99080121APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PERMIT NO
BUILDING DIVISION APPLICATION/PF,RMPP PLUMBING m MECHANICAL
�
-BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS:
SANITARY NO,
APPLICATI NSUtl TTAL D ATE
OW M: - . PITON 1 :
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CONI' ACTON' MF.: t/J LIC NO:
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❑ Consultant Fres Paid by Applicant (Initial)
BUILDING PERMIT INFO
BL ELECT PLUMB MM
❑
LICENSED CONI RACTOR;S DECLA TION
I brachy alum ton I ant lkemsed wrier provkvions f Ch"Ie, 9 (commando,
QTtY. ELECTRIC PERMIT FEF.
-r:
JOB DESCRIPTION
with Section JOf10)ol Divisimn3of the llusiness end Profess nn Cala anJ mylicensc is
in full force and affect.
License Class Lie.»
Uam ConOuedor
RESIDENTIAL:
❑DWL ❑KITCHENREMODEL
❑ ADDITION E3 PLUMBING RE -PIPE
MULTI -UNIT ❑STRUCFURAL
MODIFICATION
PERMIT ISSUANCE
APPLIANCES—RF.SIDIiNT1A1.
H IiCI'S DIiCLARA'TION
edespadi,bNo t,
rUPTO200AMPS
PANELS
. men fissions
ON
OWN -BUILDER DECLARATION Contractors o far the
follow1 hereby a(Tmm that am Busied (rain the Cmntrac Co License city
Any city orcoumy
whichimguiresa rearsom arroutt 0315 eBusinnsmproand ve. demolish, or
which ror Inc n permit ra construct, abet, improve, demolish, or repair any srtumurc
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT ❑SWIMMING POOIS
❑ BATH REMODEIIREPAIR ❑ DEMOLITION
❑0771ER
201-100OAMPS
OVER HROAMPS
SIGNS ELECTRICAL
r III thuvitionxm fur wehpctor aeaw(gned hapter9
SPECIAL CIRCIJI'F/MISC.
purnnrequlree
pursuant t0 the x acersfile
that he is licensed 9
that he is of the Canrnmor's law
TEMP. METER OR POLE INST.
COMMERCIAL'
trot c wit of Division nd Professions Codeer
ongwith Section]IXIdth Division Joftheeged exempt sCade) or
he is
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
❑ W BLDG/ADDITION ❑DEMOLITION
IKIWI?R DEVICIiS
Section 703 L5 by any applicant for a permit subjects the applicant to a civil Penalty of
t more than five hundred dollars ($500).
I, as owner ofthe ro n Y employees a compensation,
❑ t pe y, or em toded with burned astheirsole asm tion,
will dothework, and the structuress nut, orrinedofaronl ]1144. Business
ENANT - ❑ FOOD SERVICE
ROVEMFNT
❑OTHER
SWIMMING POOL ELECTRIC
OUTLETS—SWITCHES—I IX'1'UNES
a(Sec.
Liam
and Prnfeuiob Calc: The Contmereo Licence taw does not apply toff owner of
properly who builds or improves thereon, and who dues such work himself or through
-
hi.v awn provided that such improvements me not intended or offered for
NEW RESIDP.N9'IAI. 91.1?CFR Q PT.
SQ. FT. FLOOR AREA
EISQ.fTf.
however. the
sale. IL however. the building orimprovemem is sold within one yew n(mmpletion. the
owner -builder will have the burden of proving that he did not build or improve for put
pose mf cele.).
❑ 1, as owner of the property, a exclusively contracting with licensed combecturs m
•f0 U
construct Onedoes hoed Business and Professions Cale:)lhe Contractors
-
ad
ply1.ad t who initiativesthe harCorean,and
ply mos
QTY. "t PLUMBING PERMIT E
I
wnmlawdoeor such with a ommadeny
who eommets far such pmjuts wlthaumtracmr(s)licensed pursuam lathe CnnOaemr's
censeddurs
PERMIT ISSUANCE
License law.
❑ 1 am exempt under Sec. , B & P C far this reason
ALTER—DRAIN & VENT'— WA'I'EN (EA)
Owner Data
VALUATION
'ac
WORKER'S COM PENSA PION DECLARATION
BACK FLOW PROTECT'. DEVICE
I hmmbyal firm mmler Penalty nfperjury ane aftha following declarations:
e43 {NV
DRAINS— FLOOR, ROOF. AREA, GOND.
E]I have and will meardem.Cenilicae of Cunodamielf-insure ko Worker's Compem
phwh thi for by Section J]BB of the labor Code, for the performance of the
STORIES
TYPE CONSTRUCTION
FIXy'ORES —PER TRAP
work(a
work far which this permit is issued,
❑ I have end will maintain Worker's Cmmpcnsutinn Invutnnce, m reyuircd by Section
Wof the Lahr Cale, for the per(nmunce mfthe work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Currier: Policy Nn:
GAS—HA. SYSTEM -I INCA LETS
OCC GROUP
ANN
HOZ-107
OAS — li A.SYS'I'EM-O , 41EA)
CERTIFICATE OF EXEMPFION FROM WORKERS'
COMPENSATION INSURANCE
f(hissenlon nred nrn bewmpletcd il'Iho permit is for one hundred dullnrs (EI(XB
or less,)
GREASETNDU. L WASTE INTERCEPTOR
BUILDING DIVISION IL'FS
GRPASIi AI'
PLANCHECK FEE
SE—EANI'fARV—STORM F.A. 2(10IT.
Icenify that in the peRormanccofthe work for which this permite,daed, l shall
not employ any person in any manner so as m become suhlect m the Workers' Compem
ENERGYFEE
WATER HEATERWNENT/ELECTR
satima Laws of California, Date
Applicant
GRADIN EE
sS ILS FEE] A6,11F
NOTICE TO APPLICANT. If, after making this Certificae of Exemption, you should
become subject In the Waukee, Compensation provisions of the Iahm Colo, you man
WATER SYSTENVIWiATING
forthwith romply with such provi,myourthis permit shall be deemed revoked.
WATER SERVICE.
7
UG
NEW RESIDENTIAL I'hMB. SQ. PTqFrP
CONSTRUCTION LENDINGAGENCY
len ding agency Lsr the permrmance of
IharewYalfirmNmmit
issued(et.
PAS
ate Went fir
_
30
the work for which this permit is issued (Sac. 7(19], Co. CJ
i
Landers Name
1.:
Lender's Address
IOTA
1 certify that I have read this npplicatinn and state that the above information is�,-
carried. I agree to comply with xn city and county ordinances and state laws relating m
building conservation. and hereby authorise representatives of this city to enter upon the
QTY. MECHANICAL PERMIT
SEISMIC 17EE
abovamentioned property for invpection purposes.
save, indemnify and keep harmless he City of Cupertino against
(WO) agree m rm
PERMIT ISSUANCE
ELECTRIC FEE
Iiahilince,judgments costs and expenses which may in tory way accrue it'itet said City
in conseyue eofthegmnti Bmf, operron.
AI:fBN OR ADD'FO MECI{.
PLUMBINGFEE:
-
PIR HANDLING UNIT ITO IU,gI(1 CFM)
MECHANICAL FEE
APPLIC N C1fIIST NO WILL COMPLY WITH*NO-�I�
AIR HANDLING UNI'F(OVBR 10,(IW CFM)CONS'FRUCDON
TAX
Slgrm F ppllc Cnn"act
HAI D US MATGNIALS DISCLOSIJ
EXHAUST HOOD(W/DUCD
HOUSING MITIGATION FEE
HEATING UNIT (M 100.000 BFG)
511 the applicant umh ilding«cupanistomorhandlebmallousmaiedal
as defined by the Cupertino Mumc al Cstde. Chapter 9,12, and the Health and Safety
Code, Section 25532(a)'I
HEATING UNIT (OVER 100,000 H'1'U)
E] yes
Will the applicant or I'umrc building maupent use equipment or devices which
msdt husardous air contaminants as defined by the Bay Arca A it Quality Management
Dinried4
❑ Yes
PAID .—
Data Re t a
TOT
VENTILATION PAN(SINGLE RFSID)
BOILER— COME UHP OR 100,00(1 BTU)
BOILER—COMP (OVER 100,000 BTU)
AIR CONDITIONER
I have rcw1 thego(.95 of a Cnli
(orale Ilcahh 5115, 25533 antl 25514. tnnd t at if the
s rcquimmenu eater Ch1'.;d
buildingd t Nat it i.v my responsibilityly lh snaPam
ISSUANCE DATE ^ /7
NEW RESIDRN'I'IAh MECH. SQ. PT.
ofd ata issuance ofa 10
ISSUED BY:
OgsNO,orteed: eat )ae
TOTAL',
OFFICE