory
t permit to amswcl, ager, improve, demolish or repair ay sructme
ce, also requires the applicant for such Permit o file a signed statement
i y'd that he is licensed purstad to the provisions ofthe Contractor's License Law(ChaptcT9
w (commencing with Section 7")of Division 3ofthe Business and Profession. Code)nr
a L eC mat he is exempt therefrom and Ne bines for the alleged exemption. Any violation of
NScaum ]1131.5 by nny applicant fin. pored nobjects ma apphcom m a call pcnagy of
not more than five hundred dollars (S5 W}
of:of, _ ❑Las owner of the progeny, of is employees with wage as ale (See, 044, Business
E- will Pr thework,and thestructureCont a for intended or offend Law
dos non apply to ser
Business
W 3 m and Professions Crde:'I' p Contractors Licence Law Jces not apply to if owner h
his o
property who milds pr improves thereon, and who dost such work deed of of Through
his own employees, provided that such mentis old % are not intended or offend for
ole. If, however,ll the have the bot en of proving
is colo within one year of completion, the
owner -builder will here the burden of provin6 that he did not buil) or improve for pur-
poseu[salc.).
❑ 1, as owner of the pmpart , am exclusively contracting with licensed contractors in
instruct the project (Sec. 7044. Business and Professions Code:) The Comractor's U-
ceLawJcesnotapplytoannwnenrfpmpcnywM1nhuilJsorimprovestheraon, and QTY,
who contracts for such projects with a connotations) licensed pursuant o the Commctors
License Law. '
Q I em exempt under Scc. , B & P C for this rcawm
�.
®Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby under penally of perjury one of the following W(,Aees Coo
❑nt, aamdida main mina Ceo3700 of Ge Labor Cride.I tfor Workers Compere
weak
as hick hi for a Section 3]OU of the labor Crura for the perlonnance of the
work furwhich this aintaiisiorW.
1 of the fa will of maintain Worker's Compensationofthw rkfor whinsurance.ch
h required by Section
My of the Lahr Qde,for the Performance of work for roadster this permit is irsucJ.
My Worker's Compensation Insurance artier and Policy number are:
Cemcr. Policy No
FROM
CERTIFICATE OF EXEMPTION IRON WORKERS'
COMPENSATION ON INSURANCE
(Thi,section need not the completed ifthe permit is far one hunJmJ dallurs I51(NI)
or less.)
I certify thin in the performance of the work for which mix pennh it issued. Co Lcha11
not employ any Canso e. any manner so as to become subject tome Workers' Compere
0z Appliance laws of Cnlifomia, Data
O Applicant
NOTICE TO APPLICAN-L If, after making this Certifeam of Exemption. you .should
a, become subject to the Workers Compensation pruvisits1%of the Labor Crile, you must
Ime with comply with such previsions or this perned shall be deemed revoked.
P. Q
2 CONSTRUCTION LENDING AGENCY
(..1 0 I hereby anion that hem is a couslrvction lending agency for the Performance of
C4 H Ne work for which this permit is issued Inc. 3097, Ci, C.)
Q U Lender's Name
Leaden Address
FlL 1 certify that 1 have read this application and nate that the above information is
(n cares. l agree to comply with all coy:md county ordinances and state laws mlatingto QTY.
U 2 building construction. and hereby authodza repreunotives of this city to enter upon the
abovo-mcmioned propcny fart inspection purpoosl PERMIT ISSUANCE
(We) agree m sane. indemnify ane keep hamoese Ise City of Cupcnino 'again
liabilities, judgments, costs andexpenves which may in any way accrue agairotsaid City ALTER OR ADD TO MSCI{,
in consequence of the standing of this peandi,
APPLICANT UNDERSTANDS AND WILL COMPI Y WITH 4 t NON.PotvT AIR HANDLING UNIT(TO 10.000 CFM)
AIR HANDLING UNIT (OVER 10,m)) CFM)
EXHAUSTHOOD (W/DUCT)
HEATING UNIT (II) 100,11(0 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENIMLATION FAN (SINGLE RESID)
BOILER -COMP QHPOR 100,00 BTU)
BOILER - COMP (OVER Hana oNTUI
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. FT.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS
THMP. METURPMLEINST
POWER DEVIL
S W IMM ING POOL ELECTRIC
OUTLETS - SWITCHES -Ff
NEW RESIDENTIAL ELECPR
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECE DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYS?I?M.I INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4(EA) .
GREASOINDUSTRL WASTE INTERCEPTOR
GREASF,TRAP
SEWER -SANITARY -STORM EA. 2001T.
WATER HEATER W/VEffi-LECTR
WATER SYSTEM?RF,ATING
WATER SERVICE
NEW RESIDENTIAL PLMR. SQ. FT
MECHANICAL PERMIT
/ HAZARDOUS MATERIALS DISCLOSURE I T
Willthe cepplicem orfurore buildingoccupam.aueorhandle ...Nous memrial
s defined by the Cupertino Municipal Cade. Chapter 9.12, and thc Health and Safety
Cade, Section 25592(.)'1
❑Yea Fl No
l W II the applicant or furore building occupant use cyuipmem or device, which
mit hazmdeas air contaminant ax dapped by the Bay Area Air Qmbty Management
District?
❑Yea ON.
I have read the haanrdous materials requirements under Chapter 6.95 of the Call-
famia Health & Safety Code, Sections 25505, 25533 incl 25534. 1 understand that Bin,
building dra, nor currently have a tenant, that it is my rcxpansihility to notify the uavpanl
of the requirements which must be meat prior m issuance of a Canifcam of Occupancy.
FEE
JOB DESCRIPTION
PERMIT NU. 3 1 1 0 2
NITARY NO.
APPLICATION SUBMITTALDATI
❑ KITCHEN REMODEL
❑ADDITION
X719
N/C
CONTROL#
❑
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
BUILDING PERMIT INFO
PLUMB MECH
❑ OTHER
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
❑ PLUMBING RE -PIPE
❑MULTI -UNIT
❑STRUCTURAL
PAID
Data
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑DEMOLITION
❑ OTHER
COMMERCIAL:
❑NEWBLDG/ADDITION ❑DEMOLITION
❑TENANT ❑FOODSERVICE
IMPROVEMENT
1111--
S/SQ. FT
11,0111 Y Ur UUrrh MVV
FEE
BUILDING DIVISION F
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Data
Receipt#
TO AL:
BUILDING FEE
FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Data Receipt
TOTAL:
BY:
OFFICE
ISSUANCE