28520APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USEBALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING -ELECTRICAL
PERM[ 'I'NO,
�% -JC
BUILDING DIVISION APPLICATION/PERMIT
PLUMBING - MECHANICAL.
O
L O
BUILDING PROJECT IDENTIFICATION
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BUILDINGADDRESR.
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SANITARY NO.
APPLICATIONSUBMITTALDATE
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Saa—sk
0 •RN E: PHONE:' C 1�'1pc-TO1JNAME� LIC NO:yay+�'$
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Cs. — 44510 410
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NIC,
CONTROL
RCHITECT/ENGINEER: LIC NO: - AD SS:
s 3a Gos
3 o I
CONTACT: PHONE:
-
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ ❑
LICENSED C(INTRACI'OR'S DECLARATION
QTY ELECTRIC PERMIT
FEE
JOB DESCRIPTION
1 hereby alRrm that 1 am licensed tinder provisions of Chapter 9 (commencing
wt
with Section ]1X10) of Division 3 afthe Business and Pmfeasium Cade, and my license is
RESIDENTIAL:
i
L elect.
PERMS ISSUANCE'
x
-
❑STOW: 1TCHEN REMODEL
eClassnd
License
License Class LiaN
I Dam Contractor
APPLIANCES -RESIDENTIAL.
❑ADDITION ❑PL MBING RE -PIPE
❑MULTLUNIT El STRUCTURAL
j ARCHIFECTS DECLARATION
PANELS
I understand my plans shall he used os public records
MODIFICATION
pp
UP T02010AMP5
El INTERIOR ❑CHIMNEY REPAIR
.IMPROVEMENT
1 Licensed Profwaionel 2111-UXx)AMPS
OWNER-BUILDERi,C DECLARATION
1i Odd
OVER 1000AMPS
❑ BATH REMODEIJREPAIR ❑ DEMOLITION
I ma
1 hereby affirm that I am exempt from the Contactors License Law for the
1 ngreuwa(Section 7031.5, Professions Cole: Any cityorrcounty
SIGNS ELECTRICAL
[I OTHER
which
iwhich requires u consmr.edic,iandve.de
ac conswc: alcor, improve. demolish, or repair any structure
-
e, also for Permits
i poor at ceuence,nlau requires the
SPECIAL CIRCUIT/MISC.
the rovidimofant
he islits
that he i visions of the toitmflea Lawhaptensaturation
CartLicense Low (, 9
Financial.Se
COMMERCIAL
tion, with "E.I' a lboidor's
Code) or
(commencing with Sectinn]OOU)of Division3of the Buainae and Pmfessians Code)nr TEMP.ME'IER OR PULE INET.
tont he is exempt thertfnun and the basis for the alleged exemption. Any vinlmion of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
' Second 7031.5 by any applicam far apmad subjen.uhe appli... 11. u civil penalty of
POWER DEVICES
-
❑TENANT ❑ FOOD SERVICE
not more Nan live hundred dollars (8500).
iFI 1. as owner of the property, or my employees with wages as their sole compensation,
SWIMMING POOL ELECTRIC
IMPROVEMENT
will do the work, and the structure i snot intended proffered lar sale (Sec. ](44, Business
as
DOTTER
i end Professions Code: The Cmarvaims License Law docs not apply to an owner of
)UTI,21'S-SWITCHES'-FIXTUR ES
' -
roert
ppy who builds or impmves thereon, and who does such work himself or through
-
his own enpinyces, provided that such improvements am sat mmnded or offered for
NEW RESIDENTIAL ELECTS SQ Er.
SQ. FT FLOOR AREA
$/SQ. IT.
sale. If. however. the building or improvement is sold withinone year ofcomplction. the
ownerbuilder will have the burden of proving that he did not build or improve for pur-
,,a of sale.).
❑ I, us owner of the property, tun cxclusivcly controlling with licensed comrocmrs to-
onsveer the project (Sm. 7144. Business and Professions CWe:)'Dc Contractor's Li -
cause Law does not apply toanowner ofproperty who builds or improves thereon, and
QTY, PLUMBING PERMIT
FEE
who contacts for such pmjccts with a conmtetm(s) licensed pursuant m the Contractor's
Licenm law.
PERMIT ISSUANCE
❑ l am exempt under Sec. , B & P C for this reason
Owner Date
ALTER -DRAIN & VENT- WATER HA)
' VALUATION
-
WORKER'S COMPENSATION DECLARATION, BACK FLOW PROTECT, DEVICE
I herehy affirm under penalty of perjury one of the following eclaations:
] I have and will maintain a Certificate of Consent to self -insure for Worker's Compel.
DRAINS - FLOOR.R OR AREA, CONK
STORIES
TYPE CONSTRUCTION
sodas, as provided for by Sermon 37M of the Lahr Cade, for the perfomtance mite
work for which this permit is issued,
FIXTP REw PER AP
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
37M of the Labor Colds. for the performance of the work far which this permit is issued.
GAS -HA. ZINC. 4 OUTLETS
a,
APN
My Workers Compensation Insurance carrier and Put icy another are :
My
�R4(EA)
Carrier. Policy No.:
GA 'A
-
CERTIFICATE OF EXEMPTION FROM WORKERS'
- r,,.
COMPENSATION INSURANCE
GREAti__ NDUSTRL INT'_ EPTOR
BUILDING DIVISION FP.BS
(Thissection 'ern tbecmnplacd lithe permitisfonmehundrcd dollars ($IW)
\ 1
PLANCHECK FEE.
or ]a..) GREASHTRAP-,,
Icenify that in a onnance of the work Bar which this pemtit is issued, Ishall
SP,WBR-SANIT �,BA. 400
ENERGY FEL:
_-S
not employ nbecm fo the Workers'Cm L
tion Law of@ -o
Applicant
WATER NF.ATF.RW FRS
GRADING F
NOTICE TO ' LIC T: If, alter raking this Cenifim
cc of Exemption, you should
WATER SYSTIIM/TREATIN S
-
SOILS FEE
beemax subject to the Worker's Compensation provisions fthe Labor Code, you must
foMwith comply with such provisions of this proaraidaml be deemed revoked,
WATER SERVICE
LEsIDINGlend
NEW RE.SI DENTIAL PLM B. SQ. FT.
kAB Gan
AGENICyfor the Performance of
Thereby affirm CONSTRUhem CTION
'7j Date .pt«
the work for which this permit is issued (Sec 3097, Civ. C)
unto: TOTAL:
n's Name
ladcr
Lenders Address
1 cattily that 1 have read this application and state tont the above Information is
BUILDING ITE
correct. I agree to comply with all city and county ordinances and state lows relating to
QTY, MECHANICAL PERMIT
FEE
building construction, and hereby authorize representatives of this city to enter upon the
SEISMIC FEE
above in, dtinncd sty for inspection purposes,
PERMIT ISSUANCE
(We)ogre tus r.Indemnify end keep hnrmlese the City of Cupertino against
ELECTRIC FEE
lubilities,Judgm ts, co is end ex-aseswhichmay in anyway smile against said City
gLTF.R OR ADD TO MGCH.
in cnnseyvence o the 6r sting of this panni:
PLUMBING ITE
APDL U DER'FANDS AND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNIT(TO 10,(1(110 CPM)
SOI'.CE REG AT IS
MECHANICAL FEE
CONSTRUCTION TAP
i 2 Q -, f AIR HANDLING UNIT (OVER 10,Mq CFM)
tgrou:ill App - ankmaoctor Date
EXHAUST HOOD GVMUCT) -
161'
HOUSING
HAZARDOUS MATERIALS DISCLOSURE.
M 1 TION FEE
the applicant nr future huildingoad,lintstmeor him ,te musicians material
HEATING UNIT (TO 100.087 BTU)
evcr0
as defied by the Cupertino Municipal Code, Chapter 9.12, and Ne Health and Safety
;
Code, Section 25532(a)7 -
HEATING UNIT(OVER 100," BTU)
❑ YesN -
VENTILATION PAN (SINGLE RISID)
PAID sData .—�r—
Will the applicant or future building occupant use equipment or devices which
•"4/
knit hozordoos it continuations as retired by the Be, Arca Air Quality Management
BOILER -COMP DHP OR 100,D(K)BTU)
/TOTAL:
nstnct9
Yes ❑Nn
❑,
BOILER - COMP (OVER 100,:X70 BTU)
I Mve laud the harallowa materials rtgairtmems under Clapmr h95 of the Cali-
AIR CONDI'r10NER
ISSUANCE
formsnH Safety
forma Health &Safety Cade, Sections 25505, 25517 end 25534. I unJerxtand that if the
Case, Setioon:thta
and2534. 1 undimmedthccupant
NEW RESIDENTIALMF.CH. SQ. FT.
N
it ismty
of the requirements which most be amt prior to issuance of a Certificate of Occupancy.
ISSUF.DBY:
Owner nr authorired agent Date TOTAL:
OFFICE •
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Of FILE COPY
11 117 N10Rm ON NO. 10001 OF 14131ff•
HEWED
AUG Zai 1995
BLDG, INSPEC
OFTION DEP4"MM
Cffi
rrJ
SCALE: � � / f APPROVED BY: DRAWN E
DATE: REVISED
DRAWING NUMBER
0
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