31537APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
PERMITNO.
5 37
BUILDING PROJECT IDENTIFICATION
J
BUILDINGADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
1527 Poi*Y WAY
OW R' N IF a PH -N ��
3
C MIRICI'O'S NAM 4.'31ICNO
NIC
❑
CON9'ROLM
PRp CI'/ENGINEB LIC NO;
ADDRESS: `�1T1 ap���ia _ _ ��
OI
NT
COCT. PHOS
EUILDING PERMIT INFO
�rp. L. /_. \ � H '37
f—, CJ ri
❑ Consultant Foes Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
c!G 7L7N Q a�G �i.i.�
,
❑ ❑ ❑
LICENSED CONTRACTORS macr SDECLARATION
Fion7 aflirm that Lam licensed m u under nd Promtu of Chapter 9 (mmmensi is
withSection](I(p)o(Division 7o(the Businusand Professions Code, sodas license is
y
in full tome end effl
Licenx�t— � Lisp
Dere _1!` Comnctor
QTY. ELECTRIC PERMIT FEE
W O
V�❑J
Ta Y]
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL [I KITCHEN REMODEL
CADDITION [I PLUMBING RE-PIPF
PERMIT ISSUANCE.
APPLIANCES - RESIDENTIAL
�n�y
ARCHIIECI'S DECIARA'f10N
I understand my plans shall be used as public records
❑MULTIUNIT ❑STRUCTURAL
MODIFICATION
PANELS
Z Q
3
A
3 d V
iV.
O
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I .' exempt from the Cmarmors License Law for the
following reason. (Section WH I.S. Business and Professions Cnde: Any city or county
which rtquims o permit m cmustrucl, alter, improve, demolish, m repair any structure
prior to its issuance, also requires the applicant for such permit o file a signed statementSPECIAL
In., he is licensed pursuant to the provisions f,ha Cammcmr's License law (Chapter9
UPTO 200 AMPS'
❑INTERIOR [ICHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR C DEMOLMON
[I OTHER
\ wa
'[7 Ig-sigas—
201.10OAMPS
OVER IME AMPS
SIGNS ELECTRICAL
CI RCUI'UMI$C.
A SO
TEMP. METER OR POLE INST.
COMMERCIAL,
❑ NEW BLDG/ADDITION C DEMOLITION
[]TENANT ❑FOODSERVICE
IMPROVEMENT
❑OTHER
C)
L a! eG
tr.
yy
G
�<
(commencing with Section 700l Division 3 of the Businesaund Pmfea,mr, CadOm
thm he is esempt damfmm and the hasis far the alleged exemption. Any violation of
Secohm703 L5 by any opplicum for a permit subjec.dic npplicam toes civil penalty of
not more than five hundred dollars (SIM).
1. as ownerof the
❑ property. or my employees with wages sole compensation,
do work, and the not intends& m offered far.ul ]044, Bminms
POWER DEVICES
-
SWIMMING POOL ELECTRIC
L'3
a(Sec.
and fie he Commences
and Profession Gude: The Canaactors License law does not apply m an owner of
property who builds or impnrvm Neuron, end who does such tints himself nr through
EGUTLETS -SWITCHES- FIXTURES I
his o provided that such improvements are not intended or oifcred for
his awn cmplor.
NEW RESIDENTIAL ELECfR SQ FT.
SQ. FT. FLOOR AREA
$/SQ. FT.
holder the improvementist i,hdid n one ye the
owns - will h ve th bur
owner -builder or improve
will have the burden mf proving that he did not build or improve for put-
at he
volder
Fou of sale.).
TUT L:
C 1, of t s ad contracting with licensed connacmn m
p
sectthenone,
t (Sec. 044,min Business
construct the project (Sec. ]fk14, Business and Professions CmdeJ The Conlrocmre Li-
cense Law does not apply to an owner of property who builds or improves themon. add
who commets mrsuch pmjects with a contrectorts) licensed pormaann the Contrscmrs
License Law.
❑ I am exempt under See. ,B&P C fmthis reason
QTY. PLUMBING PERMIT
fl
®� {/ 1nA
,Ji7
PERMIT ISSUANCE.
ALTER - DRAIN&VENT- WATER(EAI
Owner Dom
f LCUATION�1
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the hollowing doclmations:
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
❑ I have and will maintain a Certificate of Consent to self-insum for Workers Compcn.
sation, as provided for by Section 37M of the Labor Code, for the performance of the
wryk for which this pernit is issued.
y 1 have Ind will maintain Workers Compensmion Insurance, as required by Section
ST(1R1E5
TYPE CONSTRUCTION
FIXTURES -PER TRAP
IB of NelaWrCo ,for Ne Ndormanceofthewmkforwhichin rmitis imued.
M Wmk pa�oa Insurance carrieramd Polic the
GAS-EA.SYSTEM-I INCAOMETS
OCC. GROUP
APN
GAS-EA.SYSHM-OVER4(EA)
Coale,: -- Policy No.Y 7
CERTIFICATE OF EXEMPTION FROM WORKE
7..
.7
_O
ry
abecome
y
a
L)
INSURANCE
(Tbisseetion neednot he completed if the permit is for ane hundred dollars (SIM)
or leas)
1 cenify that in the perfmrnme, of the work forwhich this permit is issued. Isiah
not employ any person in any manner so as m become subject n the Workers'Compen-
sation Laws of California. Date
Applicant
GREASPJINDUSTRL WASTE INTERCEPTORCOMPENSATION
BUILDING DIVISION FEFiS
GREASETRAP
PLANCHECK FEE
SEWER -SANITARY -STORM EA, 200 FT.
ENERGY FEE
WATER HEATER WNENT/ELEtTR
GRADING FEE
NOTICE TO APPLICANT: If, it,, making this Ccrtificare of Exemption, you should
subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this pemtit shall he deemed revoked.
CONSTRUCTION LENDINGngAGENCY
I Birm that them iso agency
3097, leasing agency farted performance of
WATER SYSTEMI TREATING
SOILS FEE
WATER SERVICE
PAID
Data Rueiptp
NEW RESIDENTIAL PCMB. SQ. FT
0H
0 :.i
{1a
i1.
for whi ed(So.
the Lnderk for whichthispermit isissunl(Sec. 309],Civ. C.)
Lenders Name
Leaders Address-
TOTAL;
TOTAL:
I cenify that 1 have read thisapplicationstate that the shave information is
coup
BUILDING FEC•
N
L) z
and y ordinances
eorrmL comply and hwith ereby uth and cnunryu and state lawsr own the
building construction. and hereby authorize mpresentatives of this city to toter upon the
QTY. MECHANICAL PERMIT FEP
�
SEISMIC FEE
H
above-mentioned propeny for inspection purposes.
(We)agree tosave, indemnify and keep harmless the City of Cupertino against
liabilitics.judgm corn and expenses which may in any way venue against said City
onsequenc fth "ro ng of this permit.
PERMIT ISSUANCE
ELECTRIC FEE
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNITfTO 10,000 CFM)
MECHANICALFEE
APPLICAN' ONI:RST ' .VD WILT OMPLY WITH ALL NON -POINT
N.
SOURCE
4
AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCOONTAX
Signature ol'Applicun nmmcmr" Date
HA2ARDOUSM EATS DISCLOSURE.
EXHAUST GOOD(W/DULT}
HOUSING MITIGATION FEE
HEATING UNIT (TO 100.00T BTU)
Will the applicant or future buil g oecupantsmre or handle hazardous material
os defined by the Cupmino Municipal CNe, Chapter 9.12. and the Health and Safety
Coda, Section 25532(a)t
HEATING UNIT (OVER 100,0(X1 BTU)
E) Yea C] No
Will the applicant or future building occupied esu equipment or devices which
emit hazakous air mitmor ants as defined by the Bay Area Air Quality Management
District?
[3y. ❑Nn
PAID `-
—A-�=—�
V Ic Receipt X
VENTILATION PAN ISRESID)
BOILER -COMP (3HP OR 100,01)0 BTU)
TOTAL:
BOILER -COMP (OVER 100,010 BTU)
CONDITIONER
I have read the ha4rdous materialsAIR
rtquiremens under Chapter 6.95 of the CXIi
ISSUAN EDATE
NEW RESIDENTIAL MECH. SQ. PT.
famia Health & Safety Cade, Sections 25505, 25533 and 25534, 1 understand that if the
building does a. comedy have a tenant, that it is my usivaadbifiq m nmify the occupum
of the tequitements which nun be met prior lo issuanva of a Cori ficam of Occupancy.
ISSUED BY:
Owna-m matimizeJ agcm IDate
'TOTAL: I
OFFICE