Loading...
00010132z zz°O W y Uz APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 00 O In / ';� 9 CITY OV CUPERTINO BUILDING - ELECTRICAL PERMIT NO, BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL BUILDING PROJECT IDENTIFICATION' BUILIIINGADDRESS: 1,318 -S. STS« i.�G 20. �u PF.eTi N a SANITARY IS APPLICATION SUBMITTAL DATE 00J ' PHONE: A:5� _ / CONTRACTOR'S NAME: LIC NO'. —OWNct`/C _ we ❑ m RDLa GTNCER: _ LIC NO: ef ADDRESS: - CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant (Initial) Bit DO ELECT PLUMB MECH L� !7 ❑ ❑ unORSder p DECLARATION LICENSEDIam Braman 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing QTY ELECTRIC PERMIT FEE JOB DESCRIPTION with Senon 70Okp fDivision] of Nc Business and Professions Coda and my license is in full lbrce and effect. Class Lich Date— Date ].i.#Contractor RESIDENTIAL ❑SFDWI, ❑ KITCHEN REMODEL ❑ADDITION ❑PLUMBING RE -PIPE ❑MULTI -UNIT ❑STRUCTURAL MODIFICATION I PERNH r ISSUANCE l' APPLIANCES -RESIDENTIAL ARCHITECTS DECLARATION I underamad my plans shall be, used as public accords PANELS UP'10210AMPS ❑INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT []SWIMMVsG POOLS 0 BATH REMODEL/REPAIR ❑DEMOLITION El OTHER Licensed Professional201.INw OWNER- exempt frDECe Contractor's 1 hereby .Dion that 1 am exempt from the Cnni n, Co License Law for the following reason (Semina 7 airless and mans Cade: Any city or county AMPS OVER I"AMT'S SIGNS ELECTRICAL. wiirM1 construct, vet de t, Ater, improve, a permit rc+eores mindI or repair any agned ' r in its the h AsorequirespooWoux.fthapplicant r sucbmiChm'mRDa comeml Ice,(Chpter9 SPECIALCIRCUM'/MISC. mathelsensedissuance. that be is licensed puation7 mart of the Cnmmnm's ense Chapter9 TI!MP.SISTER OR POLE INST. COMMERCIAL: (kh mEhslnm (commencing with Seainn]fK0)nf Divisinn3 of the Business and Professions Coda nr ad Prec'sim Nat he is exempt therefrom and the basis for the alleged exemption. Any violation of ❑ NEW BLDG/ADDITION ❑ DEMOLITION Section 7031.5 by any applicam for a q:nait subjects the applicam to a civil penalty of no lm Nun five hundred dollars(&5(10). us owner of the proper, or my employees with wages as their sole compensation, POW13R DEVICES ❑ TENANT ❑ FOOD SERVICE IMPNOVEMGNT SWIMMING POOL ELECTRIC till will do the work, and the urumure is not imended crocheted forsale (Sec. 7044* Business THER OUTLETS -SWITCHES -FIXTURES add Professions Cade: She Contmchn s License Law docs not apply to an owner n( properly who builds or improves Nerenn, and who does such work himself nr through his awn cmpinyecs, provided that ouch impmvemcnE am not intended or offered for NEW RESIDENTIAL. ELECTR SQ FP. sale. If, hi the building or improvement is sold within one year el coati the SQ. FT.P Oai AREA $/SQ, FT. ownectuilder will have the burden of proving Nat he did not build or improve for pur- pme of sAcJ. TOTAL: ❑ I, as owner of the properly, a exclusively contracting wiN licenced contradursto carom the proier, (See 7044, Business and Prafcssiona CMep The Commetors Li- cense Law does misapply to an owner 0 property who hu0ds or improves thereon, art QTY. PLUMBINGPERMIT FEE who contracts for such projects with a con raccoms) licensed parsuanno the Contractor's PERMrr ISSUANCE License lace. El I ant eaempt andXB & P C for this res�on ALTHR- DRAIN & VENT -WAl'BE CA) 01 G 2 Us, //J� VALUATION / ��� WORKS S COMPENSATION DECLARATION BACK 171 -OW PROTECT. DEVICE 11 rebyaffirm under penalty of perjury one of the following declarations: DRAINS- FLOOR, ROOF, AREA, COND. I have and will maintain a Cenifii of Consent to self -insure, for Workers Compete chin, as provided! for by Section 37M of the Labor Code, for the performance of the STORIES TYPE CONSTRUCTION work for which this permit Is issued. FIXTURES - PCR "TRAP 1 have and will maintain Wnrker'a Cnmpemeticn Insurance, as required by Section 37M of the Labur Code, for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number are: GAS -G. SYSTIiM- I INC. 40U'1'LEI'S OCC GROUP APN Cartier: Policy No.; GAS - EA. SYSTEMOVER 4 (EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPF.NSA'I'ION INSURANCE (Ibis section necdna be completed ifthe permit is form, hundred dollars($IIX) or rossJ GRIiA$P./INDUSTRI, WASTE INTERCEPTER BUILDING DIVISIONFEE' ' GRLASE TRAP PLANCHECK FEE SEWER -SANITARY -STORM EA. 200 Fr. I reirmy Nm inthe pamfonname,.Oh,work forwhich this panni, is issued.[shall not employ any person in any manner so as to bcrome subjcet to the Workers' ComNn- ENERGY FEE WKI FR HEATER WIVENTrELECTR ration Law's of Cal i!ammo. Date Applimtm GRADING FEE NOTICE TO APPLICANT: If, after making this Cenificme of Exemption, you should become subject m the Wacker Compensation provisions of the Labor Core. you most WAT13R SYSTEM/TREATING SOILS FEE fmNwith comply with such provisionsonhis pennitxhAl be deemed revoked. WATI7R SERVICE CONSTRUCTION LENDING AGENCY I hereby affirm that here is a consmetion lending agency for Performance of the work for which his peri, is issued (Sire. 3097, Civ. C) Leaders Name f� �•/�� +( I�� PAID �T''++ In NEW RESIDEMDAI. PLMB, SQ. IT. ��� It Dam "'1 `Receipt;MJ + LeadersAddress TOTAL: I certify that 1 have read this application and state that the shove infurnwtion is IIIIt DING PEE n T, QTY MECHANICAL PERMIT ; FB8 nnrect. agree N comply with all city nuW county orlinunces and nate Ines relechng to building construction, and hereby and i¢e representatives of this city to enter upon the t SEISMIC FEE above mentioned proper for inspection purposes. (We) agree to save. indemnify and keep harmless the City of Cupertino against PERM! T ISSUANCE ^ EdECPRIC'FEE Iiahi lilies, judgment,ensu and expenses which may in any way accuse against said City n yueneeu gran go P in cis ae f [at tin fIii coni+. ALI HE OR ADI! TO MECH. PLUMBING FEE AIR HANDLING UNI ITO IB(I(N) CPM) MECHANICALFEE APPLICANT UNDFIJSTANDS>Nfla WILL COMPLY WITH ALL NON -POINT SOURCERF ONS. HANDLING UNIT (OVER 10,000CFM) 2 Qa 2zAIR CONSTRUCTION TAX tore til Appllcan(rCnnt m —, Data ;14 HAZARDOUS MA'T'ERIALS DISCLOSURE EXHAUST HOOD(W/DUCT') HOUSING MITIGATION PEE HEATING UNIT (TO 100.00) RTU) Will the applicant or future building occupant store or handle haeallous material as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety Code, Section 25532pi HEATING UNIT (OVER 100,000 BTU) ❑Yes ❑No PAID VENTILATION PAN (SINGLE RESIU) Datc' HeceiplM TOTAL, Wrd the applicam m lamas building occupant use equipment Qu or devices which i, let? us air contaminants as defined by Ne Buy Arta Air Quality Management V cl? ❑Yes ❑No 1� 1 BOILER-COMP(3HP OR 100,(00 RTU) BOILER - COMP (OVER II10,0008"fU) Alit CONDITWEIR I haveread the harmonies materials is under Chapter 695 offle Cali- re,u 533; p ISSUANCP. DATE NEW BISIDENI'IAI. MECH. SQ. FT. forHealth a. safe y CMB, Secdom 25505. I, any w, 25534.1 understand for if Be, building ]«s no achy have a hat it is my rtsgm<ibiliry, ton tifytheoccupan, 7 — ey / C G O'o-p of Nem which Ccigfimy. Z ISSUED BY, Own t auNonzed gem ste TOTAL: OFFICE