30727APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE SALL POINT PEN ONLY "1.
CITY OF CUPERTINO s BUILDING -ELECTRICAL PERMIT NO. % %
BUILDING DIVISION APPIACATION/PFRMIT PLUMBING. MECHANICAL O 1 Z 1
BIIIIAINGP,RO.IEC'1'IDRNTIFICA'1'IDN
1 BUILDING ADDRESS SANITARYNO. • I APPLICATION SUBMITTAL DATE
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- • • I ❑ Consultant Fees Paid by Applicant (Initial)'_
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I hereby affirm that 1 nor licensed under Provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the B usiness and Professions Cade, and my license is
in full force
QTY ELECTRIC PERMIT'
PERMINSSUANCE
a00
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16F.
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end effect.
License Class Lia. M
Contractor
ARCHITECTS DECLARATION
1 understand my plans shall he used as public records
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APPLIANCES - RESIDENTIAL
PANELS
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❑ADDITION
Up 200 AMPS
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Licensed Professional
OWNF.R.BUILDER DECLARATION
I hereby affirm that I am exempt Earn the Contractors License Law for the
following reason. (Section 70315, Businessfc and Pro&,icons Cade: Any city or county
201.1000AMPS' -'
OVER 1000 AMPS
ELECTRICAL
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which requires a pemdt m cmwwe6 that, improve.
improve. dentnllvh, or repair any structure
prior o its isxuance, also requires the applicant for such permino file usigned statement
SPI:CIALCIRCUIT/MISC.
that he is licensed putamm to the provisions ofthe Contmmors License Law (Chapter 9
TENOR MFT ER OR POLE INST.
+00
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!commencing with Section 7") of Division 3 w ithe Business and Professions Code) or
that he is exempt decmfrom and the braise !or the alleged exemption. Any violation of
Section 7011,111 any opplicunt fora pemtil subjeandic applicant n a civil earely of
not more t hon Eve hundred dollars l$5001.
El of the progeny, or myentFlnyceswiN wagcsazNeirsolecompen&urian,
POWER DEVICES
SWIMMING
SWIMMING POOL ELECTRIC
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6 3
will do tM work and Immoral.. isnot mu nded orniTemd forsale (Sas 704y Business
and Profaxirns Code: The Convenors License Law dons not apply In as owner of
progeny who huilds or improves thereon, and who dons such work himself or through
OUTLETS -SWITCHES -FIX
his own etnpluyees, provided that such improvement, ,,a not immrided or offered for
NEW RESIDENTIAL Ill Q PT.'
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sale. If, however, the building or impavemem is sold within one year of cmnpletinn the
owner. will have the burden of Fmving that he did not build or improve for put.
pose of wda.).
1, as owner of the pmpeny, am exclusively contracting wird licensed animation to
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construct the Foiled (Set. 7044, Business and Professions Code:) Thin Contractors Ls
se Low does not apply to an owner if property who hu lld&tri lumrmm themer. trod
QTY, PLUMBING PERMIT '7`
who contracts for'such projects with a contractor(&) licensed pursuannn the Contractor's
s
PERMIT ISSUANCE
License law.
❑lam axe under See ,B&P C fur Nis r<azon
. ALTBR-DRAIN&VENT-WATIiR IRA) .
WORKER'S CO ?NSATION DECLARATION
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BACK FLOWPROTECEDEVICEI
hereby affirm underpena0 ofperjuryoneofthefollacmrmke,'
'DRAINS- FLOOR, BOOK AREA, COND.
have coil will muimainaCcnif¢me ofCnnsenunselGimure fur Wurkcr's Compcm
station, as Provided for. by Section 3701 of the Labor Cale, for the performance of the
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iFIXTURES - PER TRAP
workforwhichthispermitisissued
❑ 1 have and will maintain Worker's Compensation luxuriance, as required by Section'
3700 of the labor Code, forthe performance oflhe work for which this permit is issued.
GAS- IA. SYSTEM. I INC. 4 OU'FLEES
My Workers Compensation Immence cruder and Policy number su:
Cartier: Policy No.:
GAS -EA. SYSTEM -OVER 4 UA)'
CERTIFICATE OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE
GHEASPJINDIJSTRI. WASTE INTERCEPTOR
(This section need not he completed if the permit is lornne hundred dollars I$ IIXh
or lexa.)
GREASETRAP
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I ccaifythat imam performance .1 he week for which this permit is issued. l shall
not employ any person in any manner so us to become subject io Ne Wnrketx'Compem
satins laws of Cul i forma. Data
Applicant
SEWER -SANITARY -STORM HA. 200 FT.
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WATER HEATER WNENT/ELECTR
yNOTICE
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TO APPLICANT: If, utter making his Cenifcme of Excmplion, you aboard
become subject nt the Worker's ComPensetion provisions of the Labor Cotte, you must
forthwith comply with such provisions or this Permit shall he deemed revoked.
'
CONSTRUCTION LENDING AGENCY
I herchy affirm than there is acan&tamion andingagency forth, performanttof
WATER SYSTENIG REATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. fed.
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the work for which his permit is issued (Sec. 3097, Civ. C.)
Lenders Name
_
Lenders Address -
,
TOTAL
I certify thin I have rood this application and mine that the above information is
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comet. I agree to Comply wllh all city and county oNlnuncca end xtale laws minting u'
building construction. end herchy cohnve mpresenlalivca of this city m enmruponthe
QTY. MECHANICAL PERM IT
PERMIT ISSUANCE
above-memioned property for inspection purposes.
(We) agree m save, indemnify and keep hamtlas the City mf Cupertino against
Afj'ERORADD'TOMI7CI4,,. '
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liabilities,judgments, coxa and expenses which may in any way accuse against said City
nsegncnce of the graining of this pcmtit. -
AIR HANDLING UNIT (TO W.0(X1 CFM)
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE WULATIONS.
AIR HANDLING UNIT (OVER 10.000 CFM)
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41fililignamni
fApplicnnl/Cnma,mr Date
s EXIIAUST HOOI)(W/DUCT)
'IIALARDWSh1ATE IAIS DISCLOSURL
HEATING UNIT TO I all BTU)
Will the applicem or fmure builJin xcupam store or handle hmmdous material
as defined by Ne Cupertino Municipal Code, Chapter 9.12, and the Berlin and Safety
,Cocle. Section 25532(x)'!
HEATING UNIT(OVER IogtX10 BTU)
❑Ycs 1. .,❑No �,
s VEN9)LATIONFAN(SINGLE RESID)
Will the applicant or future building accupanl use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
fl01LER-COMPfJI1P OR 100,(KK) $TUI
District? -
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❑Yea n �No
BOILER- COMP (OVER 100,000 BTU)
AIR CONUI'IIONCR
1 have read the Lai Nous moredals tequiremems under Chapter 6.95 of the Cali
NEW RESIDENTIAL MECH. - SQ. F-n
fords Health & Safety Cock, Sections 25505, M533 and 25534.1 undersand Not if Ne
building does not currently have a tenant. that it is my responsibility to notify the occupant
of the requirements which most he met prior to issuance of a Candace of Occupancy.
Owner or authorized agent Dale
- 3'6TAL:
t OFFICE
FEE
FEE
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BUILDING PERMIT INFO
HLUG ELECT'
UMB . H
BUILDING DIVISION PT:FS
PLANCHECK FEE".
JOB DESCRIPTION -
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RESIDENTIAL:
❑SFDWL -
11
❑ KITCHEN REMODEL
❑ADDITION
'.0 PLUMBING RE -PIPE
❑MULTFUNIT, '
❑STRUCTURAL
MODIFICATION
❑INTERIOR
'El CHIMNEY REPAIR
,IMPROVEM
❑ BATH DEUREPAIR. F1 DEMOLITIQN
OMCOMMERCIAL-
0
MERCIIAL- .
❑NEW BLDG/ADDITION ❑DEM LITION
❑TENANT❑FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ, FF. MOOR AREA $/SQ. FI'.
�AlD
�.9Aa8 3 REC
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STORIES TYPE CONSTRII(TION
PAID
BUILDING ITE
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE _
HOUSING MITIGATION
FEE
PAId—�
Date Receipt#
1-3-97 TOTAL
t.
ISSUANCE DATE.
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ISSUED BY:
BUILDING DIVISION PT:FS
PLANCHECK FEE".
ENERGY EEE
GRADING FEE
SOILS FEE•
PAID
BUILDING ITE
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE _
HOUSING MITIGATION
FEE
PAId—�
Date Receipt#
1-3-97 TOTAL
t.
ISSUANCE DATE.
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ISSUED BY: