B 02982
°z5
V
W
UC
OF
L
U�
nor rnwmTTO F!L r IM IMF0Q"ATlnM WITNw RED I IVES - USE BALL POINT PEN ONLY
ill1 r........ ._..__... ..-. _......
CITY OF CUPF.RTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING pRojECT IDEN'1'INCATION
1 PERMITNO, �O L ^ JU ,S
SOOOI
BUILDING ADDRESS:
SANITARY NO.
APPLICATION, SUBMI'TT'AL DATE
OWNER'S NAME: PHONIi:_ I
CONTR 'TO'S AMM ' LICV
6
NIC
❑
CONTROLp
ARCHITEMENGINE.: LIC NO:
ADDRISS:
ntl
CONTACT: PHONE.
BUILDING PERMTI' INFO
❑ ConSDIWnt Fees Paid by Applicant (initial)
BLDG ELECT' PLUMB MFCCHH/
❑ ❑ ❑ LJ
LICENSED CONTRACTOR'S DECLARATION
I hereby i roam root I,m, f,e.aw ander prnviaianx al ebapmr 9 (camm,aaing
QTY. ELECTRIC PERMIT FEE
-
JOB DESCRIPTION
PERMIT ISSUANCE
with Serum.70f111)nf Division 3olthe Business and Pmfessinns CtMe,::Z license is
infullforcc andeB t. '�
License,ass Lie.N
DateContmcmr44-
ABCHI'HCTSDECLARATIONPANELS
undusmnd my plans sh.11 he used as public records
RESIDENTIAL'
❑SFDWL O KITCHEN REMODEL
[]ADDITION ❑PLUMBING RF -PIPE
OMUI.TI-UNIT OSTRUCTURAL
MODIFICATION
[]INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT ❑SWIMMING POOLS
APPLIANCES -RESIDENTIAL
UPTD210AMPS
I Licensed Professional
20140100AMPS
OWNER -BUILDER DECLARATION
1 hereby urOn r That 1 nm axenrpr from Thu Comr..un., License Low for rhe
mlldwlng reason.(Ser on 9031.5, Imainecs and 11ndesslons Code: Any n'ty or cony
O BATH REMODEIJREP IR El DEMOLITION
c (A HEIR
OVER IIK)1)AMPS
SIGNS LLC'1RICA.
which mutinies a permit to construct. alley improve, demolish. or repair any structure
5P[CIAI. CIRCUIT/MISC.
requires provisions of for such Contractor s Lice se Lawdemmment
prionoslits ceued pursuant
that he is licensed pursuant to the provisions of the Contmcmrs License Law QCImpmr
Ill.,
(amnncncingwith 5wtion 900D)nf Division3 oflhe llusinec. nnJ Pmfesxiom C.Ae)vr
that he is exempt therefrom and the basis for (lie alleged excmpllon. Any violation of
TEMP. ME'I'IiR OR I'OLI:INST.
$�
❑NEW BLDG/ADDITION O OF OLITION
Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
El Las owner ofthe property, or my employed with wages as their aoh, compensation,
1 will Jn lM1e work, mAthcstrvmurcixnrn Intended nnrfrered for sale(Sce. 7044,13 iness
POWER DEVICES
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
OOTfII:R
SWIMMING POOL ELECTRIC
sad Pmfcsdons Code The Commmors License Law does not apply r. zea ,renter of
OUTLIi I:S- SWI'T'CHES - FIXTURES
NEW RESIDENTIAL HLEC'IR SQ FC.
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements sm not intended or offamJ for
sale. Lf. however, the building or impowemem is slid within one year of elmpleram the
�-I S(AT RAREA
P
$/SQ, FT.
owecrhuilder will have the hard,,) of proving that he did a,,, hard art improve fm put-
^
pow oLsalc')'
❑ 1, as owner of the property, am exclusively cnnwmirig with licensed ompacmm to owmth
me prove. (Sec. Business and Professions CM.:) The Cmuncmr a Li-
cense U. does not apply to an a,a,,If property who builds so improves theme.,and
TOTAL:
JUL a as
9 MST
QTY. PLUMBINGWLR FEF:
mm m the Caumm's
who contructs for such projects with a contonvoul) I Icensed pumnn
License law.I
0 1 ran exempt undo, Sec. , B & P C fill this mason
IY Ur 6urrh.I,INO'
PLRMI'IISSUANCE CI
Owner Date
ALTER - DRAIN & VENT - WATER IF
VALUATION
WORKER'S COMPENSATION DECLARATION
BACK PLOW PR[YfECI', DEVLCL
1 hereby .flits, under penally of perjury one of the following declamtione
❑ I have it will muiamm. Cenif,meof Cornenuo self -insure for Workers Cunprm-
satinn, as provided lin by Sectio 39110 of the Labor Code, for the performance of the
DRAINS -FLOOR. RODE AREA, COND'
STORIES
'I'YPECONSTRUCOON
work for which this permit is issued.
FIXTURES - PER TRAP
1 have end will Imumarm Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of (to work for which Ills permit is issued.
GAS- HA, SYSTEM. 11NC. 4 OU' I' LETS
OCC. GROUP
AIPN
My Wotkds Compcvmlon Insurance carrier and Policy number arc:
Carrie,; Policy Nn:
GAS -EA. SYSTEM OVER 4 (EA)
CREASFIINDUSTRL INTERCEPTORWASTE IERCEPIDR
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(t his suction need nor be completed tithe l ormil is flavor lmndred dollucs($1W)
or less.)
GREASII'I'RAP
_
PLANC111iCK PER
I cenifythm in the pc,fomeurrof Thr which this permit is issued, I shall
nor employ any person in any marorn -b u�i j.1 to the Wmkcri Compel-
cO
SEWER -SANITARY -STORM EA. NK)IT.
ENERGY FEE
WATER BEATER W/VENT/ELECI'R
GRADING FEE
satinn Luis., 4falfo�rnm�late / II
Applicant ' xa""�� I
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject m the Warder's Compensation provisions of the labor Code. you must
WATER SYSTEM)TREATING
SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked.
WATER SERVICE
Can duc aRUCI i... om LENDING AGENCY
jThereby affirm theuhem is. conawaon lending agency for the Performance of
NEW RESIDENTIAL I'LMB. SQ. PI1
PAID
Dore Receipt
the work for which this permit Is issued (Sec. 3DD9, Civ. C.)
Lcadcrx Name
TOTAL:
1 Lenders Address
TOTAL:
BUILDING PEE
I certify ilia, I have read this applion ino and +toe that the above infO.mmio. Is
rrrcet.I.gme it comply wih all lily ad ecantyordinanr, mdsmm laws relating m
building construction, and hereby authorize representatives of this city to enter upan the
QTY. MECHANICAL PERMIT FEE
SEISMIC FEF.
PERMIT ISSUANCE
aMwe-mentioned properly for inspection purposes.
(We).,me mai v, indemnify and keep h mnlesa the Cityof Cupertino against
LECCHIC FEE
PLUMBING ITE
Iiohilitics,judgments, costs and expenses which tory in any way accrue against said City
in consequence of the granting of this permit.
ALTER ORADDT'O MECIC
AIR HANDLING UNIT (TO 10,1100 CFM)MECHANICAL
FEIi , 0
APPLICANT UNDERSTANDS A ND WILL COMPLY Wit '1'II ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.100 CFM)
CONSTRUCTION TAX
Signmum of Agplilant/Conuacho Dam
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOLD(W/DUCD
HOUSING MITIGATION FEE
HEATING UNIT (TO 110SK0 BTU)
Will the applimm m future building vacupantsmre in handle hazardous material
as defined by the Cupertino Municipal Cade, Cbapmr 9.12, and the Health and Safety
Calc, SccOon 2553201)?
HEA'I'INC, UNIT (OVER 100,050 BTW
-
VENTEAI ION FAN (SINGLE RESID)
OYb, No
PAID -
Date Receipt M
BOILER - COMP (711P OR 100,0100 BTU)
1 Will the applicant or future building by the B y Ace, Air Qu or devices which
emit hamnlous air ennmminams its defined by the Bay Arcu Air Quality Management
T(YI'AL: G
BOILER - COMP(OVCR 1110,000 B'I'IJ)
District'!
Oyes ON.
AIR CONDITIONER
I have read the limatdoes materials requirements under Chapter 6.95 oftbe Cali-
F ISSUANCE DATE
NEW RESIDENTIAL MUCH. SQ. PT.
mw health & Salory Code, Sections 25505, 25533 and 25534. I mdersmad that if the
bmf turn only have a tmmnt,thnt 11 is my mmonsihilfly proofy hcoccupatn
of re rarrons. vs iherac primm i;...bceofn Ccnili am
ISSUED BY: '!
TOTAL: ffq
Ow eroraidam,ed,rom Dote
OFFICE