30362APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
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PF.RMI]'NO.3162 ^
BUILDING DIVISION APPCATIONQ'ERMIT PLUMBING -MECHANICAL
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BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:
0YA
SANITARY NO,
APPLICATION SUBMTITAL DA'Z'E
OWNER'S ME'
ZONE: ^'
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CONTRR ACTOR'S NAME: LIC NO:
NIC
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/� CONTROI,p
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/EN IN .ITR: G e /�
ADDRESS: h UA /1 (
Is3f/ A 1.1,YJ �/74�
PPIONE:
BUILDING PERMIT INF
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❑ Consultant Fees Paid by Applicant (Initial)
BEL PLUMB MECHLICENSED
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OOection7B01gofuivision
aVUe
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CONTRACTOR S DECLARATION
hereby affirm that I am licensed under provisions of Chapter 9 (commencingTOB
SofNeBusincssandPmfessi... Cona ndmylicenscix
Finfulleffect.
Class Lie.
Date Canlmnor
QTY ELECTRIC PERMIT FEE
DESCRIPTIOW91
RESIDENTIALF�+OBfnrcu:md D KITCHEN RF.MODIR.
DADDITION ❑PLUMBING RE -PIPIT
OMULTIANIT Ll STRUCTURAL
MODIFICATION
PERMIT ISSUANCIi41OSFDWL
APPLIANCES - RESIDENTIAL
FOy
Zo Z
ARCHITECTS DECLARATION
1 undemm�dmy plans shall be used as public winds
PANELS
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er 4LM
4ayS;
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LicencedP fieesionul201-IgxIAMPS
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Commcmts License law for the
following mason. Seviion 7031.5, Business and P elleasinns Code: Any city ear corny
UP TO 200 AMPS
El INTERIOR ❑CHIMNEY REPAIR
IMPROVLMENT
D BATH REMODEUREPAIR [IDEMOLITION
DOTHER
OVER IgXI AMPS
SIGNS ELECTRICAL
�y
which requires a permit to construct alter. improve, demolish, or repair any auucwrt
prior In its issuance, also requires lhcapplicam for such permitin File a signed s:acmenl
that he is licensed pursuant, the provisions ufNeComraaor's License Law(Chapwr9
SPECIN.CIRCUIT/MISE,
TEMP. METER OR DOLE INST.
COMMERCIAL:
D NEW BLDG/ADDITION D DEMOLITION
�typ0
6 6 e K
(commencing with Section 7")of Division 3 curse Business and Professions Cade) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
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I„yy
❑❑<D1..,ovmmof
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Section 7031.5 by any applicant for a permit sabjectstee applicant to a civil penalty of
not more Than five hundred dollars($5n0)'
mepnipsny. or my employees withwa,v, us theirs ole compensation.
will do the work, and lhmaunure is nor imencil.,offered for side (See 7144, Business
and Pmfessions Code: The Co..,, 's Liccnu law dms nor apply m an owner of10
who build, or improves thereon, and who dors such work himself or thrush
POWER DEVICES
NT C3 FOOD SERVICE
IMPROV LMENT
OQTHER
SW I MM I NG POOL ELICCTRIC
OUTLET'S -SWITCHES - FIXTIIRFS
property
his own employees, provided that .such improvements arc not intended or offered for
sale, If. how,<g the havebuildingburden of proving is at h(idwithin one old rimprove lot the
owner builder will have the harden of proving that he Aid urn build m in:pnrvc for pur-
NEW RESIDENTIAL ELECTR SQ FT.
SQ. IT FLEA
$/SQ. FT.
0 1. assowne exclusively Promoting licensed cnm,nms i.
.weer of the rte.
T
CW Li
the project (Sec. 9014, Business and Professions Calc:) The ves
s m 70,1. B
crow
doaamfs
[.0 teas ofIniquity who mmeseand
nm Luwdoes not apply
QTY. PLUMBING PERMIT' FEE
cen%cddin-am to 11m
won Prmntea ansaedr prnjeela wire Ir a:mma.rca) hPenaed pnrsranr m ore crntraemr:x
r with,
PERM] f ISSUANCE
License I,uw.
D 1 am exempt under Sec. , B & P C fir this ream.
ALTER - URAINffi VENT -WATER (LA)
Owner Dae
WORKER'S COMPENSATION DECLARATION
VALUATION
BACK FLOW PROTECT'. DEVICE.
I heresy
mai under penaltyof perjuryencofthe follow ing
ill orker.l Co
DIhave and willfar bySetion 37M ofQeLiNs, ods, far for Workdsce or
section, as provided for by Section 3781 of the IaMn Cale, lar Ne performance of BeNe
DRAINS -0FLOOR. ROOIIAREA ,COND.
STORIESTYPE CONSTRUCTION
work fur which Nis permit is issued.
FIXTURES-PERTRAP
1 have and will maintain Worker's Compensation Inaumuce, m requi,d by Section
3700of Ne Labor Codel in the performance of the work lin which this permit is issued.
GAS -ITA. SYSTEM -I INC. 4 OUTLETS VV I
OCCGROUP APN
My Worker's Compensation houramcc caner and Policy number are:
Carrier Policy No:
GAS- EA. SYSTEM OVER 4(EA) N T- rtIIVU
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASEANDUSTRI. WASTE INTERCEPTOR
INC VISION FRES
(this section neat ani he completed ifthe permit is f hundred dollars ($1FOR
or less.)
GREASETRAP
I'1,AN PE' ` \O
SEWER -SANITARY -STORM EA. 200 FT.
Icenify Na in the any performance ofthe work forwhich this torrentsers'Ca per -shot]
not employ any person in any manner en as m become subjaun the Worked Camper-
ENERGY 'E
WATER HEATER WNENT/ELECTR
WATER SYSTEMITRHATING
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W FLewers
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fA
tf-t V
U
mita. Lows of Calif rmia. Dam
Applicant
NOTICE TO APPLICANT. If, after making this Cenilicam of Exemption, you should
becoom subject to the Worker's Compensation provisions of the Labor Coale. you must
forthwith comply with such provisions oasis pe.fish.]] be thermill revoked.
AGENCY
CONSTRUCTION construction lending
thereby affirm Nnhere mmwcuon len ding agency for performance.!
a is
fav which this permir is iaeued lSce. 31197, Civ. C.)
Lender's Name
GR '
SOILS qiE
WATER SERVICE
ac
PAID Uam sp
NEW RESIDEhT1ALPLMH. SQ. FT
TAL.
larder's Address
TOTAL:
BUILDIN ( P
1 ccnee Na I have mad Nis city and coup and stem Ism the strive information reforms is
corren l agree m comply n,and wire all city and county ordinances of and sera laws reforms t e
of Niscitymrnmrupon the
QTY. MECHANICAL PERMIT FEE
SEISMIC PEE
PERMITISSUANCB
ELECTRIC ITE
alsovemgmtioredegnnd forebyaahmixerposes.mmivev
repto coysave foreman i an keepha
abovo-(We) agree
(We)agreemsme, indemnity and keep harmless Nc City .f Cupertino against
ALTER OR ADDTO MECH.
PLUMBING FEE
liabiliriesjudgments,costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
AIR HANDLING UNIT(TO IBM) CFM)
MECHANICAL PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNI T(OVER 10,00 CFM)
CONSTRUCT ION TAX
Sonoma, of ApplicimUCunlmemr Data
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(WMUC)
HOUSING MITIGATIO FEE
HEATING UNIT(TO 100,000 BTU)
Will the applicant or future huilJingrweupom Ston.- handle haammo. rewlenal
as dented by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
Cale, Section 2553200?
HEATING UNIT (OVER 100,000 BTU)
El Yes E] No
Will Ne applicant or future building occupant use equipment or devices which
emir M1u.rrdrua air ismani nanx as defined by the Buy Area Air Quality Management
PAID
Date Receipt#
VEhT11AT10N FAN (SINGLE RFSID)
BOILER -COMP p11P OR 100.0!X1 RTU)
BOIIJIR-COMP (OVER I0o" BTU)
Dimdcl';
D Yes L] No
AIR CONDITIONER
I have reed use hamrd.us materials requirements under Chapter 6.95 of the Cali..
ISSUANCE DATE
NEW RESIDENTIAL MECIL SQ, FT
fumia He51N &Safety Code, Sections 25505, 25533 and 25534. 1 understand Nat if the
building fres not eumently have a levant. that it is my resporSdolity to roily the rmup oc
of Nc re9aimmen¢ which roast be met .nor to issuance of a Cenificam of Occupancy.
ISSUED BY: /
L:
Owner nr a,h.dred agent Dae
OFFICE