30634 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL-POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 3 O 6 3^1.}
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BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIIANICALJ
BUILDING PROJECT IDENTIFICATION
� BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
t 8
OWNEk'S NAME. PHONG: CONTk AC1Y <q M
y► � 2 ):
IRSU& aWJ NIC CONTROLM
RCHI rECIIHNGINEER: LIC NO: ADI ESS: ❑
CONTACT PHONE. BUILDING PERMIT INFO
a� 2Z QU� El Consultant Fees Paid by Appliwnl(Initial) BLDG ELECT PLUMB MECH
F 7 J ❑ e-E� ❑ ❑
LICENSED CON'TRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FF:E
1 hereby affirm that 1 um licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
OW tiZ w,h Svn n7O E.ff Dr,i, m3oRhe Businessand Profcestons Code•andmy liceme is 1'I;RMIT ISSUANCIi RESIDENTIAL
FW.
RIS ❑SFDWL ❑KITCHEN
�V V Dan Class Lich APPLIANCES-RESIDEMIAL ❑ADDITION ❑PLUMBING RE-PIPE
F zi R Date Convector
E-Om ARCHIT1 owi DECLARATION PANELS ❑MULTI-UNIT ❑MODIFI RAL
MODIFICATION
OZ—
p v�y l undctamnd my plana shall he usaJ as public mcurds CHIMNEY
REPAIR OZ—O UI'T0210AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F.~Et Licensed Profmsionul 201-1000AMPS IMPROVEMENT
CINE; OWNER-BUILDER DECLARATION OVER HX10AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION w
LL C C Q 1 hereby offrm Nm 1 oro exempt from the Cmanrctnrs Littnu Law for tM1e
pd 3 d following reason.(Section 91131.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
WW a m which mquires a permit to construct.aline improve.demeliAr.or repair any structureoQ prior as its I..mce,ah.ortuiretdw.pplicmrt for such permiuo fim.nignedsmmment SPECIAL CIRCUIT/MISC.
y'r thin he is licensed pursuant to the provisiomsofthe Contractors license Law(Chapter 9
gC
I�7+ (commencing with Section 01100)of Division J ofthe Business and Professions Code)or TEMP METER OR POLE INST. COMMERCIAL:
a S e that he is axcnmpt tberefmon and the has.,lot the alleged exemption.Any vinl:mon nt ❑NEW BLDG/ADDITION ❑DEMOLITION
X_ata• Section 9031.5 by any applicant for a permit subjects the applicant a civil Penalty of POWER DEV
E, otmnrc than Eve hundred dolluts($500). ICES TENANT ❑FOODSERVICE
I.Z 7s IMPROVEMENT
Q nLo the work.the propenctum is employees wan oroffe dfrsalei(Sec.c01Buannn, SWIMMING POOL ELECTRIC
wilSp and dothcwons andtheThe
ismaended mneme Law
does
rct apply in n Business ❑OTHER
In�� unit Professions Calc:1Tc Convocmr's license law Jmwa nm apply nm nn owner of OUTLIi TS-SWITCHES-FIXTURES
property who builds or improves thereon,and whir does such work himself or through
his awn employees,provided that such improvemmms arc not intended or offered far NEW RESIDENTIAL ELECTR SQ PT.
sale.If.however, e building m improvement is sold within one yearefcompletiun,the �Q� AREA S/SQ.lel'.
th
owner-builder will have the burden of proving that he did not build or improve for put-
made.). OCT 1
❑L m owner of the propcny,am exclusivelynd enmncdng with licensed contractorsam',Ito 1996
comm,omumla the project(Sec.]lair,Buswom,of and property
whoiun.Cade:i The Convector'.li-
mnxLawdoes notapply tnonownerotpmpcny who builds mimproves thereon.and QTY. PLUMBING PERMIT FEE •
who contracts for such projects with a contractor(s)licensed pursmnt to the Common's C ITY OF WeILH I INU
License law. PERMIT ISSUANCE
I em exempt under Sec. .B&1'C for this masa
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKEk'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of Perjury one of the followin6 declarations:
] I have and will maintain a Cenificma of Conscnu nif-insme for Worker's Compsn- DRAINS-FLUOR,RODE,AREA.COND. STORIES TYPE CONSTRUCTION
ration,as provided for by Section 3900 of the Labor Code,for the Ou,n onnance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will amintain Wmket's Condensation Insurance,as required by Sectico
37M of the labor Code,for performanec of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.r OUTLEI:S OCC.GROUT' APN
My Workers Contpenation Insurance carrier and Policy number are:
Cartier: Policy N': GAS-EA.SYSTEM.OVER r(LA)
CERT'IFICAS
'TE OF EXEMPTION FROM WORKERGREASF/INUUSTRL WASTE INTERCEPTORCOMPHNSA'1'ION INSURANCE BUILDING DIVISION ETES
(This section need not be completed ifthe permit is foronehundtaidollars(3100) GREASETRAP
or leas) PLANCHECK FEE
I certify that in performance ofthe work forwhich this permit is issued.)shall SEWER-SANITARY-STURM EA.200 FT.
not employ any person in any manner sin on nm become subject o the Workers'Com sen- ENERGY FEE
zZ ..tion laws of Coliforms.Dae WAI1;R HEATER WNENfiELECTR
O Applicant GRADING PER
iiy NOTICE TO APPLICANT:11:alter making this Canities.of Exempvon,you should WATER SYSTEMGREAI'ING
become suti ect to the Workers Compensationprovisions- of the Lebow Code,you must SOILS FEE
p na o
fnnhwith comply with such provision or this permit shall be deemed revukaJ. WATER SERVICE,
a0
CONSTRUCTION LENDING AGENCY „s NEW RESIDENTIAL PCMB. S0.FT. PAI:D D
L)O I hereby affirm thatthem is a construction lending agency far the performance of Data ei M
the work for which this permit is ismad(Sec.3091.Civ.C.)
QI.ender's Name TOTAL:
Lenders Address TOTAL'
y 1 certify thin 1 have read this.,iemion and nate that the above information is BUILDING F.
N
correct.I agree to comply with all city and county ordinances unit state laws relating as QTY. MECHANICAL PERMIT FEE
V2 Wildingconnroadon.and hereby athmim representatives ofthi,cirymrmcr.pan the SEISMIC FEL
alwve-Inemioned Pnopeany lin InspcninD purposes. PERMIT ISSUANCE
(We agree m save,indemnify and keep harmless the City of Cupertino against
K
Iiabihl'.,,a gmems.co sand es which may eymeru 'ponat said City ALTER OR ADD TO MECH.
PLUMBING
inc segue oft ti t permit.
AP LICA r U ' E f N' AND WI .COMP WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,100 CPM) FEE
S RCF IEGI'.A N' j N/)
{,(L`IVB AIR HANDLING UNIT(OVER IggIBCFM) AX
id is mmofApplican 'ommaor Uam EXHAUST'1{OOD(W/DUCT) IGATI FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaardous material HE
UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)1 HEATING UNIT(OVER Il0.IXX1 BTU)
Y ON.es VENTILATION PAN(SINGLE RESID) ate Reccip
Will the applicant or future building occupant use equipment or devices which
mit hazardous air contaminants as defined by the Bay Arta Air Quality Mangemcnt BOILER-COME'AHP OR 100.000 BTU) TOTAL:
uniict9 BOILER-COMP(OVER 100.000BTU)
❑Yes ON.
AIH CONDITIONER
1 have read the hamNous materials requirements under Chapter 6.95 of the Cali ISSUANCE DATE
forts Health&Sefny Gdc,$codons 25505,255JJ anti 25531 I umdemand that if the NEW RESIDENTIAL MECH. SQ.Ff.
building doea nm curendy have a tenant.that it is my msponibility to nobly the casms nt
of the requirements which must he met Prior to issuance of a Certificate of0ecupancy.
Owner m mam.led agent Date TOTAL: ISSUED BY:
OFFICE