29976APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F.LECTRICAI. PERMITN029976
. /� �a
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL. L v
kOM66 PICA
OFFICE
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ g ❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby am ten
ffirt I ant bcensed under p...Wess of Chapin, 9 (cmen
m.cing
Sia'..000)of Dlvisinn3of the Business and Professionrs Code, and my licen.e is
.full force end effect iL
Daa- Class L10.a ^
Date Con
QTY. ELECTRIC PERMIT FEE
�W
U
JOB DHSCRIPTION
RESIDENTIAL:
CSFDWL C KITCHEN REMODEL.
❑ADDITION El PLUMBING RE -PIPE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
Z p Z
SZ O
4-1W
fq� "aj
ip5, O U
sat 3 u, yFa
y
W X00
d o y
'^
.f. }
G
DELL
AR shah. use UECLAR TION
I nndersmnd my plans shall be tined as public rtcnN%
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm tem I am exempt from the Contractor's License Law for that
following reason (Section 7031.5, Business and Profnssiom, Cade: Any any or county
which requires a permit m cnrmuuct, alter, i pions , demolish nr repair any suucmm
pricrlo its issuance, also requires the applicant for such penniuo rile a signed statement
that he is licensed pssuanno theproviamaxofthe Conuacmr. License Law (Chapter 9
(com2nencingwiNsetion7g )af Di'ision3of Ne BusinasaMl fessions CWe)or
that he is exempt therefrom aad the basis boards, alleged exemption. Any violation of
Section ]BJ LS by any applicant bra permit subjects the applicant to acivil penalty of
not more than five hundred dull.. SSOH.
❑Los owner of the propmy,or my employees with wages us their solo compensation,
PANELS
00
UP 702AMPS
❑MULTI -UNIT ❑STRUCI'URAI.
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑BATH RF.MODELIREPAIR DEMOLITION
C OTHER
201-100JAMPS
OVER IOfkIAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.COMMERCIAL:
❑ NEW BLDG/ADDITION C DEMOLITION
❑TENANT ❑FOODSERVICE
PROVEM NT
POWER DEV IC ES
SWIMMING POOL ELECTRIC
will do the work, and the structure is not intended oroffered Iia sale (Sec. 7fN4, Business
ER
W
a' ..
and Pmfessions Cafe: The Contractors License Law Jots not apply m an owner of
property who builds or improves thereon, and who does such work himself or through
OUTLETS - SWITCHES - FIXTURES
his own employees, provided that such improvements are not imended or offered for
NEW RESIDENTIAL ELECTR SQ PT.
sale. IL however, the building or improvement is sold whin one year ofcompletion,the
SQ. FT. FLOOR AREA
$/SQ. Ff.
owner -builder will have the burden of proving that he did not build or improve for pur-
,. of sale.}
TOTAL:
C 1, as owner of the pmpeny, am exclusively contracting with licensed commonest m
construct the project (Sec. 7044, Business and Profcssinns Cale:) The Ciouncmr'x i.i
e Law does not apply to an owner orum
f property who builds or improves th,and
wusho contracts for such pmiccts with it commctor(.a) licensed pursuant to the contractor.
License Law.
C Ince exempt antler Sec. ,RSPCfor this reason
^
i L'x y sa
L 1,
3u� 1l) 1g96
QTY PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAINS VIiNT-WATER (CA)
Owner Dem
VALUATION
�"� /s �.�..%� uVU
(?r!:o
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty ofperim, one ofthe following declarations:
BACK FLOW PR(yl'P.CT. DEVICE
DRAINS- FLOOR. ROOF, AREA, COND,
, I have and will maintain a Certificate of Consent to self -insure for Worker's Camper.
s idea, as provided for by Section 37M of the Labor Code, for the performance of the
work for which Nis permit is ised.
su.
STORIES
TYPECONSTRUCTION
FIXTURES - PER TRAP D
[:I1 haveand will maintain Workers Comperamorm Insurance, us required by Section
3701 of the Labor Code, for the Performance offle work for which this permit is issued.
My Worker's Compensation Insurance caner and Policy number ore:
GAS - EA. SYSTEM -1 INC.4 OUTLETS
OCC. GROUT'
APN
Carrier: Policy No.:
GAS- EA. SYSTHM-OVER 4 (EA)
CERTIFICATE OF EXEMPTION ROM WORKERS'
COMPENSATION INSURANCE
(This motion need not becompleted if the permit is for one hundrtddallars ($100)
or less.)
GREASFANDUSTRI. WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE TRAP
PLANCHECK FEE
SEWER -SANITARY- STORM EA. 201117.
,z,
—F
I certify that in the Performance of me work which this permit is issued, I shall
nm employ any person m y manner xo av to hecnmo xuhjeet to Nd Workers' Cnmpeo-
Nation ChE ofC�'Ifomin lam,
pd
ENERGY FEE
WATER 111!A'ILR W/VI?NT/BLECTR
GRADING FEE
4
NOTICE Exemption, other you ,you mull
NOTICE. bj APPLICANT. k r; Hear Compensation
this Cisions of the
hcconre subject m the Wnrker'e Compensation pnrvisimnN of Ne Labor Code, you must
WATER 5YSTEM/IRI!ATING
i.-�^VVV'222
a [^
SOILS FEE
{Fa Y,..�
aQ
W.
W. H
fonhwiN comply wird such provisions or Nis permit sho111rc deemal revoked.
CONSTRUCTION LENDINGAG agency
Ihereby which.n thatthemtw.309,0, agency for the performance of
the wars far which this permit is issued (Sec. 3187, Civ. CJ
Landes Name
WATER SERVICE
PAID
Date d p
NEW RESIDENTIAL YLMB. SQ, FT.
TOTAL:
V1
V
lander'. Address
1 certify that 1 hove read this application and store that the above information is
correct. correct. l agree to comply with all city and county ordinances and state laws relating m
building constmetme, and herchyauteonterepresentativec ofthis city incineration the
QTY, MECHANICAL PERMIT FEE
BUILLDIN( P
SHISMIC FEE l
above-mentioned property for inspection purposes.
(We) agree to rove, indemnify and keep handless the City of Cupertino against
PERMIT ISSUANCE
ELECTRIC FEE
liabilities,judgments, cods and expenses which may in any way accrue against mid City
in consequence of the granting of this permit.
ALTER OR ADD TO MECH.
PLUMBING
AIR HANDLINGUNIT (TO 10,000 CPM)
MIiCHANIC FEE
APPLICANT DS ANO WILL COMPLY WITH ALL NON -POINT
�tLIC /RST U A' ONS.
L 0)D . b -ll -4b
`
AIR HANDLING IJNIT(OVER 10,001CFM)
CONSTRUCIONTAX
Signature ofApplicaoutfam setor Data
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD EMDUCT)
I10USINOM IGATION FEE
HEATING UNIT LTO 101,000 BTU)
Will the applicant or future building Occupant siom or handle hazardous material
m defined by she Cupenino Municipm Coda Chapter 9.12, and the Health and Safety
Code, Section 2553260?
HEATING UNIT (OVER 100,000 B'N)
❑Yes CNo
Will Ne applicant or (tura building occupant use A equipment of devices which
nit hnzallous air conmminantx as defined by the Buy Area Air Quality Management
E] yes 0 N
PAID
Dote Re ip p
VENTILATION PAN (SINGLE RFSID)
BOILER -COMP (3HPOR 100,000 BIU)
,TO,TAL .
BOILER - COMP (OVER 100,000BTU)
AIR CONDITIONER
I been read Ne hazardous mamrmis requirements under Chapter fi.95uf the if
Gxmia Health S Safety Code, Sections 25505, 25533 and 255]4.1 undersmnd that if Ne
building does not currently have a moat N. o is ua ce ofa Cerarto e o fy Ne pricy.
of Ne requirements which tunhmet Poor to ora Cenif¢ete of Occupancy.
ISSUANCE TE
� _ Arn
NEW RESIDENTIAL MECH. SQ. PT.
OFFICE