29472x ),: a', APPLICANT TO FILL,IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
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CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATIONA'ERMIT ,PLUMBING-MECUANICAL
' - BUILDING PROJECT IDENTIFICATION
PERMITNO. ^ ^ a ...e A
L �yJ 4 I/ L
`
ILUI ADDR2.S5: ,.
�Lip,
SANITARY NO.
APPLICATION SUBMITTAL DAII
h.RS N PHONE,:
S
CONTE 'S 'AML' T LI NO:
N/C
CONI ROLN
ARCHITECf/ENGI EER: - LIC NGI
)D LS5-p^ �.El
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coNTALT PHONE:
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-
-
❑ Coneullant Fees Paid by Applicanl (Initlal)
BUILDING PERMIT INFO
.01AG .ELECT PLUMB MECH
J ❑ ❑
LICENSED CONTE d rude,
I heresy afLICfiner mel 1 em licensed under S DECLARATION �'
prnviaana tar enamor'ua,attneneittg
with Semiuu]00nia'Division3 ofthe Businessvmd Pndessione Cu e,and mylicensc is
in 1'omeahave and site ct.n j � — .� - - -
License Class \` ! Lic.p
/ Contractor
Date TSDECL
A CHfI'ECI'S DECLARATIO
I understand my pians shallb dos public rccoN.e °
QT'Y. ELECTRIC PF.RMI'I' FEI7
JOB DESCRIPTION
RESIDENTIAL,
El SFDWL 'F,•a- .❑ KITCHEN REMODEL
-
❑ADDITION [I PLUMBING RE -PIPE
MULTI -UNIT OSTRUGIURAI.
' MODIFICATION
[I INTERIOR ❑ CHIMNEY REPAIR'
IMPROVEMENT
❑ BATH REMODEL/REPAIR [I DEMOLITION
❑ OTHER '
PERMIT ISSUANCE -
APPLIANCES -RESIDENTIAL,
PANELS j
_ „ /_ a\'!1.,
UPTO 200 AMPS -
cooed Pmf °
RATION
NImBUILDERhe mra
I hereby affirm`thm m I uexempt fromta the Cncmrs Liiense Law for the
fallowing reason. (Section 9031.5, Business and Professions Cade: Any city orta unty
which requires o permit to construct, alter, improve, demolish, or repair any swewrc
prior in its issuance, also requires the applicant 6msuch Pamir to file a signed statement
dual he is licensed par must to the provisions of the Contractor's License law (Chapter 9
(commencing with Section 7")of Division 3 of the nosiness and Pmfessions Code) or
that he is exempt therefrom and the Basis for the alleged exemption Any violation of
ctio
Sen 70315 by any applicant for . .or traders the applicant toa civil penalty of
nor more Nan rise hundred dollars (5500). +' ,•
❑ Las owner afore property,(it my employees with wages as their sole compensation,
will duthe work. and the sanctum is not intended or offered far isle (Sec. 9144, Business
and Pmfessions Crabs: 'Me Comoacrar's License Law does not apply to an memo, of
propcny who builds err improves thereon, and who dues such work himself or through
his own employees„provided that such improvements are not intended or offered for
tale. If. hwarler.the huildingorimprwement is sold withinone yeaeof completion the
cr-builder will haveme burden ofproving that he did nm build or improve for par-
quo ufrale.)�
7) 1, .,owner of the proprny, ver exclusively onstream, with licensed server ra m
emajoucl the pmjecr (Sec. ]Bol, Business and Professions CsAc:) The Canwctors Li-
c �sLaw does not apply munowner afpropenywho builds orimproves theieo,and
%%with
tact'forsuchy i t the ontrachu s)licimsedna pumtothe Contractors
Laems, .
0 sex thou antler Sec B& P C for this allows
201.1000AMPS
OVER 1600AMPS
SIGNS ELECTRICAL ,
SPE CIA[. CIRCUIT/MISC.
TEMP. METER OR POLE INST.
_
COMMERCIAL'"
❑NEW BIAGIAUDITION [I DEMOLITION
❑FOOD SIiRVICG
IMPROVEMENT I.
❑ OTHER
POWER DEVICES,(]TENANT'
SWIMMING PDOI, ELECTRIC P .t
OU`fL1II5- SWI 'I'CHFS-FIXTURES
,NEW RESIDENTIAL/ELECfR SQ FT,
. SQ. IT. FLOOR AREA
'1�pp !
F9•j
AR j,9hare 199 6
V,
Vf''I/UY-..
$/SQ. FC
,
-
Lr
QTY, PLUMBINGPF.R IT FEE
/+
PERMIT ISSUANCE
AITER-DRAIN&VIS
BACK FLOW PROTECI-A)EN1110E47
Owner Date
ALUATIDN
WORKER:SCOMPENSATI(INIIECLARATION .y:
I hereby aflinn under penalty of peoury one of the following declaratim s:
❑ Ihaveand will nuiiodha Cenific:ee of Conscnl nr aelGinxure for Workers Cnmpcn-
,arias, as providal foi by Section 39W of me lobar Cale, for the performance,of the
work for which this permit is iaued.FIXTURES
O 1 base and will maintain Workers Compensation Insurance, as required by Section'
39fg1 idthe Lnhor Cmde, for the petiarmance of the work Gsrw ich than permit is issued.
My Work e` satin nxu carrier and Policy—
'Ourier: Policy Nn.: d
FI 'ATE O• EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
ec
(Has section need not hecomplened lfths e permit is formhundred dollars ($100)
'nrle".) 1
• leenifythttiotheperfnrmnterto licw...k far which this permit is is sued'[,hall
nor employ any person in any nmnnerso as In hecnme object m the Worken'Cmopery
scion Laws of California. Dam
Applicant
DRAINS- I1.00R. ROOF AREA, C D.
STORIES
-
TYPE CONSTRUCTION
- PER TRAIT
-
'.. GAS-EA.SYSTEM-IINC.4OUTLE7S +.
-
OCC. GROUP
APN
..
r
GAS-EA.'SYSTEM-OVER4(EA)
GREASMINDUS'IRL WASTE INTERCEPTOR -'
BUILDING DI ISION FEES
GREASE TRAP
PLANCHECKFEE
SEWER-SANITARY-STONM P.A. 21p Ff.
ENERGY F .
WATER HCAT[R W/VENT/ELECfR
'GRADING r
NOTICE TO APPLICAW.. If. after making this Certificate of Exemption, you should
become subject to the Workers Cwatpenxatlon prosbians of the Labor Code, you most
fonhwim comply with such provisions orchis permit shall M dremed revoked.
CONSTRUMONLENDiNGAGENCY
I hereby affirm thunhen,isoconstruction landing agency l' or the perfornwn car
the work for which this permit is issued (Sec. JE99, Civ. C.)
Lender's Name
WATER SYSTEM/TREATING
WATER SERVICH
SOIL ,
PAID
keceiptM
NEW RISIDEIAL PLMB. SQ. FT.
'
-
TOTAL:
Lender's Address ' -
TOTAL: .
BUILD'1 FEE
ve rend thin application and orate list the abase monomania.is
”I certify tbai 1 have
,d. l once to comply with all city and county ordinances and state laws relating to
re
ta color rise' ,• h
hulldingi'onmm�iod, and theory mrhoriec represennniveo ofthia ciryg
abuve-mentinned Ferocity for inspection puryases.
(We) agree to star, indemnity and keep hamalr s the City of Cupenino ngoinst
liabilities,judgments, costs and expenses which may many way accmeatlmad said City
in consequence of the granting of this permit" s'
'APPLICANT UNDERSTANDS AN VILI. COMPLY WITH ALL, NON -POINT
SOURCE REGULATIONS.
- / Y7�
l�ai
_
QTY. MECHANICAL PERMIT FEE
-
SEISMIJ FEE
'
PERMIT ISSUANCE -
FLEA IC FEE
ALTERORADDTOMECH.
PLUMP GFEE
XIR HANDLING UNIT fTO 10,01 )CPAP)
MECHANICA -EE -
AIR HANDLING UNTf(OVER 10.1KKI CFM)
CONSTRUCTION X
m
Signli hector Dam
'/ HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Crile. Section 25532(a)'f -
E] Yet ❑No; x
\ Will the applicant of future nothing oecupanl ase equipment nr devices which `
mit hazardous air contaminants as defined by the Bay Arca Air Quality Management
Distrin2 t
❑Yee ❑No
- ,r
sl have read the hamolons materials' requirements under Chapter 6.95of ffeCdi-
fomia llwlih & Safety Cade, Scions 25505, 25533 and 25534. I undenund Nat if me
radiant doer nor uurzendy Mrvcutcnunt. that it is my respmtsibiliry ro nmify the acupom
mfine rcquiremena which must be mer priunaixsuance ufn Cenifiwte of Occupancy.
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATI FEE
..
HEATING UNIT fI'O 100.00 BTU)
HEATING UNIT (OVER 100.00) BTU)
r •;
PAID.'
Date Rear M '
VENTILATION PAN (SINGLE RFSID)
BOILER -CAMP (JHI' OR 100.000 BTU)
BOILER -COMP (OVER 100. 000 TU)
AIR CONDITIONER
- ,SUANC T
4,4
1SSUEDBY:
NEWNESIIIENfIAI. MECII. SQ. FT.
'
Owne'.1ine mrirsl.,ran - .Dare
- IOTAL: `
OFFICE