29984APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING - ELECTRICAL
PERMITNO. w
BUILDINGDIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
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BUILDING PROJECT IIH M'IFICATION
BUILOINGADDRESS:
A9171 NAS L/qP D'e-
SANITARY NO.
APPLICATION SUBMITTAL DATE
OW A�� �� 90 CONTRACTOR',; NiME:_ LIC NO:
NIC
❑
CONTROL #
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1RCHITECTWNGINMR: LIC NO: ADDRESS:
CONTACT. PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (initial)
SLUG ELECT PLUMB MECH
X ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
wilh Section 7001 Division 3ofNe Business and professions Code,and my license is PERMIT ISSUANCE
in full fare. and effect.�Fuu License Class I3c.g
Date Contractor APPLIANCES - RESIDENTIAL
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JOB DESCRIPTION
RESIDENTIAL '
DSFDWL ❑ KITCHEN REMODEL
CI tULTIUNIT ❑ PLUMBING R PIPE
MODIFICATION
❑INTGRIOR ❑CHIMNEY REPAIR
IMPROVEMENT
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poATH REMODEIIREPAIR 0 DEMOLI770N
❑ OTHER
ARCHITECT'S DECLARAI'[ON pgNF.IS
i understand my plans shall he used i s public recruits
UP TO 20 AMPS
Licensed l'rofessianal - .' 201-1000AMPS
OWN[BUILDER DECLARATION
I hereby affirm that 1 emm Contractor's frothe Coctar's License Lew for the OVER If00AMP5
following reason. (Section 703 1.5, Flushness and Professions Coda: Any city or countySIGNS ELECTRICAL
requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance. also requires the applicant for such Permit file o signed smremeat SPECIAL CIRCUITIMISC.
that he is licensed pursuant aide provisions.( the Cnnmetur's license Law (Chapter 9
COMMERCIAL:
❑NEW BLDG/ADDITION ❑ DEMOLITION
[]TENANT ❑FOOD SERVICE
IMPROVEMENT
❑ OTHER
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(commencing with Section 7000) of Division 3 of the Business and Professions Code) or TEMP. METER OR POLE INST.
that he is eaempt therefrom and the basis for the alleged exemption. Any violation of
1ection70315 bymyappPi,ant fur a pemtitsubjects the applicant to a civil penalty of POWER DEVICES 1.
not mote then five hundred dollars ($50).
1. as owner of the property. or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work, and the struclum isnot intandesl m offered da sale (SMJ(W4, Btio.c s
and Professions Code: The Contractor's License law does not apply to an owner of, OUTLETS -SWITCHES -FIXTURES
property who builds or improves dertom and who dace such weak himself m through
his own employees, provided that such improvements me not intended or offered for NEW RESIDENTIAL ELECTR SQ IT.
SQ. FT. FLOOR AREA
SISQ. FT.
side. If, however. the building or improvement is sold within one year of completion. the
caner -builder will have the burden of proving that he did not build or improve (m put-
•
pose of sale.).
❑ Lae ow er.I'the prrpeny, am exclusively contracting with licensed contractors to TOTAL:
construct the project ISM. 7fW4, Business and Professions Code:) The Commencer Li-
nxlawdcesnotavpl man owner of prnpeny who builds. rimprovesthereomand QTY. PLUMBING PERMIT FEE
'w he contmetsf r pearl d trector(s) licensed pursuant m the Contractors
� t
License PERMIT ISSUANCE
la se oder _,B&PC al reason
ALTER -DRAIN&VENT-WATER BEA)
Owner
a� VALUATION
r lb
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RKER'S COMA) SA'I'ION DECLARATION BACK FLOW PRor=. DEVICE
7.!,'.0R'
Ihrc mirm under penahy'yAperjury one rl the following Jeclumtions:
'
❑llean dwill moinmineCenificme ofConxmtp xlGimurt for Workers ComPen- DRAINS- FLOOR, ROOK AREA, GOND.
cation, as provided far by Section 3100 of the labor Code, for the Nifermence of the
STORIES
TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES -PER TRAP '
1 have and will maintain Worker's Compensation Insurance. as required by Section
390 of the Labor Core, far the perfnmmaceof the walk for which Nis permit is iseni GAS-EA.SYSTEM-IINC.4OUG.ET$
My Workers Cnmpensmion Insurance carrier nnJ Policy number arc:
Carrier: Policy Nn: GAS - EA. SYSTEM OVER 4 (EA)
OCC. GROUP
APN
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CERTIFICATE OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE GRI'.ASEdNDUSTRL WASTE INTERCEPTOR
(This xctirin nttdnot he rompided ifNc permit is (mane hundred J011ars (810)
or Ito") I GREASE TRAP
ubjet to permit is issued. , Compen- SEWER -SANITARY -STORM EA. 20 M.
Foy any that sur in Persay sooner of the becomork e subject
not employ any pawn in any manner w as to become suhjecno the Workers' Compen-
smion laws of California. Date
BUILDING DIVISION FEES
PLANCHECK FEE,
ENERGY HE
Applicant
GRADING GRADING FEE
NOTICE TO APPLICANT. IL after making this Cenificme of Exemption, you should WATER SYSTENIT EATING
subject o the Workcea Compensation provisions of Ne Labor Code, you most
forthwith comply with such provision,,,, this permit shall he devoted revokeJ. WATERSERVICE-
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM SQ. FE,
I hereby affirm that there is a construction lending agency for the performance of
the work far which this permit is issued (SM. 3097, Civ. C.)
Lenders Name
rj)
abecome
W
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U n
fL
SOLS FEE.
-
PAID
Date IN,
TAC:
Q U
lenders Address TOTAL:
Ha
I cenify that 1 have read this application and state that the .hove information is
BUILDING FEE
e
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correct. l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
brddingcnnswclinn, anJ hcsehy authorize representatives of itis city t. enter upon the
shave -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmlese the City of Cupertino against PERMIT ISSUANCE
SEISMIC IEE O
ELECTRIC FEE
liabilities,judgments, costs and expenses which may in any way accme against said City ALTER OR ADDTO MECH.
ego ting of this permit.
Onsegnc s the g '
PLUMBING FEE
APPL NT UNDE N) ILL COMPLY WITH ALL NON-INTAIRCPM) INT PIR HANDLING UNIT (TO 10,00
SOI' CEREGUI. T
MECHANICAL FEE
AIR HANDLING LIM r(OVER 10,000 CFM)
/p
CONSTRUCTIONTAX
Sigaat of rcanUC.nmaztm )ate EXHAUST HOOD OMMUCO
HAZARD ATERIAIS DISCLOSURE
HOUSING MITIGATION FIiE
dl the epplicantorfut uddingcecupam stmeorhandlehumakor material HEATING UNIT(TO UMW BTU)
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as defined by the Cupertino Municipal Code, Chapter 9.12, and the Bubb and Safety
Code, Section 25532(u)9 HEATING UNIT(OVBR IOJs(li BTU)
❑Yes ON. VENTILATION FAN( SINGLE RBSID)
PAID
Will the applicant or future building Occupant Use equipment or devices which
emit hamWour air conwmirecr s as defined by the Bay Area Air Quality Managanent BOILER -COMP (3HPOR 100,0001311)
Diraim9
Year ❑Nr BOILER- COMP (OVER 10,00 BTD)
Becmpt H
TOTAL:
I have read the hoodoos materials AIR CONDITIONER
requirements under Chapter of the Cilie
ISSUANCEDATE
ata Nat if the NEW RESIDENTIAL MECH. SQ. fed.
Health &Safety Code, Sections 2c5505,25533 and 25574, a notify the
building
hWding does not currently have stenant, that. ismyce
,
of the requirtn¢nu which most be met Prior to issuance of a Cenificme of Occupancy.
of. oninInnotifythepancy.
UED BY:
Owner or authorized agent Date TOTAL:
OFFICE