29639i
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY `
QTY. ELECTRIC PERMIT
CITY OF CUPERTINO BURRING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL
" BUILDING PROJECT IDENTIFICATION
as H Q
ZOr7
OZ4
Q
and effect
License Class Lic#
Dale Contractor
BUILDING ADDRESS: -
- SANITI
-
PANELS
UP T02W AMPS=
"q
Licensed Pmfessianel'201-100)AMPS
�IRCHITF,CT/ENGINEER:
OokE 'S NAME: PI NE:
LcSf
LIC NO:
CONTRACT R'S NA ' LIC NO:
1 at "
AWkESS: -
OVER 1000AMPS
N/C
❑
FSO
CONTACT: PHONE:
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INET_,'
nthat
0
0,ky
'
❑ Consultant Fees Paid by Applicant (Initial)
BBLD
Ip�7aCZ
FOO
uUmNShD CONI KAU IUR3 116cLAKAGUN I -
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
usinsand Professions Code, and my license is
with Section 700(fis Division 3of,he Bes
In full fmce
QTY. ELECTRIC PERMIT
PERMIT ISSUANCE
as H Q
ZOr7
OZ4
Q
and effect
License Class Lic#
Dale Contractor
APPLIANCES—RESIDENTIAL
ARCHITECT'S DECLARATION :
Innderetsnd my plans shall be used as public mentis
-
PANELS
UP T02W AMPS=
OCC. GROUP
-
Licensed Pmfessianel'201-100)AMPS
MODIFICATION
G C4�j
W,p�
irypi55,� O L O
, ,t ,.. Oat I am BUILDER m Ce Carlo DN
I hereby .(flan that 1 am exempt from the Gmtrnnors License Law for too my
following rt. a (Section,7031,5, and n Cwle: Any Illy or county
OVER 1000AMPS
SIGNS ULEC9RICAE'
FSO
t, alsoss
.r, de
demolish,
which requires n permit in construct, alter. Improve demolish, or repair any emtnnre
prior to its issuance, also requires the applicant for such permit o file a signed statement
he is licensed prrsuan, to he previsions of the Contractor's license Law (Chapter 9
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INET_,'
nthat
0
0,ky
(commencing with Section](11Mp of Division of the Business and Prof cions Code)or
thm he is exempt therefrom and the beds for, the alleged exemption, Any O.Imeas of
FOWERDEVIC S -
� N
dO
mwill
0i �.r
Section 7031.5 by any applicant for a pemtit subjects he applicant to a civil penalty of
a more than five hundred dollars ($500).
rlale(Se. compensation,
❑. do the work, theand pmperty,or is employees d moldered for
dose work, and, ThewifictureCont is not intended o Law do for sale (pec. W144, Business
and Pml'c cions Code The Contractor's License Law doer not apply to an owner of
pmperty.who builds or improves thereon, and who does such work himself or through
SWIMMINGP DL CTRIC
OUTLETS —. I ES—PIXTURP,:
-
TOTAL:
his we employees, provided that such improvements arc not intended or offered for
NEW RESIDENTIAL - CTR
BUILDING PEE
SEISMICFEE I
ELECTRIC FEE
sale. If, however, the building or improvement is sold within one year of completion, the
,
PERMIT ISSUANCE a
o r -builder will have the burden of proving that he did not build or improve Orr pun
PLUMBING PEE
AIR HANDLING UNIT (TO I0,000 CFM)
Pas, of aide.):
AIR HANDLING UNIT (OVER 10.000 CFM)
CONSTRUCTION TAX
❑ 1, as owner of the propeny, am exclusively contracting with licensed contractors to
EXHAUST HOOD(W/DUCH
HOUSING MITIGATION, FEE
conswet the protect (Sec' 7044, Business and Professions Code:) The Contractors Li�
- -
HEATING UNIT (OVER 100,100 BTU) -
ase Use does not apply to an ownerofpmpeny who builds or improves thereon, and
Q9`V. PLUM Bi P IT
Date Receipt#
who contracts for such projects with a contrachrod licensed pursuant to the Comm ns',
PERMIT ISSUANCE
AIR CONDITIONER
LicenseLaw.
❑ I am exanpt under Sec. ,B& P C for this reason
ALTER — DRAIN &VENT— WATER I
-
-
:EE JOB
2963
PERMIT INFO
COMMERCIAL'
El NEW BLDG/ADDITION ❑DEMOLITION
L1 TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ FT.
SQ, Pr. FLOOR AREA
PBE �' `'• ,is
-:AAA%, n _
•�
Z
70 O'
a`tom'
W �'y
Q
iL7"
0
Q U
W
i.y iA
U
•
�Dishin"41
SFUWL
❑ KITCHEN REMODEL
`
DITION
El PLUMBING RE -PIPE
TYPE
MULTIUNIT
El STRUCTURAL
OCC. GROUP
-
MODIFICATION
GREASUANDUSTR, WASTE INTERCEPTOR
❑ INTERIOR
❑CHIMNEY REPAIR
-
F.
PCANCHFCK FEE
ENERGY 17EE .�
IMPROVEMENT
WATER HEATER WNENT/ELECTR
GRADING PEE
❑ BATH REMODEUREPAIR ❑ DEMOLITION
WATER SYSTF,M/fREATING
_
[:]OTHER
WATER SERVICE _
-
PAID''
COMMERCIAL'
El NEW BLDG/ADDITION ❑DEMOLITION
L1 TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ FT.
SQ, Pr. FLOOR AREA
PBE �' `'• ,is
-:AAA%, n _
•�
Z
70 O'
a`tom'
W �'y
Q
iL7"
0
Q U
W
i.y iA
U
•
�Dishin"41
Owner '. Date
I hereby affirm under penaltyofpenury 6v of the fATION ollloiwiinng declamtions:
I have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
,all... as provided for by Seen.. 37M of the LabopCode, for the perforunscientific
work for which Has permitisissucd. -
El 1 have and will maintain Worker's Cnmpensstion Insurance, is required by Section
3700ofdac Can., Cods. for he performance of the work for which this permit is issued.
Mop
Y War en ''°n [a ca im and Policy a her.
Carrieoilpl�C/llLggl{, +±SA Policy Na
CERTIFICATAOFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred Jot lars 0100)
or less) -
I certify that in the performance of the work for which lhls tan nit is issued l shall/
not employ any person in any mannr...... furnace sobjecthe Workers'Compen-
cation Laws of C.lifornia. Dare
Applicata
BACK FLOW PROTECT. DEVICE
.^ •^"'^•'•,'•
^I`
DRAINS— FLOOR, ROOF; AREA, COND.
STOLLRIES,
TYPE
-
FIXTURES—PER TRAP
GAS — EA. SYSTEM -I INC. 4 OUTLETS
OCC. GROUP
-
CAS—EA.SYSIEM-OVER4(BA) t
GREASUANDUSTR, WASTE INTERCEPTOR
BUILDING DIVISION FE
CREASE TRAP - -
-
F.
PCANCHFCK FEE
ENERGY 17EE .�
SEWF,,R— ,SANITARY — STORM EA, 200 f"1'furnacem
WATER HEATER WNENT/ELECTR
GRADING PEE
NOTICE TO APPLICANT: If, after making this Cenlficam of Exemption ymi shoal.)
become subject to the Worker's Compensation provisions of the labor Circle, you must
farhwilh comply will, sock previsions or Ihis permit shall be deemed revoker.
CONSTRUCTION LENDING AGENCY
I hereby affirm that hem is r oreanmion leadmIl.liney for the peffonnancoof
he work far which,Itis permit is issued(Sec. 3097, Civ. C)
Lender's Name
WATER SYSTF,M/fREATING
_
SOILS FEE
WATER SERVICE _
-
PAID''
NEW RESIDENTIAL PLMB, SQ. Ff
Date "Receipt#
-
TOTAL:
_ _
Lender's Address
BUILDING PEE
SEISMICFEE I
ELECTRIC FEE
1 certify that 1 have read this application and state that the above information is
correct.)agree[, comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to mucrupan the
above-mentioned property for inspection purposes.
_ . (We) agree to save, indemnify and keep harmless the City of Cupen int aguimt
liabilities,judgments, veins and expenses which may In any way accrue agalnztsaid City
inconsequence ,fine granting ofhis permit. -
APPLICANT' UNDERSTANDS AND WILL COMPLY WITH ALL NON=POINT
SOURCE. LATICES.
i Qr
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE a
ALTER OR ADD TO MUCH.
PLUMBING PEE
AIR HANDLING UNIT (TO I0,000 CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10.000 CFM)
CONSTRUCTION TAX
Signature of It. t/ onorator Date
HAZARDOUS MATERIALS DISCLOSURE `
Will the applicant or future building occup:ml store or handle mtzarrous material
as defined by the Cupertln. Municipal Code, Chance 9.12, and the Health and Safety
Code. Section 25532on? ,
❑Yes E:] No
IWill ,he applicant af.fmum building ac.upam use equipment or devices which
it hazardous air contaminants as derived by the Bay Area Air Quality Management
❑Yes []NoBOILER=COMP(OVER
.,
I have mad the hazardous materials requirements under Chapter 6.95 of the Cali-
forma Health & Safety Code, Sections 25505; 25533 and 25534. 1 andcmand that if the
building does not commit, have a tenant, that it Limy responsibility to notify the occuprm
of the requirements which mus, be met prior to issuance of. Certificate of Occupancy,
EXHAUST HOOD(W/DUCH
HOUSING MITIGATION, FEE
HEATING UNIT (TO 1010,000 BTU)
- -
HEATING UNIT (OVER 100,100 BTU) -
PAID
VF;NT)LATION CAN(SINGLE RESID)
Date Receipt#
BOILER — COME CHIP OR 100,000 BTU)
I(IO,OO�BTU)
AIR CONDITIONER
ISSUANCE DATE
y
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. ET.
-
Ovac'miuhorizel.,car Date
T A
OFFICE