29776APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING. ELECTRICAL
PERMITNO.
RUILDINCDIVIS10N APPIAC_ATI N/PERMIT PLUMBING � MECHANICAL
r / -Z BUILDING PROJF,IT IDENTIFICATION
L J4 / FVC
2 9 7 7 6
10
BUILDING ADDRESS: //�/
SANITARY NO
APPLICATION SUBMITTAL DATE
OWNER'S NAME:If I PHONE:
4- ^6 p 9/
L l' U
CONTRACTOR'S NAME: LIC NO:
NIC
El•
CONTROLp
\RCHITECf/FN INF, R: LIC O:
C=�z3a
ADDRESS:
CONTACT. PHONIi:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
B�L/D3G PLO MIF
�0
)0
LICENSNSFFRAC R:SDECfAATION
I hereby mmm that 1 am licensed under provision, of chapter 9 (commencing
with Section 7") of Division 3 of the Business and Professions Code, and my license is
n full force and cffcm.
License Class Lick
Dam Comnunar
QTY ELECTRIC PERMIT FEE
Woo
u
F ,, �Z ..
�Urj
��R
F.7y
ZOn?
JO DESCRI ION
SPDWL ❑KITCHEN BE ODEL
❑AUDITION El PLUMBING kIiI'IPi3
❑MULTI-UNIT ❑STRUCTURAL.
MODIFICATION
PERMIq' ISSUANCE
gPPLIANCf:S-RIiSIDGNTIAI.
ARCHITECT'S DECLARATION
I understand my plans shall: used a public records
PANELS
OZ— �
[-�F"W
Q
3 F
y
E""O�
UP TO 200 AMPS
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑BATH REMODEI/REPAIR DEMOLITION
[]OTHER
Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Commmorn License Law for the
following reran. (Swoon 7031.5, Business and Prolcssione Calc: Any city m county
which reymres a pe„m,,, ex muum, :mer. improve, demolish, nr repair any swmure
prior to its issuance, also requires the applicant for such promi to f le a signed "WithoutSPECIAL
201-1000AMPS
OVER IIKg1AMP5
SIGNS ELECTRICAL
CIHCUI r/MISC.
E�}
wyQ�
a a c C
that he is licensed pursuant to the pmvh,imv,of the Contractors License lsw(Chapter9
(commencing with Section 0000)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
TEMP. METER OR POLE]NST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
_1a•
y
❑46'iLothe
Senion 7031.5 by any applicant for a permiistifeets the applicant mnnvil penalty of
.'it me Non rive hundred dollars ($500).
owner ofthe priority, usaltheir (Site compensation,
will Pathe work Code: pwc.904L Business
nm lmacense
POW17R DEVICES'
❑TENANT (]FOODSERVICE:
IMPROVEMENT
'
D O'I'HhR
SWIMMING POOLIi1.ECTRIC
OUTLETS- SWITCHES - FIXTURES
is
1
Law owner of
Law d«s nm apply to
he Contractors does are a
and ProfesNo Code: The C
b es theme and w if
progeny who builds m improves themun, and who does such work himself or through his own own employees provided that such improvements are not intended in offered for
side .If, however . the building or improvement issold widen one yearafeona,uni n,the
owner-builder will have the burden of proving that he did not build or improve for pun/)Ise
NEW RESIDENTIAL ELEM SQ FT
SQ. FT FLOORAREA
y
y PJ
$/SQ. LT.
su of sale,.
, liccnd rontmctnry m
❑ 1, as owner of the property, am exclusively contracting will, u
conswc, the project (Sec. T1,114, ausmwsa and Pror siona Cade:) The Commcmrs Li.
c m, sc law does not apply an owner of pmpemy who builds or improves thereon,and
N ��CCJJ
a � � yp
C
TOTAL:
QTY. PLUMBING PERM]' FEE
who contracts for such projects with a cormacto0.$) licensed pursuanuothe Contractors
/p
r v U
PERMIT ISSUANCE
License law.
D l am exempt under Sec. .B&PC for this reawn
Or H
CUrt Ilhr
ALTER- UHAIN& )
Owner Oam J
Ho us� VAI.UATIp/Y
WORKERS COMYE:NSAI'ION DECLARATION e V
I hereby offrm under penul,Y of perjury mac of the following d«lara,ionr.
BACK FLOW PR ,V Ii
a
/
e]Ihave and will maintain a CeriOcam of Consent to self-insure for Worker's Compcm
ration, u Provided for by Section 37W of,he Latter Code, for nee performance of the
wart for which this permit is issued.
D I have and will maintain Worker% Compensation Insurance. as required by Section
30W of in, Labor Code, lir the perfscramucof the work farwhich this permit is issued.
DRAINS-FLOOR, ROOF. .A ON.
5T HIES
YP C uS RUCTION
FIXTURES-PER TRAP "7W
GAS-EA. SYSTEM-I INC. 4 OUTLETS
OCC. GROUP
APN
My Workers Campensntion Insurance come, and Policy number sere:
Cmrice Pulley No.:
GAS -EA. SYSTEM OVER 4 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section r,aJ not be completed if the permit is fnrnne hundred dollars (SIM)
or leas.)
1 crady that in the Performance of the work far which this Permit is issued, I %hall
Nom ) gem
not employperson in an ,o become subject to the Workers Com
GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GHEASETRAI'
PLANCHECK FEE
S
SEWER-SANITARY-STORM EA. FT.
ENERGY FEEAI& OA
WATER IIIiAT CR W/V ENT/F.LF,CTR
Z
Q �
.~N.
[S1
d 0
U O
fA Fthe
Nation Laws to California. Dr¢anner
H
GRADING FEE �
SOLIS Flili / /
t
PAID
Dam °np
Applicam
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you all
forthwith comply with such provisions at Permit shut[ he deemed revoked.
CONSTRUCTION [.ENDING AGENCY
l hereby affirm that hem is a constrection lending agency for the performance of
work for whichthis permit is issuOil (Sec. 3097. Civ. C)
WATER SYSTEMIFREATINO
WATER SERVICE
NEW RESIDENTIAL PCMB. SQ. F-F
>aL!a
W
Ey
V Z
Lenders Name
/
BUILDI
TOTAL:
Lender's Address
1 cer ily that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county ordinm,ce% and state taus mlaing in
building construction, and herby authorize representatives of this city m enter uponshe
QTY. MECHANICAL- PERMIT FEE
SIESM1 sE
PERMIT ISSUANCE
above-mentioned property for inspection mr, vor,
(We) agree to save, indemnify and keep harmlauhe City of Cupertino agaimt
fiLECB
ALTER OR ADDTo MECH.
PLUMBING P
liabilities.judgments, coal and expenses which may many way acemeagainst said City
in crosse,mare of the grmaing if this penun.
AIR HANDLING UNIT(TO 10,000CFNE
MECHA AL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER I0.000 CFM)
CONSTRUCT] .'TAX
Signature of ApplicandCon,mctor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST FOOD(W/DUCT)
HOUSINGMITIGA ION FEE
HEATING UNIT (TO 100.0i BTU)
Will,hppl lean, or future building occupm mstore nr handle huemdaus material
m
m defined by ,he Cuperinu Municipal Code, Chapter 9.12, Cad the health cad Safety
Code, Section 25532(u)'I
HEATING UNIT (OVER 100.004) BTU)
❑Yes ON.
Will thea licant or future building Occupant use equipment or devices which
pp g y pan Area Quality
t hassNa,s air contaminants as defined h the Bay Arca Air Qualit Management
y g
)amui!
❑Yes F-1 No
VENTILATION EAN]SINGLE REIO)
PAID
Dote RtteiPt M
BOILER- COMP(3HP OR IW." BTU)
TOTAL:
BOILER - COMP (OVER I0b,( 1]ITU)
AIR CONDITIONER
]have red Ne hazuJous mamrials,cyuimmen¢under Chap,cr fi.95 of the Cali
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. PT.
fnmu Halt & Safety Code, Swoons 25505, 25533 and 25531. 1 understand that if the
buildingd«s no, currently have a wourn. mat it is my respmsihiii, m notify the cov,sen,
of the requirements which must 4 met print to ISsua„ce of a Certificate of Occupancy.
TOTAL:
ISSUED HY�
Owner,, outhoused agent Dam
OFFICE I C