S 0939 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 0939
BUILDING PROJECT IDENTIFIT]ATION '
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
E:
( t�`'t?�iq ViIsCPt
AME: PHO —/ C NTP�ACT R'SN f '6n.
� J�x' l/ � NEC CONTROL If
ARCHITECT/ENGINEER: LIC NO: REsSS • ���� ❑
0 43owleg-1 U,4ol,
CONTACT: PHONE: S�)j 5BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ [:1 ElLICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE III"'
I henchy affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
awo,Z withSation]01Kp ofDivieion3ofthe Business and Profession Code,and my license is PERMIT ISSUANCE RESIDENTIAL
F W in full force and effect `�
LUV License Clasa C- -Lia it -79L6 ❑SFDWL ❑KITCHEN REMODEL.
APPLIANCES-RESIDENTIAL
rF ate Con DELL ❑ADDITION El PLUMBING RE-PIPE
I„p ARCHITECT'S DECLARATION PANELS LJ MULTI-UNIT L1 STRUCTURAL
Z O Z 1 understand my plans shall he axed as public rccards MODIFICATION
O Z UP TO 200 AMPS
FSO Licensed Pmfessmnl ❑INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-IgX1AMP5 IMPROVEMENT SWIMMING POOLS
`j
PL W 1 hereby affirm that I am exempt from the Cenvamm's License Law for the OVER IOIIOAMPS El BATH REMODEL/ P EMOLITION
�y�j4 O y U following reason.(Section 7031.5,Business and Professions Cade:Any city or county ElOTHER
W 3 W F which requires a permit m contract,alter,imve prodemolish,or repair any structure SIGNS ELECTRICAL
O prior to its issuance,also requites the applicant for such mit to file a signed statement x
y per ga SPECIAL CIRCUIT/MISC.
Y Nathe is mecing sedwith
proximal to provisions ofthe Buirrors License Law(Chopmf9
C� (commencing wbh Sedion 70gp ofpivision3of the Business and Professions Gule)or
W ❑O TEMP.METER OR POLE INST COMMERCIAL,
d q m C that he is exempt therefrom and the basis for the alleged exemption.Any l violation of NEW BLDG/AUDITION ❑DEMOLITION
JC V.
Section LS by any applicant fnrapermit subjects the applicant toacivil penalty of POWER DEVICES477
�I not more than five hundred delta,($500). TENANT ❑FOODSERVICE
SQp I,nowner ofthe property,or my employees wi0 wages as theirsnlecompensmiun, SWIMMING POOL ELECTRIC IMPROVEMENT
❑
aF will do the work,and the stm on,is not intended or offered forsale(Sec.9044,Business - TITER
Land Professions Code:The Contractor's License Law does net apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or oRetek for NEW RESIDENTIAL ELECTR SQ Pf.
sale.If,however,the building or improvement is%old within one year of completion,the SQ. FaD40)AREA $/SQ,FT.
caner-huilder will have the burden of proving that he did not build or improve for par- D
pose of sale} -
❑I,as owner of the property,.B exclusively contracting with licensed contractors m TOTAL:
wnse Law d project(See ply it)44,Business and Profession ds or ir'pte Contractor's IJ-
c se Lawdoesnot applyean ownerofpmpeny who buildsorimproves Nereoband QTY. PLUMBING PERMIT FEE
who contracts for such projects with o wnmador(s)IleenaW pursuant the Conwemr's '1
License Law, PERMIT ISSUANCE
❑lam exempt under Sec. - ,B&PCfnr this reason
ALTER-DRAIN&VENT-WATER(EA)Owner Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby nMfm maker penalty of ,my one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compem DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 37W of the Labor Cale,for the Performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700 ofthe Lobo{Cade,for the performance of the work for which this permit in issuW. GAS-EA.SYSTEM"I INC.4 OUTLETS OCC GROUP APN
My Wa_yQnirvenCCJasaynee carrier and Policy
Cartier 'TWT CW
Policy Nn.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE- GREASETNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This.section need not no completed min,permit is for one hundred dollars($1 W)
or lees) GRNASD TRAP
PLANCHECK PEG
I certify Boom the any andmnxof s to bac mefor subject
this permit is issued Lshall
not employ any person in an manner so as to become suryjecunthe Workers' SEWER-SANITARY-STORM EA.200 IT.Y Pen- ENERGY NEE
zArmon Laws of California.Date
O WATER HEATER WNENT/LLECTR
Applicant I � GRADING PEG
y NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should EATING
abecome subject the Workers Compensation provisions of the Labor Code,you must SOILS FEE
forthwith comply withxuch provisions 0,this permit shall be deemed revoked. T BSERVICE
z CONSTRUCTION LENDING AGENCY NTIAL PLMB. SQ.FT PAID _
U 0 I hemby afRrm that hem iso coneuuttion lending agency for the pefformnnce of Dam R cer
(L C� the work for which this Permit is issued(Sec.3097,Civ.C.)
0 U Lenders Name OTAL
Lender's Address TOTAL:
fytt a I certify that 1 have mad this application and state that the above information is BUILDING FEE
it V) correct.l agree to comply withal]city and county ordinances and state lawn relating In QTY' MECHANICAL PERMIT 'FEE
UZ building construction,and hereby amhorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree m save indemnify and keep humdess the City of Cupertino against PERMIT ISSUANCE ELECTRIC DEE
liabilities,judgments,costs and expenses which may in anyway accrue against said CityALTER ORADDTO MECH.
in ,sequence of the granting of this Permit. PLUMBING FEE
APPLICANT UNDERAND WILL COMPLY WITH LL NON-POINT AIR HANDLING UNIT(TO 10,1X1(1 CPM)
.
SO EGA "e". J MECHANICALF
(I 914u� '/ AIR HANDLING UNIT(OVER 10,1100 CFM) CONSTRUCTI TAX
-11 S,Wume of Appi,mid/C.atractor /' Date EXHAUST HOOD(W/DUC13 HOMING M IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupont store or handle hazardon material HEATING U NIT TO I WAX)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code Section 25532(a)] HETIATING UNIT(OVER 100,000 BTU)
EJ Yes ❑No
VENLATION FAN(SINGLE RESID) PAID -
pate Receipt N
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
emit huzeNous air contaminants as defined by the Bay Am Air Quality Management
DlsaioY) TOTAL'
❑Yes ❑No BOILER-COME(OVER 100,000 BTU)
I have mad the havuNous materials requirements under Chapter 6.95 of the Culi- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 2550-5,25533 and 25534.1 understand shot if the NEW RESIDENTIAL MECH. SQ.FT.
building does not commit,have a tenant,that it is my rcsgmsi esonfim notify the occupant
of the requirements which must be met prior m issuance of a Cenificme of Occupancy.
Owner or authorized agent Dore 'TOTAL: ISSUED BY:
OFFICE