30793APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL"
BUILDING DIVISION APPLICATIONWERMIT PLUMBING - MECHANICAL.
BUILDING PROJF.CI' IDENTIFICATION
PERMITNO, w O
"x11 9
BUILDING ADDRESS: /j
Co e z& L/N�fP /5 71 21 C [A eA 56 1 L (
SANITARY NO.
APPLICATION SUBMITTAL DATE
�, 1
DWN2S Nhl 0� iONE:
C RACTOR' ME: a� ,� LIC N
NIC
❑
CONTROL p
ARCHITF.CTIENGI ;Ek: LIC NO:
N
ADDRESS.
s -i Ave, LOS A65
- IONE:
CONTACT:
BUILDING PERMIT INFO
I O
�� _ / y SL /
JTIA, v & 1
358-&q51/_
❑ Consultant Fees Paid by Applicant (Initial)
BLED}G ELECT PLUMB MECH
;lam ❑ ❑ .
LICENSED CONTRACTOR'S DECLARATION
1 hereby alarm that 1 am licensed under Provisions of Chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE
with Section 7")of Division 3ofthe Business and Professions Cale, and my license is
in full home an ',? d effect.�p S�/l
R ID,[y_ ENTIAL, ,
❑SFDWL C1 KITCHEN REMODEL
APPLIANCES -RESIDENTIAL
Licenu azs.-r--,. 11ii�—Cloth
Date=41=-ClI< Contractor T�+'- AR
ARCHITECT'S DECLARATION❑MULTI-UNIT
I cram, my plans shall be used as public records
❑ADDITION ❑PLUMBING RE -PIPE
❑STRUmRAL
MODIFICATION
[:1 INTERIOR (:1 CHIMNEY REPAIR
IMPROVEMENT
PANELS
UPTO200AMPS
Licensed Professional
201-1000AMPS
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Coatrmoes License Law for the
following reason. (Section 7031.5, Business and Professions Cade: Any city or county
vvv___ATH REMODEDREPAIR ❑DEMOLITION
OTHER
OVER 1000 AMPS.
SIGNS ELECTRICAL
which medicine a permit to cruswct. alter, improve, demolish, or repair any atrventim
SPECIAL CIRCUIT/MISC.
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of Ne Contractor's License taw (Chapter 9
(commencing with Section 7") of Division 3 of the Business and Prfe.mom Code).,
TEMP. METER OR POLE INST.
COMMERCIAL:
than he is exempt therefrom and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section 7031.5 by any upplamat for ap mait subjects the applicant to v civil penalty of
.at more than five hundred dollars ($500).
01, as owner ofthe pmpeny, or my employees with wages as theirsnle compensation.
will do the weak, and Ne structure is not intended meffored for sale (Sec. 70,1 4, Emoness
(:]TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
and Professions Crile: The Convector, License Law does not apply to an owner of
property who builds or impmves thereon, and who does such work himself or through
his own employees, provided Not such improvements are not intended or offered for
sale. If. however. the building or improvement used wampum year ofe mpdetion,the
OUTLETS-SWITCHES-FI%TURES
NEW RESIDENTIAL ELECfR SQ FT.
SQ. FT.
E/SQ. TIE
owner-lamider will have the humor cf pmving that he did not build or improve for pun
Nse of sale.).
❑ 1, as owner of the CmCeny, am <,,Ia,i,,Iy...meting with licensed contract.. to
JAN 1
JAp{f RECIft
TOTAL:
,mmart the prject (Sec. ]044. Business and Professions Code:) The Contra,,,', Li.
certe Law dce, not Illy ,.,,.an, of property who builds or imprnves thereon and
reparmanothe Contommes
such projects with acotactoddlicensdu
whocotnes for m
License Law.
i] I um exempt under Sea. , B & 1' C forthis reason
Cb i/
CRYVt Wry k�-IND
,
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE:
Owner Data
-WATERA)
ALTER - DRAIN&VENT(E
- VALUATION
SOC 0
WORKERS COMPENSATION DECLARATION
BACK MOW PROTECT. DEVICE
1 hereby eafum under Certify of perjury one of Ne following declarations:
DRAINS -FLOOR. ROOF, AREA, POND.
❑Ihave and will forbyineCeni37M of the Labor Code, surefer Worker.Comped-
ration, as provided for Section 3]W of the Labor Code, for the performance of the
STORIES
TYPE. CONSTRUCTION
work for which mi issued.
FIXTURES - PER TRAP
I have and will maintain Workers Compact he w Insurance, az required by Satin.
ill maintain Workers
3]00 of the Labor Code. for the performance of the work for which this permit is issued,
GAS - EA.SVSTEM-I INC. 4OUTLETS
MCI GROUP
APN
My rkerCnpon Rumne cartedey
CarteriL�`PlYNonu S�
GAS -EA. SYSTEM-OVER4(EA)
CERTIFICATEOp EXEMPTION I7ROM WORKERS'
COMPENSATION INSURANCE
GREASEIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FfiBS
(This session mad not to completed if the permit is for one hundred dollars 5100)
or less)
GREASETRAP
PLANCHECK FEE
I certify that in the performaMeofthe work for which this permit is issued, l shall
not employ any peon in any manner so as to haeume subject to the Worket%Compen-
SEWER -SANITARY -STORM EA. 200 FE'
ENERGY FEE
WATER HEATER WNENT/ELECTR
GRADING FEE
sation Laws of California Date
Applicant
NOTICE TO APPLICANT. IL after making his Cer ifiews of Exemption, you should
becomn rhjat to the Workers Compermium p..vislomi of the Labor Code, you must
WATER SYSTEMr1RBATING
SOILS FEC .
WATER SERVICE
Forthwith comply with such provisions or this permit shall be deemed revoked.
' CONSTRUCTION LENDING AGENCY
I hereby affirm that Here iaaconawcdon lending agency fonhe pertmrm race of
NEW RESIDIINI'IAt, PCMB. SQ, IT.
PAID
Data Raeiptg
the work far which Nis Permit is issued (Sec. 3097, Ci, C.)
Lender's Name
TOTAL:
Lemlers Address
TOTAL:
1 certify that 1 have ted this application and state Nm the id ove information is
BUILDING FEE
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE -
correct I agree w comply with all city and county ordinances and suite laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above -mention! progeny for inspection purposes.
(We)agree to save, indemnify and keep harmless the City at Cupertino against
PERMIT ISSUANCE
ELECTRIC FEE ��
PLUMBING FEE
liabilities.judgments. costs and expenses which may in any way accrue against mid City
consequence,in of the grendng of this permit.
ALTERORADDTOMECTL-
AIR HANDLING UNIT (TO 10,000 CPM)
MECHANICAL FEE
APPLICANT,JJPDERSTANOS AND WIT COMPLY WITH ALL NON -PONT
SOURCE EC ATIONS.
AIR HANDLING UNIT (OVER 10,0011 CFM)
CONSTRUCTIONTAX
1� 17
Si rare pplican1lCom ,tor Df
EXHAUST HOOD(W/DUCO
HOUSING MITIGATION FEE
NA DOUS MATERI .. ISCLOSURE
HEATING UNIT (TO I(p,000 BTU)
Willy Potunibuilding nc anter huddle
9.12, Health add Safety
as defined by the Cupertino Municipal C Chapter 9.12, and the Health ofd Salary
theCper
Cede. Section 255321a)! J
❑Yes �Nn -
HEATING UNIT (OVER 106,000 BTU)
PAID
Orae Receipt Is
VENTILATION PAN (SINGLE RESID)
mantra building bymoupant eBuseequipmentordeviceswhich
Will the air contaminants
'emit hnsurdoos air conmminunu us defined by the Bo Area Air Quality Management
Y Y Y 6
BOILIik-COME (3HPQR lIXI.(100 BTU)
'TOTAL: .
BOILER -COMP (OVER 10.0300 BTU)
Disvicr'f
E3 Yes Xu
AIR CONDITIONER
I have read the havmlous materials requirements under Chapter 6.95 of she Cali.
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. ET.
forma health & Safety Code, Sections 25505, 25533 and 25534. I amen mnt that if the
building does not carently haven Imadt. that it is mym,onsibilay toramify thcoc,apant
.
of the requirements which must be met prior to issuance of o Cenmficute of Occupancy.
ISSUEDBY:
TOTAL:
Owner nr authorized agent Date
OFFICE