29979APPLICANT TO.FILL IN INFORMATION WITHIN RED LINES - USE BALL P61NT'PEN ONLY �• '
s
CITY OF CUPERTINO ?' - BUILDING -ELECTRICAL, -
IT PLUMBING MECHANICAL..
BUILDING DIVISION APPLICATIONTP RMIN
'BUILDING PROJECT IDENT1FICATION
.. rPER MIT NO ��
-
'
BUILDING ADDRESS: - H - -
SANITARYNO,
APPLICATION SUBMI'1'1'AL DA'IH
Q' I 'Y1�.U%Da� V G.S _ � '
116WNL' NAME: y� PHO
, 9— /.1 Q+4�Q �
C TR CPO
"y`NAME: r- LIC NO;
N R G C
NIC
❑
CONTIi(lLM
ARCHITECT/P.NGINEF.R: LIC NO.
MURLSS: - .
_
'BUILDING
CONTACT:,•,. ,PHONE: _
-
PERMIT INFO
- -
❑ Consultant Fees Paid by Applicant (Initial)
RLDG ELECT' PLUMB MECH
I.Q=Z
. 1400
�UUr
- - . LICENSED CONTRACTOR'S DECLARATION
1 hereby rm that 1 am licensed uprovisions under pvons of Chapter 9 (commencing
affi
with Section 7000).f Division 3 of the Rnmecssand Professions Code, anlm license is
y
in full force std effect. '
License Class Lick _
DateContractor
QTY. FLECTRICPERMIT - FEE
-
JOB DESCRIPTION
RESIDENTIAL ' -
El D❑KITCHEN REMODEL
El ADDITION (_1 PLUMBING Rr�piPE"
❑MULT-UNIT ❑STRUCTURAL
MODIFICATION
-
PERMD'ISSUANCH
APPLIANCES' -RESIDENTIAL
�
ARCHITECTS DECLARATION
undernund my plans shall be used as public recoils
PANELS
z8g1
Q
p¢���dd •]
a 4 F
License) Professional ..
OWNER -BUILDER DECLARATION
I hereby air". that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Businessman! Professions Ce: Any city or county
.UPT0200AMPS
'
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMEN'I'i�
❑ RATH REMOD; EFIR � DT�IOL}TION
❑ OTHER �'�/`jA .e.o.
20LI(MOAMPS
OVER IUMIAMPS
SIGNS ELLCfRICAI.
m¢
�.
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such perntiuo file a signed statement
that he is licensed Persian, in thepmvislnns of the Crimractorb License Law (Chapter 9
SPECIAL CIRCUITIMISC.!i
/7 G
TEMR METER OR POLE INST,
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
OTEN ANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
W00
6 c C
'^Section
y
D•
6
S
' ^ 0
' W
w ^
(commencing with Section]000) of Division 3 ofthe Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
9031.5 by any applicant for a permit subjects the applicanuo a civil penally'd
not more than Ove hundred dollars (1500),
1, as owner rf the property, or my employees with wages us their sole compensatiom
roti License Law does of apply to an Business
and the he Contractor's
and Professions
and Professions Cale: The Conammr'ac License Law does not apply to an owner of
POWER DEVICES
SWIMMING POOL ELECTRIC
-
OUTLETS - SWITCHES -FIXTURES
6
property who builds or improvers financed, and who does such work or through
-
his o
his own employees, provide) that such improvements are not intended or offered for
i deed or
aide .If, however, the building or improvement is sold within one year ofcompletion, the
owner -builder will have the burden of proving that he did not build or improve for pur-
pose of srle^)c
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 1044, Business and Professions CMe) The Comraor'I Li
NEW RESIDENT 'IAL 'ELECTR 5
.Fel'. FLOOR AREA
II�� pp fir,
P Hr 8 Ily
SISQ. FT.
-
- TOTAL:
cense Luw, does not apply torn ownerofpropeny who builds or impmves thereon, and
QTY, PLUMBING PERMIT FEE
who contracts for such projects with a cormorants) licensed pursuant m the Contractors
PERMIT ISSUANCE
License Lw.
L am exempt under Sec. ,B&P C for 1homannn
F7(,
Q
'JUN I 1996
ALTER - DRAIN & VENT- WATER (PA) -
°a"
WORKER'S COMPENSATION DECLARATION
VALUATION
CITY Ur wrizHnNU.
BACK FLOW PROTECT. DEVICE
•°w"`n
1 herebyaffirm under penalty ofpejuryone of the following Jalker'sCs:
DRAINS - FLOOR, ROOF,AREA, COND.
to for Worker's Courtlier- of the
1 ❑um,.ave and will for by eCeni 37M of the wat to Imor Cod,
vadum az provided for by Section 3100 of the Lubm Cude, for the performance of the
, STORIES
TYPE CONSTRUCT ION
work far which this permit is
FIXTURE$ - PER TRAP
❑ 1 have and will maintain Warner's Compensation Insurance,
artier' require
Essued.
which an i
My of Ne Labor Cndpfonthsumme cancer and Polic forthis pemtit is issued.
My Worker>Compensation lnsurnce carrier and Policy number are:
GAS - EA. EYS'I'EM-1INC. 40fITLLTS
OCC. GROUP
AI'N
t'aut'er: I Policy
GAS - EA. SYSTEM -OVER 4IRA)
FROM
IEXEMPTION FROM WORK[RS'
CERTIFICATECOMPENSATION
COMPENSATION INSURANCE.
(This section need not be completedifthe permit is furore hundred J911an($1(107
or less.) -
'
GREASE/INDUSTRL WASTE IM'GRCEPI'OR
BUILDING DIVISION FENS
GREASE TRAP
PLANCHECK FEE
SEWER -SANITARY -STORM, 200IT.
-
,rectify that in the any mannece r this permit is the Workers' Counties-
not employ any person in any manner m az m become subject m the Wakens' Campcn-
as e work for to
Oz action Laws of California. Date
- z Q Applicant
ENERGY FBE
WATER HEATER WNENIVELECTR
GRADING PEE
WATER SYSTEM/fRfiATING
t:A NOTICE TO APPLICANT. If, after making this Cenificte of Exemption, you should
a ; become subject to the Workers Compensation provisions of the Lbor Code, you must
forthwith comply with such provisionsor this permit shall he deemed revokev.
0. '
a z CONSTRUCTION LENDING AGENCY,
U0 Thereby affirm that there is a construction lending agency for the performance of
SOILS FEE ,
WATER SERVICE.
PAID
Data Receipt
NEW RESIDENTIAL PLMB. SQ. Fr.
p the work for which this pemtit is issued (Sec. STO. Civ. C.)
01'-' Leaders Name
Lenders Address
L unify that I have mad this application and state that the above information is
TOTAL:
TOTAL:
BUILDING FEE
((AA correct. l agree to comply with all city and county ordinances and state laws relating to
�z buildingconswction.andherebyauthorivereptesenutivesupon
QTY. M ECI IANICAL PERM IT FEE
SEISMIC FEE
s above-mentioned piopeny for inspection puryosen.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
PERMITLSSUANCE
ELECTRIC FEE '
ALTER OR ADD TO MECH.
PLUMBING FEF.
liabilities,judgments, costs and expenses which may in any way accme against said City
eqga
in consequence of rhe ming of this Norms.
AIR HANDLING UNIT (TO 10.000 CFM)
AfECHANICAI. FEE g
'
APPLICANT UNDERSTANDS AND L COMPLY WITH ALL NON -POINT
' SOURCE UL IONS.
%�
AIR HANDLING UNIT (OVER IB,000CFM)
CONSRUCTIONTAX
'wf�� %�
EXHAUST HOOD (W/DUCD
Sign reof ApplicaHAZA DO Uam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building coupon store orhancite hasNous material
,
HOUSING MITIGATION FEB
HEAPING UNIT LTO mQ00a BTU)
a defined by the Cupertino Municipal CMe, Chapter 9.12, and the Health and Safety
CMe, Section 255320)1
❑Yes F-1 No
Will the applicant or future building occupant use equipment or • which emir havtdous air contaminants as defined By the Bey Arta Air Quality
Management
gement
District,
Dyes' r nNo
HEATING UNIT (OVER 101,000 BTU)
PAID / ^'
Date ReceiptM
VENTILATION BAN (SINGLE RESID),
BOILER-COh1POHPOR 100,000 BTU)
TOTAL:
BOILER - COMP (OVER IW,WH BTU)
-
AIR CONDITIONER
I have mad the hurNous contends eunder
m,u 533n Chapter Ceti-
ISSUANCE DATE
NEW RESIDLNTIAL MECH. SQ. FT.
fomlaHealth git.&Safety Gde. Sections 25505, 25531end255b1.1 understand dor if the
me have ismy the cecupant
Cilitycate
'
he met pthato
ofthe resent eats which onfy
of the requirements which must be ton poor to nfa Certificate of Occupancy.
uace ofir
ISSUED BY: (�
Owner or authonecd agent - Dam
TOTAL: fflM
OFFICE
5
zz
O
CC
UJ _
O_ O
Z) z
U O
LL I-
0
Ow
Lo
ADDITIONAL PERM FEES
BUILDING PROJECT IDENTIFICATION
VALUATION
noon Ess ) I+ O (
OWNEP'6 �.,,
NAME
FEE SUMMARY
coNrnAcron s
NAME'�� HA�.Icli(? 12�-
LIC, NO
BUILDING
PLAN CHECK
FEE
carvr BAC1ON s
Aooness
PHONE
SEISMIC FEE
OTV. ELECTRIC PERMIT FEE
UTLETS- SWITCHES -RECEP
ELECTRIC
39 ` c
LIGHTING FIXTURES
PLUMBING
APPLIANCES- RESIDENTIAL
PANELS
MECHANICAL
�L
SIGNS
TOTAL
( '
J yIve
SIGNS TRANS.
SPECIAL CIRCUIT
EMP. METER OR POLE INS.
AENMir vauoanory
or
ISSUANCE DATEBloc.
MOTORS SEE FEE SCH.
SERVICE CHANGE
TOTAL7 l
J
GTV. PLUMBING PERMIT FEE / i
nlle�clT.
�l.J
nlc.
MECH.
ALTER -DRAIN & VENT -WATER (EA.)
BACK FLOW PROTECT. DEVICE
✓
J
YYY
f
1
DRAINS -FLOOR, ROOF, AREA COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1 INC.4 OUTLETS
GAS - EA. SYSTEM - OVER 4 (EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS- 1 INC 5 V.B.
LAWN SPRINKLERS - OVER 5(EA.)
SEWER -SANITARY -STORM EA. 200fl/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP,
TOTAL
GTV. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
AIR HANDLING UNIT (TO 100000.F.M-1
AIR HANDLING UNIT (OVER 10000C.F.M.)
EXHAUST HOOD (WITH DUCT)
HEATING UNIT (TO 100,000 B.T.U.)
HEATING UNIT (OVER 100,000 B.T.U.)
_
VENTILATION FAN (SINGLET
BOILER -COMPO H.R or 100,000B - TU)
901LER.COMP 10a!1100DOOBTt0 SEE FEESCH.
— C7
TOTAL