30470APPLICANTTO FILL IN _INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT. PLUMBING.. MECHANICAL.
BUILDING PROJECT LDENTIFICNI [ON
PERMIT No. 3 O /1 7 O
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BUILDING ADDRESS:
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SANITARY NO
APPLICATION SUBMI'PI'AL DATE
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❑ Consultant Palrrby Applicant (Initial)
BUILDING I'F,RMIT INFO
BLDG ELECT PLUMB MECIi
El. El
LICENSED CONTRACTOR'S DECLARATION
I hereby Biy` that I am licensed under provisions of Chapter 9 (rommense is
with Sadon]fXXO of Uivisianl .fibs Business etM Rvfessibns Code, and mylicense is
ale reels <rcat.A f�
License less G Lim.p `-'
Da¢ Cnmracmr
QTY.
ELECTRIC PERMIT
FEE
JOB DESCRIPTION
RESIDENTIAL:
❑ShDWL El KITCHEN REMODEL.
CADDITION ❑PLUMBINGRE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
El INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
❑ BATH RFMODELREPAIR ❑DEMOLITION
❑ OTHER
-
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
AR ITECTS IJIiC1.ARATION
Iundcrn:md my plans mall he uscdm public rmnrds _
Licensed Professional
OWNER - BUILDER DECLARATION
1 hereby affirm that 1 am exempt front the Contractor's License Law for the
K; Ilowma reason. (Section 7 031.5. Business and Professions Cade: Any city or county
hich requires it permit to construct, alrec improve, demolish, or repair any structure
pliono its issuance, ulmreyuires theapplicam branch fears a file. signed statement
Utut he is licensed pursnantto the pmvisions of the Contractor's Licene Law (Chapter 9
(vn.ancrong with Section 701N)of Di vision 3of the Business and Professions Ctad <)or
Ilmt he is exempt therefrom and the basis into, alleged exemption. Arty violation of
Suction 7 031.5 by any applicant for a permit subjects the applicant) it civil penalty of
nut more than five hundred dollars (S500).
0 Laa owner of the pmpeny, or my employees with wagnmtheirsnle compensation.
will do the work, andthesuucmmi ... t intended mothered forsale(Sec. 71H4. Business
and Professions Cede: The Contractor's License Law does not apply to an owner of
property 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
owner-milder howevegthehuillmhoden offemcnt sold did non build r improve
er- builder will have the harden of proving that Ire ditl not build or improve tarpon,
Disc m" .1c.). '' -
❑ tam owner ij the property, run exclusively commuting with licensed mmit i
container project (Set. 7444, Business anJ professions Code:) The Commetoh ti-
tense Law dries not apply to an owner of property who builds or improves thereon,
who convects for such projects with a contmctor(s) licensed pursuant to Me Contractor's
License Law.
❑Iumexempt under Scc. - ,B &PCfnr this reason
PANELS
UI'T020n AMPS
201- 10MAMPS
OVIiK IOW AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
1EMEMEI'E ORPOLEINST
COMMERCIAL:
❑ NEW BLDG /ADDITION ❑ DEMOLITION
�TGNANT [I FOOD SERVICE
IMPROVEMENT
[I OTHER
1'O E VICES
SW POOL ELECTRIC
LIi TS TCHES - FIXTURES
NP RESIDE E :CTR SQ F-r
SQ. FT. FLOOR AREA
:/ Q�
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'. ail 1996
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''ma�yy
QTY, PLt[mu GPERMIT
FEE
PERMIT ISSUANCE
ALTER- GRAIN &VIINT -WATER (EA)
Owns, Date
MU�Ir'VAI.UATION
uVC/
WORKER'S COMPENSATION DECLARATION
I hereby aBma under penalty of Perjury one of the following declarations:
1have and will mounting is Cerdimme of comenuo self -insure for Worker's Counter-
smion, as provided for by Section 37M of the Lana Code, for the Performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700ofth Lmor Code, lira the performanceofthe work for which this permit iv Issued.
My Worypis fjynpepyk anj;uyrre&icntnd Policy number are:
Currier: /VJ (19e Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisseullon need not be completed film Permit is forouehundreddo[l.n (SIM)
or less.)
leenify that in the performance of the work for which this permit is issued, I.sha11
notemPloy any Per any manner so as it) haome subject to the Workeri Cam Pam
antinn Laws of .' 'n oUAte _
Applicant ./r
[LACK FLOW PROTECT. DEVICE.
DRAINS - FLOOR, ROOT: AREA, COND.
STORIES
TYPE CONSTRUCTION
FIXTURES - PER TRAP
GAS- EA.SYSTEM -I INC.40MLETS
OCC. GROUP
APN
GAS- EA.SYSTBM- OVER4fP.A)
OREASFJINDUSTRL WASTE INTERCEPTOR
-
BUILDING DIVISION FEES
GREASE TRAP
PLANCHECK FEE
SIiWER- SANITARY -STORM EA. 200FT.
ENERGY FEE
WATER HEATER WIVEN'1 ELECTR
GR FEE
TO APPLICANT. oft ;tog Nis oflustso Exem'f ptinn, you should
become subject the Worker's Compensation prnviaionsof the lahnr Code, yno most
forthwithco.piywith such provisions or this permit shall be deemM revoked.
CONSTRUCTION LENDING AGENCY
Ihemby able.thvnhem is. construction lending agency fort he Performance of
the work for which this permit is issued (Sec. 3W7, Cis, C.)
Lcrdeds Name
WATER SYSTEM /fREA'1'ING
SO SPF.
WATER SERVICE
Late Receipt#
NEW RESIDENTIAL PLMB. SQ, FT.
TOTAL:
Lcnder'x AJdrexs
TOTAL:
-
1 certify that I have read this application and state that the above infonandon is
correct.) agree tut comply with all city and county noil ... ecsandmaeluwamlmingm
buildingconstmnion. andherebyauthorizercprcumativesofthiscitym <nrerup�nthe
Anse- memioned property fur inspection purposes.
save,
(WO.S. tut se, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way aceme against said City
in consequence of the granting of this permit.
APPLICANT UND17RSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
B ILIJING :E
-
QTY. MECHANICAL PERMIT
FEE
'MICFF..
PERMIT ISSUANCE
..F.CII(IC E
Ihs BING HE
ACfER OR ADD TO MF.CU.
AIR HANDLING UNIT (O III,OW CUM)
'CHANIC LFEE
AIR HANDLING UNIT (OVER I0,000 CFM)
CONSTRUC ONTAX
Signature of AppliceHA7A DO Dam
HAZARDOUS MATERIALS a DISCLOSURE
Will the the Cupertino furore building occupant r 9.12, handle Health and Safety
C defined by the Cupertino Municipal Code, Chapter 9.12, and the Health unJ Safety
Gxie, Section 25332(.)'1
E] Yet E] No
Will the applicam or future building occupant use equ ipme or devices which
nt
Bit hazardous air commandants as defined by the Bay A. Air Quality Mxn..i mom
DislrictT �
❑Yes No
I have marl Ir auk us materials requirements under Chapter 695 of the Cali-
fomia Health & Sate Cale, Sections 25505, 25533 rntd 25534.1 andentand than if the
Ijuiliingdoes ally have that it ontyr'aptmibility to notify thooecupmn
a
of the m t hi tau: / mil�su ,,,m///n///ttJJJof�v/C,eni/E toyysl [,ke{up�nncyy /'
e -U7 -
EXHAUST HOOD (W /DUCT)
HOUSING MI IGATION FEE
HEATING UNIT (TO I W,fXXI BTU)
HEATING UNIT (OVER 1(0,00l) BTU)
PAID
Date t#
V EN'ITLATION FAN (SINGLE RESID)
y01LFR -COMP (THE OR I W,ODO B1'il)
TOTAL
BOILER -COME (OVER 100.000 BTU)
AIR CONDITIONER
ISSUANCE DATE
�l
ISSUED BY:
NEW RESIDENTIAL MEGA. SQ. FL
-
Owner ore onzW agent
TOTAL:
OFFICE