30979APPLICANTTO FILL IN
USE BALLPOINT PEN ONLY
CITY OF CUPERTINO BUILDING- ELEUI RICAL rrasmrr is".
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL 30979
1 <<
OFFICE
2 in rECT/ENGINEER: LIC NO:
ADDRESS.
❑
CONTACT. PHONE:
BUILDING PERMIT INFO
•
❑ Consultant Fees Paid by Applicant (Initial)
BL ELECT PLUMB MECH
❑ ❑ ❑
TROZ
FO'
Cuter
GUU
LICENSED I .. CUNT ands, s DECLARATION
I hereby affirm tont I nm licensed under provisions of Chapter 9lcommencing
with Senior](X10)nfDivisionJ of the Business and Pmfessinns Gule, end my license is
res full force and effect.
License Class Cris
QTY. ELECTRIC PERMIT
FEE
J09 DESCRIPTION
RESIDENTIAL•
❑SFDWL ❑KITCHENREMODEL
❑ADDITION ❑ PLUMBING BE PIPE
❑MULB'I-0NIT ❑STRUCTURAL.
E3 INTERIOR El CHIMNEY REPAIR
IMPROVEMENT _
❑ BATH REMODEUREPAIR El DEMOLITION
❑OTHER
PERMITISSUANCE
APPLIANCES - RESIDENTIAL
'Don'Date
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OZ-0
TSDEtor
ARCHITECT'S DECLARATION
1 understood my plans shall be used as public records
PANELS
PANELS
UPTO 200 AMPS
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FAQ
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Licensed Professional r
DECLARATION Cor oto
I hereby affirm that I am exempt tram the CosionsCo e; Any a Law for the
that I a exempt
following reason (Section ]031.5, Business and Professions Cale: Any city or Worry
which requires a pemtit to consumer, alter, marrow, demolish, or repair any structure
prior to its issuance, also requires the applicant for such Permit to file a signed statement
that he is licensed pursuant to the provisions of the Commdols License Low (Chapter 9
(commencing with Seainn]O(1(pnf Division of the Business and Professions Code) or
that he is exempt Nerefmm and the basis for Ne alleged exemption. Any violation of
Sec0on 7031.5 by any applicant for upermit subjects the applicanto e civil penalty of
nm more than five hundred dollars ($5(1).
E] 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and Ne soman is not intended proffered for sale (See, 711ek4, Business
201-1000AMPS
OVER I0M AMPS
SIGNS ELECTRICAL �
SPECIALCIRCUTDMISC:0,t'�4,.
TCh1P. MUTER OR POLE INS'1:1 ��`
POWER DEVICES r� �,^.,_
SWI MMI NG POOL. ELECTRIC 'iN \`.,
COMMERCIAL:
11 NEW BLDG/q{D�� ��M}fy�'ITION
[]TENANT{ T 4Op{ERVICB
IMPROVEMENT
`'t OTHER
m
and Professions Code: The Cuntraclnls License Low does not apply to a owner of
Pmpeny what builds m improves human, snit what does such work himself ter through
his own employees, provided that such improvements are not intended or offered for
sale. ILhowever, the building or improvement is sold within one year of completion, the
OUTLETS- SWITCHES -FIXTURES `s'p
r
'
NEW RESIDENTIAL FLOM ITT -_'l
\
SQ. Fl`TI. RJ.REA
$/SQ. FT.
menerrbuilder will have the burden of proving that he did no build or improve for par-
Mae of
Y
TOTA ..
one who licensed C contractorsdon'si-
❑ L as owner of the pmpeng am sines and contracTreasonous
consumer the pmjea (Sec. ]BML Business and Professions ds or i The s thromen, Li-
Li-
cense Lew does not apply a an owner of properly who builds or improves thereon, and
who contracts for such projects with acomradnr(s)licensed pursuant to the Contr ears
Qcm.
I utn axe under Sec. ,B&P C fur this man
mDoe
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QTY. PLUMBING PERMIT F.
PERMITISSUANCE
omer«�"
ALTER - GRAIN & VENT - WATER (EA)
RACK FLOW PROTECT. DEVICE
VALUATION
WORKE'R'S COMPENSATION DE ATION
I hereby affirm under penalty of perjury one of are following declarations:
DRAINS- FLOOR, ROOF, AREA, COND,
Q l have and will maintain a Cenificnte of Consent to self -insure for Workers Compete
sodium, m provided! for by Section 37M of the Labor Code, for the Performance of the
STORIES
7V Pr: CONSTRUCfION
FIXTURES- PER TRAP
work for which this permit is issued.
0 I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the labor Code, for the Nrforrrence of the work for which this pemtit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
GAS - EA. SYSTEM -I INC. 4 OUTLETS
OCG GROUP
APN
Cartier: Policy No.:
GAS - EA. SYSTCMTOVER 4 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This woman nail not be completed ifdo, permit is fromm hundred dollars (SIM)
or less)
GREASP/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE. TRAP
PLANCHECK FEE
SEWER-SANITARY-STORM P.A. 200 f4.
,z
O O
Vl
F;
I certify that in the performance of the workforwhich this porins is issuedlshall
not employ any person in any tomer so as m become subject to the Workers' &pen-
ration Laws of California. Data
Applicant
ENERGY IEE
WATER HEATER W/VENT/ELECTR
GRADING FP.P.
d youshumid
NOnCR camesTjear ma WinnANT: s Compensation
Nis Certificate the
Exempt] ndooCode
baomesubjecty it Wahers Campeor this provisions of the Labor Cade.you must
..I
forthwith warty wird such provisions or this permit shall be deemed rcvnkW.
WATER5YSTCM/1'REATING
SOILS FEE
WATER SERVICE
04
cz
L% O
CONSTRUCTION LENDING AGENCY
l hereby alRrm thin is a construction lending agency for the Performance of
PAID
NEW RESIDENTIAL. PLMB. SQ. FT.
Dam Receipt as
L>ti F
O
>s
raj)
U Zbuilding
Ne work for which this Permit is issued (Sec. 3097. Civ. C.)
Lenders Name
Lenders Address
TOTAL:
TOTAL:
I cenify that 1 have read this application and state that the above infotmmion is
correct. I agree to comply with all city and county ordinances and state laws relating to
composition, and hereby authorise representatives of this city to enter apes the
QTY, MECHANICAL PERMIT FEE
BUILDING FCC
SEISMIC PEI?
ti
above-mentioned property for inspection purposes.
(We) agree o save, indemnify and keep harmless the City of Cupenin, against
PERMITISSUANCE.
ELECTRIC FEE
liabilities.judgments. costs and expenses which trey in any way accrueegainstsnid City
in consequence of Ne granting of this permit,
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FCC
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SO' REGULATI NS.
AIR HANDLING UNIT (OVER 10.0(10 CFM)
CONSTRUCTION TAX .
1
, L✓s-O..w casiY./ Z, L rj�
Signature of ApplicanUContraaor Dom
MATE ALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT(1'0100,000 BTU)
Will the applicant or future building occupant store orhandle haxamous material
as defined by Ne Cupertino Municipal Coda, Chapter 9.12, and the Health and Safety
Code, Satipn 25532fa)7
HEATING UNIT (OVER 100,000 BTU)
E] yes ❑No
Wi11 es applicant or Tatum building by are B use AreaAir Qu Br Mara Which
nit havrdous air contaminants as defined by the Bay Arta Air Quality Management
Distrin?
❑Yes ❑No
PAID
VENTILATION PAN (SIN GLE RFSID)
Data Rcceip,#
BOILER -COMP (3HP OR 100,(1011 BTU)
TOTAL:
BOILER - COMP (OVER 100,000 BTU)
AIR CONDITIONER
I have read the hamordous materials under of Cali-
mlu 533
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
forma Health & Safety Cade, Sanious 25505, 25533 and 25534. I undersand that if the
an 1 and rsto
OFFICE