99120092APPLICANT FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY i / Zoy
OFFICE,
F CUPERTINO BUILDING - ELECTRICAL
ING DIVISION, APPLICATION/PERMIT rING PROJET IDENTICAL
FIC RUILDLUMB NOOK, MECHANINICATION'
PERMIT NO.
LBUILDING.ADDRESX
LooNA
ITARY NO.
APYLICAT ONS MITTAL DATE
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❑ Consultant Fees Paid by Applicant (Initial)
1
BUILDING PERMIT INFO
BLDG ELECT PLUMB, MUCH
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- LICENSED CONTRACTRSD LARATION
I hereby affirm that 1 m licdnsed u sur Chvper 9 (comate cin,
with Station'nan)nfo 3 Dhe Bnx dP f ,hoe Cnde,aad mylcese is
in full farce and effect.
License Class Lic#
Date Contractor
f.
QTY. - ELECTRIC PERMIT FEE
JOB DESCRIPTION -
,RESIDENTIAL'
❑SFDWL [-1 KITCHEN REMODEL
❑ADDITION [I PLUMBING RE -PIPE
❑MULTI -UNIT El STRUCTURAL
MODIFICATION
❑INTERIOR [I CHIMNEY REPAIR
_
PERMIT ISSUANCE: '-
APPLIANCES -RESIDENTIAL
-
j 1TCCT5 DECLARATION
11 1 t e cd es public records
�
PANELS •• -
UP TO il,
W
pt; -1
'4 p
a0 rU
3
iti-
' IMPROVEMENT L] SWIMMING POOLS
❑ BA'T'H REMODEUREPAIR ❑ DEMOLITION
_
❑ OTHER
.tuned odsona
.OW k UILDER DECLARATION
I hereby affirm (hal t exempt from the Contractor's Licence Law for the
following reason. (Section ] . L.S, Busimess and Professions Code: Any city or county
which foquims a permit to construct, alter, improve, demmish, or repair any s n'tare
prior In it, issuance, alsorequims the applicant for such Permit to fie a signed statement
201-1000AMPS
OVER IOfM) AMPS -
' SIGNS ELECfRICA4
SPECIAL CIRCUITI C. -
rn
y
6�
y o
�YCI
puiyuam to thep'rovisinw n[the Commends License Law Chu h'er9
(het bo isliccrewd < I
Code) or
(wmmeacing wilk Section 760(ffif Division 3 of the Businessand Pmfessinms Ed
that he k exempt (hemfmm and the basis for the alleged co mpdon. Any ,minion of
Section 9031.5 by onyoplrlicani fofvpermit subjects theapplieunt to a civil pench)of
OI
TEMP. METER OR P.EINST.
_
COMMERCIAL:
❑ 8W BLDG/ADDITION ❑ DEMOLITION
TENANT ❑ FOOD SERVICE
POWER DEVICES
^Q
u, mom (ham five hundred dollars ($500).
❑I, as owner of lhepmpeny,nnny employees with wa,es vs theirsnlc compensation.
isms onded I mothered for. (S 9040. Business
wdld thewalk, and the t t . lm
IMPROVEMENT
El OTHER
SWIMMINGPOOLIILECTRIC,
am
and P f : C.dd: 7T Contract v License Law does n r .,ply t owner of16
,,.,my who b Ids na impowe,theme, and who does such work himself or though
his own thaperwees, provided the( such improvements are notintended Becd for
said. If,however, the building or improvement is sold within naeyeerof contpmlimdac
OUTLETSi SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTk SQ IT.
SQ. FT. FLOOR AREA
$/SQ. FT
er-builder will havethe burdenof proving that he did mol build or improve for par-
_
- TOTAL
'cerse
Pose of sale)it
El T, a: f (h property, =1 exclusively contracting with licensed t ions o
construct tit pa wh (Sce. 701D Bodiless end Profc,,mra Code )'Th Contract
Law does not apply to an ousuctofida,wity who hudds or improves thereon, and
QTY I PLUMBING PER FEE
who threatens for.such projects with a contractor(s) licensed pufsaam to the Contractors
,
ISSUANCE
License law.PERMIT
❑ l ant meanpt under See. .B&PCfor Ode reason
I.
wool ± Dale
WORKERS COMPENSATION DECLARATION
ALTER- DRAIN & VENT- WATER EA)
- VALUATION
fl� O.p -
BACK FLOW PROTECT. DEVICE
I hcrchy affirm under penally tuf perjury one of the following declarvlions:
✓O��
✓✓✓
STORIES'
TYPECONSTRUCHON
-
❑ I have and will maiiimin a Certiffc:ac of Consent to self -insure for Worker's Cmmpen-
sarin ,. as providul for by Section 3900 of the Lahm Cade, candid performance of the
work far which this permit is issued.,
DRAINS- FLOOR, ROOF, AREA, 'OND.
FIXTURES - PER TRAP
'
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Sermon
39W of One Labor Code, for the performance of the work for which this permit is issued
My Worker's Compensation Insurance carrier and Policy number am:
Carrier: - Policy Na:
GAS - EA. SYSTEM- C.4 OUTLETS
Imo/
OCC. GROUP,
f
APB -
3l �" C52
GAS -EA, SY .M-0VER4([?A)
--EA
GREA5 DDSTRI. WASTE INTERCEPTOR
- CERTIFICATE OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE;
-
BUILDING DIVISION FEES
(Thiexeelion need am be aimplewi lfthe permit is fortune hundred dollars($ I W)
irz less)
G �ASETRAP
PLANCHECK FEE ,
EA. 200 F..
ENERGY FEE
I eerily that in (heperformanco Of the work for which this pc nal is iso d.I shallSEWER-SANITARY-STORM
Out employ any person in any manner so as to become subject to the Workers' Compen-
WATER HEATER W/VIINT/ELECTR
WATER SYSTEM/TREATING
WAIERSERVICF.,I
GRADING FEN
Z
W 0
U 0
Lb Hthe
LUT7
a
f..l p]
U Z
salidn Lvwraf California. Date-
Applicant I - -
NOTICE 10 APPLICANT. If, after making this Certificate nl Exemption, you should
beemic,,ohdOtt to live Workers Cm peasatum pam sons of the Labor Cale you must
forth ithcomply with suchpovis ns or this permit shall be deemed revoked
- CONSTRUCTION LENDING AGENCY
i I hereby affirm that there is a candolaimn hodingagency for the permorance of
walk for which this permit is issued (St.. 3097, Ci¢C.)
Iacadera Name
SOILS FEE
PAID L u ;;
Date 1 Rweipr#
1
Fe1
BUILDING FBF, -
_
NEW RESIDENTIAL PLHL SQ. FT. I�
1 _ I�
TOTAL:
I
Leaders Address
information
i eenilty that 1 have read this nosiwlim i and smta that the above es
correct. I agree to uimply with all city and county ordinances and slam laws relating to
building construction, and hereby authorize representatives of this city t0 enter upon the
ahnve-menldhod property for inspection purposes.
(We) zgot to save, indemnify and keep harmless the City of Cupertino against
QTY, MECHANICAL PERMIT ` i FEE
- -
SEISMIC FEE '
PERMr F ISS DANCE t
'
.'IMTRIC PE -
ORADD TO MECH.
PLUMBING FEF. I
dabilities,judgments, costs and expeaseswhich may in any way accrue against said CityALTER
achim,macenflhe grent gufthisperml,
AIR HANDLING UNIT ('1'014fKKI CPM)
MECHANICAL FIiE
APPL TUN RS S AND WILL COMPLY Will ALL ON -POINT
SO' EG
AIR HANDLING UNI'I'IOVER IO,WO CFM)
CONS'I'RUCfION TAX
-
-
Sig 1 i App icamIC t or �, Dme
H OUR MATERIALS DISCLOSURE
Wfll thcitmiicat future huildiag occupant amid or handle hazardous mnterial
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (7) I WAS) H' N)
'
-
'pal Code, Chapmr 9.12, and the H.10, and Safely
Code, Section 2.5532ed'
as def ned by the Cupenm�f.ut!
1 [GATING UNIT (OVER 11111,(1(10 BTU)
'
VE NT[ LATION FAN (SINGLE RESID)
' [3 YO, '
I'
PAID
Dale Receipt#
-
BOILER 'COMP (THP OR 100,(IOU NTD)
Will the applicant building occupant use equipment or devices which
emit hazardous air cnnmminvms o defined by the Bay Area Air Quality Management
,
TOTAL:
BOILER -COMP (OVER I(H.000 BTU)
OlsrimE
El Yes is
AIR CONDITIONER _
"
I have read rbc huzardou anatrialslcquiremems under Chapter 6.95 fthe Coli-
ISSUANCE DATE ,
NEW RESIDENTIAL NEED, SQ. Ff..
forma Beal Safety Cr hmu25505.25533and 25534.1 der, dthatif Ile
bulldin s to 11- t 'e mmnt, that it is my renpnnaihiliy onomourn pant
(If l iR P '' tet prior ld i"annce of erti cy.
` Q(
ISSUED BY:
I; TOTAL:
Ousisroyhollorizeragem D: e
OFFICE,