30052APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT - PLUMBING-MECBANICAL
BUILDING PROJECT' IDENTIFICATION
PERMITNO. O O NJ Z
BUILDINGADDRES$:
ea'o 5C - flF 1,4 D
SANITARY NO.
APPLICATION SUBMITTAL DATE
q al
OWNER' AMG: PHONE:
V
CONTRACTOR'S NAME: LIC NO:
V J
N/C
❑
CONTROL
ARCHITECTANGINEER; LIC NO:
ADDRESS:
33s Shu
CONTACT: PHONE:
O % O—/7//
Q/gC
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC�H
❑ �� alEC
LICENSED CONTRACTOR'S DECLARATION
1 all affirm that I it, Iieemw under provisinm of Chapter 9 (commencing
with Section Division 3Ofthe Business and Professions Code, and my license is
m full for unit Recto/C j b e3 JK �Z . J7
License s 1.in#� /�
Date GonlDECL
iI,ECI'RIC
QTY IPGRMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑ SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑ PLUMBING RI:PIPE
❑MULTI -UNIT ❑TURAL
MODIFICATION
❑INTERIOR 0 CHIMNEY R17PAIR
IMPROVEMENT
❑BATH REMODEI/REPAIR ❑DEMOLITION
,,w /� �� /t
❑ OTHER _fir �1hodl Ze
{ �'Af �'
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
ARCHITECTS DECLARATION
understandI understand my pions shnrecorecordsMODIF
li he used as public records
-
PANELS
�
_ UPT0201AMPS
Licensed Professional
OWNER BUILDER DECLARATION
I hereby affirm that I um exempt from the Contractor's License law for the
following mason (Section 7031 S, Business and Professions Code: Any city or county
which requires o permit,dmm commit, alter, id too such
h permitdemolist m repair any swcmrc
ovisionof fm Comelor'toicense ned owIChapteenl
thatheis licensed pursuant to the provisionsof the Cnmmness License Low IChount 9
that hur oiucensed grsuant toihe provisions
the Business and Professions Count or
(commancingis exemit Section and of Diaiiioor the
he is exempt thertfmm and the basis for the alleged exemption. Any violation of
Section 9031.5 by any applicant for a permit subjects the applicant to o civil penalty of
not more than Ban hundred dollars ($500).
[:1 1, as owner of the property, Or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 700, Business
and Professions Code: The Contrvcmrs License Low diva not apply to an owner of
pmpeny who builds or improves thereon, and who does such work himself or through
his awn employees, Provided that such improvements are not intended or offered for
sale. IL howevegthe building Or inipmvement is sold within one yearofmmpleriogthe
owner -builder will have the burden Of proving that he did not build or inipnrve for put
pose of aide). I
❑ 1, as owner of the properly, . B exclusively contracting with licensed nnooemt%m
i-
construct the pruned (See. o an Business and property who bei Code:) The es then ton. Li-
censeimprove thereon.end
nselaw does nmapply man owner ontract rs wimseif pursuant
who c.mmcu for such p projects withnc.ntracmgs)IicenscJ punuannoohe Commnnr's
License law.
❑ Iamexemptunder See. ,B&PCfmmisrmcma
201-I000AMPS
OVER IIXXIAMPS
SIGNS P.L.ECI RICAL
SPECIALCIIiCUITIMIgC.
TEMP. METER OR POLE INS'I'.
lls�that
OMM _R -IA'
❑ NEW BLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELEM SQ
SQ. FT. FLOOR AREA
[w
ti 1996
U,
" L,.
', I,u
$ISQ. FT.
.
TOTAL,
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER-DRAIN&VENT-WNIER(EA)
Owner Date
- VALUATION
WORKER'S COMPENSATION DECLARATION
I heathy effinn ander pennhy of perjury one of the following declarations:
I
Hisveend will maintain.Cenificam OfConsem msel&insure for Wmker's Compcm
satinn, as provided for by Section 3700 of the Labor Code, for the performance of the
k for which this permit is issued
WI have and will ammain Worlds Compensation Insurance, as recut red by Section
39f10 of Ne LnNn Gde, for the perfurtnance of the work for which this permit is issued.
My Worke[y Cympensation Insy=Cc carrier and Policy ntytateJye:
Cartier. T`u✓a"so1.a� Policy No.: ,/V /7�4
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thi"mia n need not M contplued ifthe permit is for mulardmd dollars ($11X))
or lased
I cenify that in the permoremceoOhe work for whichthis vernflo, issued, Doll
not employ any person in any manner so as to become subject'. the con Co.,..
satinn Laws alifomiis Data
Applicant
RACK FLOW PROTECT. DEVICE
DRAINS - ILOOR, ROLE AREA, COND.
STORIES
OCC GROUP
TYPECONSTRUCTION
APN
FIXTURES - PGR THAT
GAS -EA. SYSTEM -1 INC. 4 OUTLETS
GAS- EA. SYSTEM OVER 4 (EA)
GREASUINDUSTRL WASTE INTERCEPTOR-
BUILDING DIVISION PEES
GREASE TRAP
YIANCH[CK hF.E `
SEWER-SANITARY-S'fORM EA. 200 F1'.
ENERGY FEE
WATER HEATER WNF.NT/ELGCfR
GRADINGFEB
NOTICE TO APPLICANT: If, after mukin is Cedifeate of Exemption, you should
become sable,,,, the Worker's Cnntpcnsm n pm baion, of the lahor Code, you must
forthwith comply with such provisions Or this permitshvll he domed rev.ked.
CONSTRUCTION LENDING AGENCY
I hertM1y affirm that them isaronswetion lending agrncy for the performance of
the work for which this permit is issued (Sm. 3097, Civ. CJ
Lender's Fit
WATER SYS TI?M/4REA'I'ING
SOILS FEB.
WATER SERVICE
PAID
Date Receipt#
NEW RESIDENTIAL PL.MB. SQ. FC
TOTAL:
Lender's Address
TOTAL,
BUILDING FEE
I cenify that 1 have real this application and mute that the aMwe intonational is
come[. I agree ill comply with all city and county ordinances and sum laws mining to
building construction, and hereby authorize representatives of this city to enter upon the
moose-menlioned prnpeny for inspection purposes.
(We) agree t. save, indemnify and keep families, the City of Cupir ion against
Iiahilities,judgmenos, costs and expenses which any in any way accrueagainet said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SovgymREGULATIONS.
z6
QTY MECHANICAL PERMIT FEE
SEISMIC PER
ELECTRIC FEE
PERMIT ISSUANCE
ALT ER OR ADD' 10 MECH.
PLUMBING FEE
AIR HANDLING UNIT TIO 10,WB CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of ApplicunUContrector Done
HAZARDOUS ATERIAIS DISCLOSURE
Will the applicant or future building occupartdom or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)9
.❑Yes FNO
Will rhopp rrbuilding bei
emit hrzanous air cohaminonts its defned by the tiny Area AirQuality Management
Milliner?
[I yes F-1 No
I have mad the hazardous materials requirements under Chapter 6.95 of the Cali-
forms Health & Safety Code, Sections 25505, 25533 and 25534.1 undersand that if the
building does not cumemly haven IennnL that it is my re,so bility to notify the Occupant
of the mquiremenos which must he met pm r m i ..... ve of a Certificate or Occupancy.
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION PEE
HEATING UNIT (TO I(XI,(I(XI BTU)
HEATING UNIT (OVER 100.000 BTU)
PAID _
Dau Receip#
VENTILATION PAN (SINGLE RESID)
BOILER-COMP(HPOR HNlON)RTU)
TOTAL:
BOILER - COMP (OVER 100.001 BTU)
� J
AIR CONDI'T'IONER �\
ISSUANC17 DATE
)
ISSUED BY:
NEW RESIDENTIALMECH, SQ. FT.
Owne monhorizedagent Date
TOTAL:
OFFICE