2012611 1-Iiro
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CITY OF CUPERTINO BUILDING 'ELRCI'RICAL
IIUII.DING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMITNO.`— O
SOOOI /v_``
HUILDINGADDRESS:
SANITARY NO..
APPLE TION SUBMITTAL DATI
/NFNiTt� z ooi� C UP���n.vf/
!'
OWNER'S NAME:
NAME
CO,�(\�O���O/'y / 1 N //O
�� N Oil
NIC
❑
CONTROI.p
:HITLCI'/F.NGINEER: LIC NO;
)OW/a. s�s.
CONTACT: PHONE:
BUILDING PERMIT INFO
BLDG 91 PLUMB MUCH
1'SJ
%�LFftLES�. 0
❑CmnsultnntPttsPaid M1yApplicant (Iniliap
_ _
LICENSED CONTRACTORS DECLARATION
1 hereby arfrn that um licensed under powbinis of Chapter 9(commencing
1
QTY. I?I,I:CTRIC PERMIT 'FEE'
JOB DESCRIPTION
PERMIT' ISSUANCE fO
with Section 700(onf Division Jrfthc Dismiss. l'n +i s ,and my lice« is
in full force and effect
RESIDENTIAL'
❑SFDWL ❑ KITCHEN REMODEL
APPLIANCES -RESIDENTIAL
Littnse Cl s Lic.p
Dec Convamor
[]ADDITION ❑ PLO MBING RF. -PIPE
❑MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
[I INTERIOR El CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
CHTIECFSDECLA A
1undcrsm p •s public records
PANELS
-
UPT0200AMPS
Licensed Pmfcssiomn t
201-1000AMPS
OWNER -BUILDER DECLARATION
1 hereby affrm tom I em uempt from the Commamr', License Law for on,
t following reason. (Section 7031.5, Business end Professors, Code: Any city or county
[I BATH REMOUIiI./lilil'AIR ❑DIiMG1.ITIQN
❑0TH R
OV131111N1(IAMPti
,SIGNS ELECTRICAL
which requires a permit m construct. alcor, improve, demolish, or repair any structure
prior to its issuance. also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions ofthe Contractors License Use (Chapter 9
'^
SPECIAL CIRCUIT/MISC. V
,
;
(commencing with Section]lNtO)of DivisionJnf the Business and Pmfcisions Gde)nr
that he is exempt therefrom and the basis for the alleged exemption, Any violation of
Section 7031.5 bymy applicant for a permitsuhjeete theapplic,cal we civil penally of
rtmorroma live herself dollars ($500).
M 1, as owner of the pmpnrty or my employccv with wages as their sole compensation,
will do the work, and the,truco a Is not intended oroffered forsale (See 7M4. Buvincss
and Professions Code: The ConuumoR Licence law does not apply m an owner of
TEMP. MM Ell OR POLE INST.
❑ NEW BLDG/ADDITION ❑ DEMOLITION
El TENANT ❑ FOOD SERVICE
IMPROVEMENT
El OTHER
-
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES -FIXTURCS
-
NEW RESIDENTIAL ELECTR SQ FT.
property who builds or improves thermal, and who docs such work himself or thmugh
his own employees, provided that such improvements art not amended m offered for
sale. H.. however, the building or improvemem is sold within nneyemof completing, the
SQ. FT. FLUOR AREA
WSQ. FT.
nerbuilder will hove the burden of proving that he did not build or improve for puts
'
-
OPAL:
Fuse "fork.).
Los owner of the propeny, am exclusively contraaling with licensed contractors to
condoner the project (Sea. 7144, nosiness and Professions Gxlep'Ihe Contractor's Li.
tense Las, does not pplymnnuwnernf,imperty who huilds or mimics ther, on,and
s, -
QTY. PLUMBING PERMIT' t IEE
who contracts for such projects with a convaom4s) licensed pursuant to the Concluder'.,
PERMIT ISSUANCE rl
Licene law.
1 am exempt under Sm. . B & P C for this reason
Owner Date
ALTER - DRAIN & VENT- W
VALUATION
WORKER'S COMPENSATION DECLARATION
BACK FLOW PRUI'ECT. DEVICE
I hereby affirm under penalty of perjury one of the following deductions:
STORIES
TV PE COINS I'HDCTION
I have and will nminmi n a Cenificme of Consent to sco insure for Workera Compem
lotion, as provided far by Section 7700 or the Labor Colc, for the performance of the
work for which this pennit Is issued.
DRAINS- FLOOR. ROOF, AREA, COND.
FIXTURES - PER TRAP
❑ 1 have and will maintain Workers Compensmirn Insurance, as required by Section
37W f,he Lahr Cee. far the Performance of the work for which thispe it is'ss oed.
My Werke C s ' Insurer cartitt Policy o 3�c i� 7
Policy No
OCC. GROUP
APN
GAS - EA. SYSTEM- I INC. 4 OUTLETS
GAS- EA. SYSTEM -OVER 4 (EA)
^ PTION FROM W6W KERS'
' COMPF.N ION INSURANCE •
GR ASE%INDUS'1'RL WASTE INTiRCEPI'OR
BUILDING DIVISION PUTSthe
(fhiv section need ern become tied if permit is for one handled dollars (SI WI
err Ievs.7
GR[�SI3'I'NAP
PLANCHECK IEE -
-
SEW13N-SANITARY,-STORM EA. 200 FT.
ENERGY FEE,,bore
Icertify than in tiro ro ormunrcmd, work rnr which this pennit is i.vxued, I shall
not employ any person in any manner so as a become subject m the Workers' Compere
WATER HEATGR WNENTT1_ECTR
GRADING IEE
uves i f Confrmia, Dam
Applicant t
NOTICE TO APPLICAM': If, after taking this Cenifeate of Exemption, you should
become subject to the Worker's Compensation pmvidom of the Labor Cade, you must
WATER SYSTEMaREATING
SOILS FEE Is -
forthwiN comply with such provisions onhia pennit shell he deemed revoked
WATER SI7RVICE
CONSTRUCTION LENDING AGENCY
t heeby olllrnnh them is u eomswnion lemdir, agony fnr the perfnrmomcc of
N13W RESIDENTIAL PLMB, SQ. FT.
ca
OTU,:
c the work for which this pennh is issued (Sec. 3097, Civ. CJ
o Lender's Name
TOTAL:
Lenders Address
infuriation is
I certify that 1 have read this application and state that the above
I carrier. l agree a comply with all dryand county ordinances end some laws relating m
building construction, and hereby auNorize representatives of this city m enter upon the
QTY, MECIIANICAL PI7RMIT FEE
JAID
PF.RMI'I' ISSUANCE
ALTER OR ADD TO MECH.in
' above-mentioned property for inspection purposes.
(We) agree err snug Indemnify and keep herandca the City of Cupertino against Iiabilioes,jadgmenNca,Ivtmd expenses whichntay in mry wayaccme againstsaid City
consequence of te gru ou gof IIdx permit.
AIR HANDLING UNIT (TO I0,000 CFM)
MECHANICAL 143E
APPLICANT UN !RSTANDS AND WILL COMPLY WITH ALL NON POINT
$ODRC • CD 'I'I S ���111 l
AIR HANDLING UNIT (OVER I0JMN 24 ANS;9
EXHAUST HOOD( W/DUCT)
CONSTRUCTION TAX
SI ... too,inAgllicantlCortaram Date
HAZARDOUS MATERIALS DISCLOSURE
Will ther,,deam or fertile building mcuprm sure no handle Inearkn, material
HOUSING MITIGATION FEE
HEATING UNTr(To IOq(NN) TI Y Ur Vuf L.tT 111 VV
as derned by the Cupertino Municipal Code, Chapter 9.12 and the Health and Safety
Code Section 25532(a)7HEATING
UNI'r(OVER 100, XI lGli
VENTILATION FAN (SINGLE RUSH )
El Yes ❑No
PAID
-
Date Receipt of
BOILER-COMP(JHPOR I(1(1.(N7(1 RTU)
Will the applicant or future building occupant use equipment or devices which
n hazardous air contaminants as defined by the flay Area Air Quality Management
TOT
District!
❑Yes ❑No
BOILER - COMP (OVER 100,000 BTU)
AIR CONDITIONER
1 have read the hnzurdous materials rcquircnems under Chapter fi.95 of toe Cali-
from. Health & Safety Calc, Sections 25505, 25577 125534, 1 understand that If the
building does not emrrcody ouve n tenanu, that 11 is noy responsibility to really me ocaupo nt
ISSUANCE DATE
N13W RESIUBNPIAL MECH. SQ, FP.
of the nequiremea which must be met prior to issuance of a Certificate of Occupancy:
ISSUED BY:
TOTAL:
Owner or amhoriud «gem Dam
OFFICE