31411APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL.
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eu r;1N?W9k,PHONE: CONTRACTOR'S NAME,:
OFFICE
FEE
CONTACT. PHONE:
O KITCHEN REMODEL.
.NITARY NO.
kh S LIC 4 -we 19 L8
❑ Consultant Fees Paid by Applicant (Initial)
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LICENSED CONTRACTOR'S DECLARA'HON
I haehy affirm that 1 am licensed under provisions of Chapter 9 (commencing
e,d my license is
with Section 700l Divisions 3 of the Business and Protessiuro Codon
in full force and offal.
License Class Lie. If
Dara Convuctm
QTY ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCIiS-k1iSi RESIDENTIAL
ARC14UECTS DECLARATION
1 understand my plans shall M used as public records
PANELS
UPUP TO 20a AMPS
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Licensed l'mfrWoral
OWNER -BUILDER DECLARATION
1 hereby affirm that ) um exvam,t boon he Contractor's License Law for the
following reason. (Section 70315, Business and Professions Code: Any city or county
201-I000AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL.
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2:
which requites a penal m csmswn, alter, improve, demolish. or repair any :Baum
prior to its issuance. also mquircloonpplicant fill such penniim flea sigtrcdsmtement
SPECIAL CIRCUEHMISC.
i { y
that he is licensed pursaatuo the provisions of the Contractor's License Use (Chaplet 9
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u'
(commencing with Section 700(bof Divisiom Sof he Business and Professions Csde)oo
That he is eamnpl mercam,land the basis fm the ulleged cacroUine. Any violation of
Section 7031.5 by any applicant fm a pem,b subjects the apprcmtt to a evil penally of
TEMP. MUTER OR POLE [NST.
MWIiR DEVICES
LLX1
=p
p..
h 3 m
t more than five hundred dollars (5500).
Las owner of the propcnyar mY employees with wages as their sole compensation,
will clothe work, and the saucmre is not intended or offered for sale (St Jf44, Business
and Professions Gds: The Coommor's License Law does tent apply to an owner, of
property who builds or initiatives thereon, and whit does such work himself or through
his awn mnployaes, provided that such intmnvcntens are not Intended nr off 2red lo,
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURE,!
NEW RESIDENTIAL ELEC'IB SQ FT.
sale. If. however, the building or improvement is slid within one year ofcompletion, the
aorner-builder will have the burden of proving that he did not build or improve for pur.
T�
pose of sale.).
❑ I, as owner of the prepety am exclusively contracting with licensed contractors to
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combat the project (Sec. 7044. Business and Profc,own, Cine) The Conwetoo's I.I
active Law does not apply to an owner of properly who bdildsor i oproves mere nm.and
QTY. PLUMBING PERMIT
1
who vanwms for such propwa with a caramctor(s) licensed pursuant to the Contractors
PERMIT ISSUANCE
License Law.
O I an comp, under Sec. . B A P C for this mann
ALTER - DRAINA VENT- ATERILIA)
"
Dae
WORKER'S COMPENSATION DECLARATION
HACK FLOW PROTGCI. F C .
.Owner
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will uncommon a Certificate w Corecatto self -insure far Worker's Compete
DRAINS -FLOOR, ROORAR CO
salion, in, provided for by Section 37M of the Lahr Code, too the pctfmtmatce of the
work for which this permit is issued,
{tl I have and will maintain Workers Compensation Insurance, as required by Section
p�er�m,#it�s issued.
(1j110 ofihc Labor Code, for In, varlriawmaef the work ttoqop4,
FIXTURES - PER TRAP \
GAS- EA. SYSTEM I INC. 400
�wshqiesh�rtiyhis
Carr iMy s lq(Ginpca�u io tout ynrr',they No.yaJd7OSON/JI
GAS -EA.SYSTEM -OVER 4IHA)
CCEERRTI�FICAT40F EXE, 'ION FROM WORKERS'
COMPENSATION INSURANCE
GREASEoNDUSTRL WASTE. IM1TERCF:PTOR
GREASETRAP
IThissectioJnbecontpletedRthc pcnniI is faromburdaddoiloo($1LN)
SCWER-gANITARY-STORM EA. 2IM)FT..,employanypernymaner.Z
Iccnilythmfbmnuna flM1e Bark hmwhich lhupcfmil is isxued,isbull
WATER HEATHR WNENT/ELECM
.Brion Wes ofDae
Applicant
NOTICE TO APPLE A. I': If, ether making this Certificate of Exemption, you should
WATER SYSTEMOKHATING
a^
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V 0
D. F
ULando',
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a
F to
become suhjcct lot Worker's Compensation pmvisinns of the Labor CM4 you most
Iimhwili contplY rah such provisions illi Ibis permit shall6c Jcctncd revoked
CONSTRUCTION LENDING AGENCY
Thereby Rrm that them is a construction leasing agency for the performance of
the work for which his permit in issued (Sec. 3097, Civ. C.)
Nam.
WATER SERVICE
NEW RESIDENTIAL PCMB. SQ, Ff.
'TOTAL
Lender's Atli ...
I certify that 1 have mad this application and .state that the above information i.
cod.eLlagmemrnmply with all city and county ordinances and state laws relating m
QTY. MECHANICAL PERMIT
C.) Z
bmidingconswction. and hereby nolo < mpmaemativesofthis city toemer own the
PERMIT ISSUANCE
aMv.-mentimled property for inspection Par owe .
(We) ll,mr m save, indemnify and keep handless me City of Cupertino against
ALI'IiR OR ADD TO MECH
limbilhlea,jud,notai , costs and expenses which nay in any way sector against said City
in consequence of the grmam, of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNIT (TO IL" CFM)
SOURCE REGULATIONS,
AIR HANDLING UNIT (OVER 10.100 CFM)
t
Signmure of ApplicaDatc
C
EXI{AUST HOOD (W/Wq
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or l'utum building occupant 4nre or handle hvardouv material
BEATING UNIT (TO 100.000 BTU)
as defined by Ne Cupertino Municipal Cede. Chapter 9.12, and the health aryl Safety
Code, Section 25532(0)'
HEATING UNIT (OVER 1011.000 BTU)
VENTILATION FAN (SINGLE RESID)
OYc' ONo
BOILER (3111' OR If10,fNN) BTU)
Will the applicant or Toon building oa'npam use c,liptmcnt o, drviccs which
emir hasallous air contaminants as defined by the Bay Area Air Quality Management
BOILER -COMP (OVER I W.000 BTU)
District".
Ely. O N.
AIR CONDITIONER
I have real the hsmNoo, materials myuirememis under Chapter 695 nfine Cali-
NEW RESIDENT ]AL MECH. SQ. Fr.
forma Health A Safety Cmc, Sections 25505. 2.1.933 and 25534. 1 understand thus if the
building does not eunently have a tenant. that it is my resgmsihllhy a notify Newcuponl
of the nquincmenu whi,h must be met prior to issuance of a Certificate of Occupancy.
OFFICE
FEE
JOB DESCRIPTION
FERMII so' 31411
O KITCHEN REMODEL.
.NITARY NO.
APPLICATION SUBMITTAL DATE
❑MULTI -UNIT
❑STRUCTURAL
l l S9. �
N/C
O INTERIOR
CONTROL#
IMPROVEMENT
O BATH REMODELIREPAIR []DEMOLITION
OOTHER
BUILDING PERMIT INFO
BLDG
ELECT PLUMB MECH
El❑
JOB DESCRIPTION
RESIDENTIAL
O SFDWL
O KITCHEN REMODEL.
❑ADDITION
[_1 PLUMBING R&PINE
❑MULTI -UNIT
❑STRUCTURAL
MODIFICATION
O INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
O BATH REMODELIREPAIR []DEMOLITION
OOTHER
COMMERCIAL:
O NEW BLDG/ADDITION O DEMOLITION
O'ITiNANT O FOOD SERVICE
IMPROVEMENT
❑OTHER
SQ. FE FLOOR AREA
PAI®
FEE DEC 51996
CITY Ur is;urr.nolU
- 1 C VALUATION
lilacv
PLANCHECK FEE b
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Doc Receipt #
TOTAL:
BUILDING PEI?
FEE SEISMIC EEE
ELECTRIC Fl?I?
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt #
ISSUED BY:
ISSUANCE DATE