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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. - ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL
` BUILDING PRO)RCp mBNTIPIGTION -
PERMIT NO.
30135
BUB.DINGAD'DRRlESS:
I/v eg?_( V10
SANITARY NO.
APPLICATION SUBMITTAL DATE
.28 s` -z
OW ER'S NAME: PHONE:
CONTRACTOR'S NAME: LIC NO:
(
NIC
❑
CONTROL#
CHITECDENGINEER: LIC NO:
ADDRESS: Oysvp(ax
3OZAAJ15 i4jo l F, silo
CONTACT. PHONE:
'
❑ Consultant Fees Paid by Applicanl (Initial)
;(RX .7AVBUILDING PERMIT WPO; - {''u •N : '.
BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICTJJSED CONTRACTOR'S DECLARATION
I hereby aR that 1 am licensed under p
provisions of Chapter 9 (ammcneing
a1N Seetia ] 0007 ofDivisionJofthe Business and Profwsiem Code, and my license is
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JOB DESCRIPTION
RESIDENTIAL: '
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION [I PLUMBING RE -PIPE
C1 MULTI-UNIT El STRUCTURAL
MODIFICATION
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT
O BATH REMODELIREPAIR ❑DEMOLITION
0OTHER
—�-
PERMITISSUANCE
S�
APPLIANCES - RESIDENTIAL
Dak 6- �G-'4� Contsa_�m ^jJ�t(hl'CfTSl6N(
ARCH=S DECLARATION
.�, luedemund my plain slWlbe uredupublic recalls
`
PANEL
UPT0200AMPS
Limed Professional '. -
( 4 OWNER - BUILDER DECLARATION
} . 1 hereby air= that 1 am exempt from the Conrrecrors Liame, Law fa the
w wing reason. (Saxioe 7031.5. Business and Professions Code: My city m aunty
which requhsi a Pemdt in amtrun. ales, improve, demolish. or repair any structure
pridFm its issuance. also requires the sppBwnt fm such permit in fide a signed statement
that he is IiaPsrd puma.1 an the pmvuio#s W the Contraners Lkswe Taw (Chaptw9
(ammcndng with Section7000)efDiAb. 3 of the Business and Pmfcames Cods) or
than he is exempt tM fire. and the bssa for the alleged wemptioe. My vmhsioo of
Section 7031-1 by any applicant for a permit subjects; the applicant in a civil penalty of
i.tm ore than five hundred collars .;s ec .....: .... .. .'
❑Liss ownmafthe propeny,amy employa� with wegwulber wle cmnpensstloq
will do the work. W the structue u test intended meffved fa We(Sec.7041. Buinas
and Prefwsiow Cade: The Cootracusrs liana Law does not apply to an owner of
property who builds or impmvw thereon, and who does each work himself or through
his own cmpleye s, provided that such Inlpnovemenk are not intended or offered for
14e. If. haweveq the buildinlori.fuen, s.tis sold within aoe yearefampletion, the
owtrcr- builder will have the burden of proving thin he did rust build or improve for por-
pcaeof
O Lea owner of th ptopary. w exclusively eontr Ling with Baturd ceratracuses on
anMlel tier, prafeel (gee. 7M4. BYelaw am Pmf #amen Code:) The COntrYtora U-
come Lawda. not apply ban owner efpmparty, who builds or 1. wthereon, and
wboaouau for such rat with. coe ,.t
pmt tnama(a)liamsrd pmivantusthe Conuano /s
Lis sum-as );'g ,F, -.
❑ISm ,smpI under Sec., ,B &PCfathi.reasa
.-r..
201- I000AMPS
OVER IOW AMPS
2
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC
_`,
w W
TEMP. METER OR POLE INST.
COMMERCIAL
(]T`EW BLDG/ADDITION ❑ DEMOLITION
r7/'r ".',a. ANT ❑FOODSERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING POOL ELECMC
OUTLETS- SWTTCHPS- FIXTIIRFS
NEW RESIDENTIAL ELEC R SQ Pr.
SQ. FT. FLOOR AREA
_ r.
LSQ. FT.
ors
.Q
TOTAL:
ftSP:y R5 ^Plai puskM'
' y-.. Cyi}F"
'�+'4%cM 'sPlUMBING PPFRMITa5i 1
nn.� .nvmarvnvwnmwnrx : r'1•sdv,' �"YM&.wnt
rtYiPEB
PERMIT ISSUANCE pr
ALTER- DRAIN & VENT - WATER( )
BACK FLOW PROTECT. DEVICE
Ow m Due
VALUATION
` $�ggb.
u`',F ::, {r�;- WORKER'S COMPENSATION DECLARATION
1 hereby &W= underpamlty of perjury one of the following declananions:
he'veand will mamodit. Cemanauxofconant to self -i.me fa Worker. Counter-
u provided for by Section 37W of the Tabor Cede, fa the performance of dx
wakforwhichthispemtitisissurd J .,' .'
0 I lave and will maiaWn Worker. Comprnsstian Wutana, u required by Section
3700 ofthe labor Code, for the performance ofthe work for which this permit is issued.
My WOrke�riL.� n'ppemnss�tion Insurance carrier and Paliq numbe
Carrico 'I#AT>c em Policy NO.: ljyr_143 -)7
DRAINS - FLOOR, ROOF, AREA, COND,
gT0
�`,` "� } ' -•
TYPE CONSTRUCTION
-
FIXTURES- PERTRAP
GAS- EA.SYSfE I -I INC.40UTLb7t
OCC. GROUP
APN
GAS- EA.SYSTEM- OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
:. COMPENSATION INSURANCE
(This radon need ore be completed Vote permit is fm ane hundred doll. .$ 100)
orless) ^,
'', laruty thss intheperfomma ofdr wmkfo wNCh Nice permit is issued, IsluB
rat employ any pmou in any manner so u us become subject m the Workers Carapace.
.don laws of Celifnnis. Date
Applicant
GREASEIINDUSRU. WASTE INTERCEPTOR
BUILDING DMSION FEEg -qr.; `'P(,'y;,;a;�
GREASETRAP
PLANCHECK FEE
SEWER- SANITARY -STORM EA 200 Ff.
ENERGY FEE
WATER HEATER WNENT/ELECTR
GRADING FEE
NOTICE TD APPUCAM: U. after making this Certificate of Esemption, you should
becmyg subject m the Worker's Compewti. provisions of the Latter Code, you must
forth4M amply with such pmvisiom or this permit shall be domed revoked.
. CONSTRUCDONLENDINGAGENCY
) '•,: htteV affirm than there is aconswcnon lrnding agency loathe perfomunce of
theb4t fgaNCh this permit is isssed (Sec. 3M. Civ, C.)
Lenders Name
WATER SYSTAMITRFAIINO
WATER SERVICE
SOILS FEE
PAID
NEW RESIDENTIAL PLMB. SQ. PT.
Data Receipt#
TOTAL:
Lender Address
TOTAL:
I cattily that 1 have read this application and stale that the above information is
areeL 1 agree m amply with ell city and county ordinances end skte laws relatin6 toQ7y,:;
building construction, and hereby authorize representatives of this city to enter upon the
above - mentioned property for inspection Purposes.
(We) agree m save. indemnify and keep harmless Ne City of Cupertino against
liabilitiw,judgments.costs and expenses which may in any way accrue against mid City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE ULATIONS.
Ito ///Ln:tw 4 -7 X,-fb
BUB.DING FEE
_ h
_ ? MECHANICAL PERMIT �-3'"
h''° -FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
SL
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT (TO 10.000 CFM)
MECHANICAL FEE
AIR HANDLING UNIT IO,OW CFMI
CONSTRUCTION TAX
Signawreof ApplicanU mr Date
HAZARDOUS MATERIALS DISCLOSURE
Will therpplicanton future building cc ..... Imrear handle hazmdovs arterial
as defined by the C.,nino Mmdciprl Code. Chapter 9.12, end the Health and Safety
Code, Section 255321.)?
[3 Yes ❑No
Will the applicant of fumm building oeupa. use equipment or devices which
• emit hnmdous air conuminans as defined by the Bay Area Air Quality Management
Dimcl?
❑Yes No
I have read the barudoos materials requirements under Chapter 695 of the Cali-
Gomm Ewith & Safety Cade. Sections 25505. 25533 and 25534. 1 understand that if the
bantling dos nee currently have. recent. cut it is my respomibility to notify the occupant
Of the requirements which must be mat prim. issuance ale Certificate of Occupancy.
EXHAUST HOOD(WIDUCC)
HOUSING MITIGATION FEE
HEATING UNIT ITO 100,0071 BTU)
HEATING UNIT (OVER MAW BTU)
PAID
VENTILATION FAN (SINGLE RESID)
Data Receipt #
BOILER -COMP OHP OR 100.000 BTU)
TOTAL:
BOILER - COMP (OVER IW.IXq BTU)
AIRCONDITIONER
ISSUANCE DATE
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. FT.
Owner or euthorired agcm Dam
TOTAL:
OFFICE