S 0871APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATIONIPF.RMITS PLUMBING MECHANICAL.
NUILDL:NG'PR(IJEFT IDENTIF'ICA'DON
P12RMIT NO.
08'71
V V 1
LDINO ADDRESS:
9G Rif SrNYA/S GRCZ l' 8r✓A
SANITARY NO.
API'LICAI'U N SUBMITTAL. DAT(?
I,
ONNER:S NAME': PHONE:
CONTE OR'S NAME: LIC NO:
AuFlc ewtir 3
N/C
❑
CONT Ro l.4
1ARCHITECT/ENGI NEER: LIC NO:
ADDRESS:
CONTAC9': "HONE:
BUILDING PHRMIT INFO
BLDG IB.IiCT I'hI1MB MIiCH
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACIOR'S DECLARATION
I hereby affirm that 1 am licensed under provisiovx of Chapter 9 (comntemdng
with Seen..70XXBmf Division 3ofthe Nuxinessand Pm(cssi:, Cal�e,/tnd my license is
in full force and eDcel. /9'1 31
License Ch", !'irk Lic.N DDi I
Uete C r
QTY ELECTRIC PERMIT FEE
JON ESCRIPTION
RESIDENTIAL,
❑SIl)WI. ❑ KII'CIIFNREMODHL
❑ADDITION ❑I'hUMBING REPIPIi
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
PAIR
[I INTERIOR ❑SW[MNEYRF.00I,
IMPROVEMENT �SWIMMINC POOLS
El BALL] REM01 il.l X AIR )I!M(I T 1R
❑OTHER
IOIyy DO
�UF"
U
u, a,
to p,
FOy
Ozv�
pp
�F (: F'I^L�
� a
ow U
3 F.
pl!RMI'I'ISSUANCF
p,
AI'PLIANCIS-RESIDI!N'1'IAI.
A CHITIiLTS UECLARA'1'ION
S DEC
lundmmnd my phis shell he usW azpublic rccorl
PANELS
UP TO 200 AMPS
Licensed lknfassinnnl
OWNER -BUILDER DECLARATION
1 heath IHrm that 1 am exempt Gant the Contractor's Livorno Law lin the
Y
following Mason (Section 7031.5, Busincxs and Pndessinns Code: Any city no mm�ty
gal-I(XMIAMPS
OVER look) AMPS
SIGNS ELECTRICAL
❑� LL
Ir-LL'Oa
which requires u permit m madmct. alter, roup rme,.lenuddish, or repair any srnctnre
pdue,. its ismanes,.N.Iftquitestheapplicmnt for such pe.inofile a signed Merriment
SPECIAL CIRCUIT/MISC.
't }
OC
W y e a
>LL!1 u•
.bat he is licenced Putsuanno the provisionsofthe Commetnls License Law(Chapter 9
(commencing with Section 700 )of Divi,ion3 ofthe Business and Professions Code) or
that he is exempt therefrom and the hnis far the alleged cnemption. Any vinlation or
Section 903ts Ilya, applicant our n permit sorters tN,diwnt m u civil pcnnhy ar
TEMP. MEIT.R OR POLE INST.
COMMERCIAL;
❑ NEW BLDGIAODITION ❑ DEMOLITION
❑TENANT ❑I GOD SERVICE
POWER DEVICES
POWE
a
F-�
adand
not more than live lmndred dollar, ($500).
Las owner of the re ,,arm minme with wages tote theirsnle mm ensu0on,
❑ P a Y Yc P Y 6 P
R do the work, and the structure is not intended modifered lin vale (See 7014, Business
Professions Code. The Contractors License Law does not apply to an owner (i(
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvementswu not intended or offered lar
are. If.however, the buildingor improvement is sold within one year afcompleumn. the
owner-huilder will have the burden of paving that he AIA not build ar improve for par-
IMPROVEMENT'
❑OTHER
:NGPOOLELI1,,C
st—
OUTLITS-SWITCHES-FIXTUR S
NEW RE IDENTIAL ELECfR Ff.
SQ. FI'. 14,00E AREA
P A 1 D
&SQ. FF.
TOTAL :
la,xe of sole.).
L nof the property, am exclusively conVading with licensed nmuaetnts m
❑a ower
muswcl the project (Sec. 7044. Business and Profession, Code:) The Contractor 1.1-
c seL.awdo,sot apply to no ownerof,,,,,My who buikbor bnpmvex thereon,and
25 Y_kq
NOVn FWJJI{�
QTY PLUMBING PERMIT F'
who contracts far such projects with to coatmetols) licensed purxuatn to the Commnor9
License Low.
/� f�PE
�t.
/�'
PERMIT ISSUANCE y
E_]I am exempt under See. ,B& P C for this reason
111
❑
VUNLII
Owner Date
AI.4'ER - DRAIN & VENT'- WA'I'IiR (EA)
VALUA'I'I(1N
WORKERS COMPENSATION DECIARATION
BACK FLOW PROTECT. DEVICE
•
I herehya0irm under pcnaltyof perjury one fthe following declmatinns:
(have and will maintain aCeni0atenf Consenun self -insure (nor Workers Cmnpen-
sation, ant provided for by Section 37M of the Labor Gide, for the performance of the
work for which this permit is tainted.
DRAINS- FLOOR, ROOF AREA. CONK
YIORIES
TYPECONSTRUCTION
FIXTURES - PER TRAP
GAS -VA. SYSTEM -1 INC. 4 OUTLETS
1 have and will maintain Worker's Compensation Insurance, as required by Stoma
37004the LammC:al, for (he performonmid the work Far hichytxhin permit is issued
OCC.GROUP
APE
C�My Workct�(�lry��ypaJuss/im catdc Polof Policycy No'
GAS -1!A.SYSTEM OVIiR4fEA)
GREASOINDUSTRL WAS LE INTERCEPTOR
CERTIFICATE OP'. MPT1ON FROM WIIRKERS'
COMPEiNSA'I'ION INSURANCE
BUILDING DIVISION PEES
(ThLesceti,mmvd not he completed Rolm permit is fon,ne hundred dollars 100)
or less.)
GREASE 'I'RAP
PLANCHECK FEE
SHWEI(-SANITARY-STORM EA. 200 FL
ANERGY FEE
mainly tbnlimhc perliamuncc nOhavockforwhlchthis pennnlx issued, Andl
mat employ any r,on in any manner xo re to became subject on the Worketa' Ca I,a-
WAIER BEATER WNENT/ELEC'IR
WIG FR SYS LEMOREAI ING
GRADING FEE
Oz
z 0
a;
Lki tti
aa
U C)
F+
sation Laws of California. Dam
Applicant ''
NOTICE TO APPLICANT: Lf, after making this Certificate of Exemption, you eha0d
hecnme sobies, to the Worker's Compensation pmvisinns of the labor Code, you nest
forthwith comply withxuch provisions nor this permit shell be deemed revoked.
CONS'IRCfION LENDING AGIeNCY
II
omstmn loading, ency for the perfnnnmme nl
flitm I hcMhyuthat here is u emio
the work far which this permit is issued (Sem. 3097, Civ. C.)
Lenders Name
SOILS FEE
WA'I'1!R SERVICE
PAID
Dom Reccip.p
NEW RIiSIDEN'IIAI. ('LMB, SQ. IMI'.
' TOTAL:
'IOTnI.:
U
0 nJ
ky,
V)
U 7�
Lendeea Addrees
BUIhDING iii
I certify that L have read this application and state that the shave information is
emrec.. I agree In comply with all city and county ordinances and state Laws totaling not
huildingconxtruction, on hereby nuibnri rcpresc I live, o1 ,1... city 1. .let apex, Ota
TY MECHANICAL PERMIT FEF.
SEISMICFE
('BRM IT ISSUANCE
ELECTRIC 1*
meovemcminncdpraper for M"mft pu acs.
(We) agree m s , mosireft nnJ ke sharmlesx the City mf Cupertino ngainxt
ALTHR OR ADD TO MSCI I.
PLUMBI ,FEE
Imbilities.judgmems,c sandexpe seswhic magi eyw acme against said City
in conseque emus noit.
AIR HANDLING UNIT(TO IO,XIOCFM)
MECHANICA. 4!L!
APPLICANT IN TSTA' �') 'll Cf. PLY ITH ALL NON -POINT
S URCE RCI A' ION
AIR HANDLING UNI'I'(OVER 1l000CPM)
CONSTRUCTION 1
11-2s'll
EXHAUST GOO]) W/DUCT)
HOUSING MITIGATION FEE
Signamrc nlA licanl/C uannr Dam
HAZARDOUS MATERIALS( SCLOSURE
HEATING UNIT ITO 110,1000 BTU)
Will thea111M.M.r fortune buildimgoecupamnoteor handle barallounnmedal
az defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 2553200
HEATING UNIT OVER 100,0I0 BTU)
VI!N'TILA'PION FAN ISINGIA REBID)
❑Yes No
Will the applicant or Iatorc building m use equipment m devices which
pp gbythe.BOILER-
emit harallom air comaminan0 as def red hY the Bay Area Air Quality Management
PAID -
Dote Receipt 4
COMP DHP OR 1X0,000 BTU)
)TI'i'AL:
COMP (OVER 110,010 BTU)
DisWcl'1❑Yes FIN.BOILER-
AIR CONDITIONER
I have read the hazardins materials requirements under Chapter 595 of the Cali
ISSUANCE LATE
NEWRE.S RDI!NTIAI. MHCII. SQ. 17.
Tapia Ileahh & SnfIty Cade, Sections 23505.25533 and 25534. 1 nmdentand that if the
baildiag attained anten0y have it.... on. thath is my m,ponvMi lit, to ami fy the:coeapwn
of Ne requirements which must IN met prior to issuance of Coni Irate of Occulumcy.
DEAL
ISSUED BY:
Owner or authudred agent Date
OFFICE