30591APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUD DING. ELEL'TB
BUILDING DIVISION APPLICATION/PERMIT _ PLU]IBING -MECHA
❑ Consultant Fees Paid by Applicant (Initial)
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LICENSED CONTRACT'OR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (rommencing
with Sa0on7000OHivision 3 oflhe Business and Profession Code.and my license is
in full force and ellen.
License Class Lic.N
Datc Cammmor
QTY ELECTRIC PERMIT
PERMIT ISSUANCE.
APPLIANCES —RESIDIIIAL
ARCHUFcTR DECLARATION
I understand my plans shall b< used ax puhhc records
PANELS
UP TO 200 AMPS
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Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Commemes License Law for the
following reason. (Section 7031 .5, Business and Professions Cade: Any city or county
which requires a mr-mit to contract, suer, improve, demalish, or repair any amcmre
prisms its issuance. also requireslbe applicant forsuch permitto is a signed statement
he is licensed pufstmal to the Provisions al'the Contractors License Law (Chapter
101-Io00AMPS
OVER 1000AMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUI'1'IMISC.
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(cnmmencingwiNSecuon]IN0)of Divisinn3offin Business andl'rofcaskm,Ctdgar
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Seetion 703 IS by any applicant for a permit subjects the applicant m e civil penalty of
not more Nun five hundred dollars ($500).
❑ L n owner of me property, or my employees with wages as their sole compensation.
will do the work, and the structure is not intended or offered for We (Sm. 71W. Business
and Professions Code: [he Conformities License Law does not apply to on owner of
property who builds or inmmecs Ihermm, and who does such work himself or through
his own employees, provided that such impmvamcros are not intended or offered for
rrNp. METER OR POLE INST
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL, ELECTR ti tT.
sale. IL however, the building or improvement is sold within one year ofcompletinn, the
wa ser -builder will have the burden of paving and he did not build or improve for pur-
TOTAL:(
pose ofsale).
I] I, a,owner of the property, am exclusively comncting with licensed con=lon to
QTY, PLUMBING PERMIT I
construct the project (Sec. 70,D. Business and Professions CNet) The Contractor's Li-
mine Law does not apply it) an owner of property who builds or improves Borrow, and
who contracts for such projects with o contactors) Ikcnsul pursuant to the Contorea rs
PERMIT ISSUANCE
Limane Law.
❑ 1 we exempt under Sec B & P C for this reason
ALTER - DRAIN & VENT - WATER (EA)
Owner Date
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
1 hereby offal under penalty of perjury one of me fallowing decloration:
❑ I have and will maintain a Ccnificme of Consent to self -Insure for Worker's Compen-
DRAINS- FLOOR, ROOF. AREA, CO ND.
,a,.... as Ion, dal for by Section 3700 of the Labor Code, for the performance of the
work for which this Ixrmit is issued.
FIXTI1RES - P17R TRAP
0 1 have and will maintain Worker'., Compensation lawoo ce, ax required by Section
37M afore Labor Code, for the performance nl the work for which this permil is issued,
GAS— EA. SYSTCM.I INC. 4 OUT LUIS
GAS — EA. SYSTEM -OVER 4 (EA)
My Workers Compensation Insurance carrier and Policy number are:
Cartier: Policy No.:
GREASFANDUSIRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
(Thissetlon mud not he completed lime permit is furore hmulredilanars(SIW)
or coI
SEWER — SAN] fARY— STORM EA. 200 IT.
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Icerily that in the performance to work for which this permit is Issued, I shall
not employ any perm in any manner so as m become subject to the Workers' Conifer -
.alio. laws of Cal ifomio. Dam
WATER HEATER WNII4MECFR
N
Ap (men
NOTICE TO APPLICANT. If. after making this Cenificate of Exempt...... should
WATER SYSTE-M)TREATING
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become subject to the Workers Compensation previsions of me Lahr CNe, you must
forthwith comply with such powisinnsor his permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
WATER SERVICE,
NEW RESIDENTIAL PLM. SQ. II'.
'C)
�Pthe
construction lending agency for the perfnronce of
I hereby albino that there is uam
work for which this permit is isvued(See, 3097, Civ. C.)
gY)TAL:
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S
F' N
lenders Name
lenders Address
QTY. MECHANICALPERMIT
1 mat that 1 have read this application and state hat the.Mwe .... tion iz
correct. l agree to comply with all lay and county ordinances and state laws relating to
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hot i lding construction. and hereby authorize representatives of this city nr enter upon the
PERMIT ISSUANCE
above-mentioned progeny for imrse inn pmposc,
(We) agree to save, bmmnnify and kwp himiles,; the City of Cupertino against
ALTER OR ADD TO MECII,
iahiliaes,judgmema, costs and expenses which may in any way accrue against said City
in nscquence of me gm droll of his perms.
AIR HANDLING UN1r(TO IQWOCFM)
APPLICNNTUNAND WILL COMPLY WITH ALL NON -POINT
SOU,r/5{ REGU� 10�/4�
yA k��'
Aift HANDLING UNTT(OVER 10,000 CPM)
EXHAUST HOOD(WIDUCT)
Sigwl r , Ima t t, mor Oa¢
HAZARDOUS MATERIALS DISCLOSURE
Will tboappl icon or future building oc,uleat score or handle hmanlousmatmlal
HEATING UNIT CI'O 100,(%10 BTU)
as defined by be C.,Uiro Municipal Cook. Chapter 9.12, and rite llauhh and Safety
Code, Section 25532(0)'!
HEATING UNIT (OVER 100,000 BTU)
VENTILATION PAN (SINGLE RESID)
❑Yes NO
Will he applicant or furore building occupant use equipment no devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Mwerem rd
BOILER—COMP(311P OR 100.000 BTU)
BOILER — COMP (OVER 100,M)BTU)
Di anal
❑Yes F7 No
AIR CONDITIONER
I have read the hm:Wnus materials rtyuiremcnt, under Chapter hYS of Ne Culi�
NEW RESIDENTIAL MECH. SQ. ET.
famla Health & Safety C,de. Sections 25505. 25533 and 25534. 1 understand that if are
building dues no¢urtcn)lym �.yl tenant. that it is my msponsibiliry to notify the occupant
Of me requlRml en#hi f// met prior to is,uance of a Ccnificme 9f (Xrpnifaige.
OFFICE
30591
SANITARY NO. APPLICATION SUBMITTAL DATE
a ��6
NIC CONTROL#
El
BUILDING PERMIT INFO
BLDG loLFCT PLUMB MECH
❑ ❑ ❑
FEE JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION C1 PLUMBING RE -PIPE
❑MULTLUNIT ❑STRUCTURAL
MODIFICATION
C1 INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEL/REPAIR [I DEMOLITION
COMMERCIAL:
❑ NEW BLDGIADDITION El DEMOLITION
❑TENANT OFWD SERVICE
IMPROVEMENT
❑ OTHER
SQ. I•T 1. RJRf3
OCT 41996
J
CITY OF CUrtH i IND
STORIES
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Data Rrealpto
BUILDING FEE
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Rccargo a
TOTAL:
ISSUED BY:
VSQ. PC