B 0327APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUII.DING- ELECTRICAL. PERMIT 0327
BICA
UILDING DI VISION APPLICATIONIPERMIT PLU.+mmG--r HhFN IFIC SOOO�
aV a Ixi\C BINGParti- MECITA 'IFIDATION
s-/ y
OFFICE
ARCHI CTIEN i CC _ LIC N(:
ADDRESS: _ /a
L ✓l.. -.5;er0
❑ Consultant Fees Paid by Applicant (Initial)
CONTA PHONE:
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BUILDING PERMIT INFO
BLDG 17 ECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm est I am licensed under provisions of Chapter 9 (commencing
d with Section l(NNgof Division 3 ofthe Business anP,ofessions Cide,and my license is
in fun force and efced. 67
License Cl Lic.p
Date Conuamor
Q'TYELECTRIC PERMIT FEE
J06 DESCRIPTION
RESIDENTIAL
❑SFDWL ❑ KITCHEN REMODEL.
[]ADDITION E) PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
El INTERIOR ❑ Cl IIMNI7Y REPAIR
IMPROVEMENT E] SWIMMING POOLS
❑ BATH REMODEUREPAIR 0DEMOLMON
(]OTHER
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W O F,
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LL O F
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECI"S DECLARATION
I had ershand my plans shall boumdas public renals
PANELS
UI"I'02W AMPS
Licensed Professional
OWNER-BUILDHR DECLARATIONthat I am exempt from the Contmctora License l.aw far the
hereby affirm
(ollirwingreason.(Section 9031.5, Business and Pro(esviens Cmle: Any city or county
which requires a permit to roamed, abet, improve, demolish, or repair any strvcture
pri to it,-. . alk, res,inc,th ,dicarn falstromPenmu fix it :bed smcroven
301-1050AMPS
OVER I0M10 AA11'S
SIGNS ELECTRICAL.
SPECIALCIRCUI'TIMISC,
GCCO
ca
^N
=NIT
C
a
that he is liceresedpar t te the provisions of fl C rman' License Law(Chaper9
(co e g with Sect 11100) !Obis is fth B sines addl :ions Code)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031,5 by any applicant for a go t subjects the applicant to a civil penalty of
not more tan hfive hundred dollars ($500).
❑ Las reef ofthe property, or my employees with wages as their sole compensation,
will do the work, and the sauaure is net intended orommd for sale (Sec. ](114. Business
and Professions Coded The Contractor's Livens, Law does not apply nm na owner of
property win builds or iinprmoe thereon, and who does such work himself or through
his own employees, provided that such IniphOemerts are nut intended oT offered for
sale, If, however . the building or improvement is sold within be year of cnmpletinn, the
THMP ME] ER()R POLE I NST.
�—
COMMERCIAL: �A
El NEW RLDGIADDI'I'lof - ❑ DEMOLITION
❑TENANT El 1700D SERVICE
IMPROVEME;
❑OTHER
or
POWER DEVICES
SWIMMING. POOL ELECTRIC
OUTLETS-SWI"I'CI1ES FIXTURES
— —9
NEW RESIDENTIAL. ELL Sp FI'.
ro [D>FF .FE
o ner-builder will have the burden of proving that he did not build our improve for pur-
O 1, as owner of the patient, am exclusively contracting with licensed contractors to
r Oct /1
OTAL:
ommuse, the pracet (See. ]BLL Business and Pro essbm Ciale) The Cnmracwrs Li.
cense Law does not apply to an owner of property who builds or improves thereon, and
-
QTY, PLUMBRMIT FEE
_
who contracts for such projects with a emmm�nrts) licensed pursuant to the Contractor's
PERMIT ISSUANCE
License Law.
1 am exempt under Seo. , B & PC for this mason
Owner Date
ALTER - DRAIN& Y^T -W,41 ER (EA)
O V
WORKER'S COMPENSATION DECLARATION
I hereby ufrom under penalty.! perjury one of the following declarations:
BACK FLOW PROF'. '.
STOMP
TYPE CONST'RUCIOP
/?.-. M
�V
❑Ihave andwill mainwineCenificam of Cnnsem mself-insure far Workers Compen-
sation, as provided for by Section PINI of the L ide r Code, for the performance of the
work for which Ihis permit is issued.
DRAINS - FLOOR. ROOF, AR
FIXTURES - PCIt'I'RAP
I have and will nelntnin Worker's Co ilwasation Insurance, as inquired by Section
rrrvwhich this permit is issued.
3700 ofthe Code. for the performance of the work for
GAS -EA. SYSTHM-I INC, 4 OUTLETS
OCC. GROUP
APN
Labour
My Work rj.,,�/3tie mnceranicinlc y NnY✓ n
CarL �///.a alp ZCQ�
n _ itr
GAS -EA. SYSTEM -OVER 4 (EA)
CERTIFICATE OF EXCM PTION FROM WORKERS'
COMPENSATION INSURANCE
GREASEIINDUSTRLWASTE INTERCEPTOR
BU HAA NG DIVISION FEES
(This section need not he completed if the permit is for one hundred dollars(5100)
or less.)PLANCHLCK
GREASETRAI'
PI!H
SEWER -SANITARY -STORM LA. 200 ]IT
ENERGY FEE
lanify diet inlhoperferainceol fic"als for which this pertains issued, I stall
er-so as to become subject the Worked Compen-
not employ any porsnn in any mannn
WATER HEAT HR W/VENT/F.LECTR
GRADING FEE
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UUndid',
6.
Ir N
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sation Laws of California. Date
Applicant )
NOTICE TO APPLICANT. IL after making this Cenificam of Exemption, you should
become subject o the Worker's Compensation provisions of the I.aMu Code, you must
forthwith comply withsuch provisions or this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
Ilmmby vlTnn thud them Veaconstnm,inn lending agency Jr, the perfnrence of
the work far which Ibis prom, is lsvuoff (Site . 3199, Civ. CJ
Lenders Name
WATER SYSTEMTTREATING
WATER SERV ICE
SOILS FEE
PAID
Uum Receipmb
NEW RESIDENTIAL PLM B. SQ. FI'.
Ttil'AL:
TOTAL:
Address
BUILDING PER
I that 1 have read this application and state that the above information is
certify
correct. l agree to comply with all city and county ordinances and state laws relating to
building connmmion, and hereby amharim representatives of this city m enter upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC PEE
PERMIT ISSUANCE
ELECTRIC FEE
ubovomentioned property for inspect inn purposes.
(We) agree Io.s: ve, Indemnify and keep Lamle•• the CIE oI Cupertino again•,
ACrEa OR ADDTO MI?CH.
PLUMBING THE,
I'mbilaw,,jedgnicoo.ensorad .,arme,whicbony in any w.yr,crou,ninam said City
in consequence Of (it granting of this peri,.
AIR HANDLING UNIT Q'O IO,IXM1 CIrM)
MECI IANICAL FEE
APPLICANT '. -RST NDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE .'I' ATI
s/
AIR HANDLING UNIT (OVER 10.000 CPM)
CONSTRUCTION TAX
Si. rTate
fAZARDOU aIN,S DISCI.OSIIRE
ill theapplieam o alae buildingoccupmnsmm ale off, harmlousmawrod
EXHAUST HOOD(W/IIUCT)
I1OUSINGMI'TIL1A'I'IOsl
HHATING UNIT ('Is) ll,f,hhl3'I'U)
as defined by the Cupertino Municipal Code, Chapter 9.12, amt the 1{nOth and Safety
Code. Section 25532FU?
❑Yes [I No
I GRATING UNIT (OVER 100.000 BTU)
PAID
Date art
VF.NTILATIONPAN(SINGLERESUH
Will the applicant or future huildingrocupans tomeim,ancon our devices which
m t hazardous air contaminants as defined by ]he Bay Area Air Quality Management
BOILER - 3111T OR 11110.000 BTU)
COME (
TOTAL: -2 e 9. gIc
BOILER -COMP (3VP.It 100,000 RTU)
Uislrict?
E] Yes El No
AIR CONDITIONER
I have rcne ere hazallous materials reyuiremenms under Chapter b.95 of the call-
ISSUANCE DATIi
NEW RESIDENT IAL MECH. Sp. FI'.
forma Health & Safety Cade. Sectinm 25505, 8533 and 25534.1 undconami Nat if the
building does ner cwmen0y have a tenant, that it is my responsibility to notify the wereprat
h
J
of the requirements which ..at be met prier m issuance of a Cenificam of Occupancy.
77 ^
ISSUED BY: "Oe /'h/TOV C(,s
TOTAL:
Owner or authorised agent pact
OFFICE