30186APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PERMIT NO. /� O
186
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
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BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: -
SANITARY NO.
APPLICATION SUtlMI'RAL DAT
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OW CONTRACTOR'S NAME: LIC NO:
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%RCHITECDENGINEER: LIC NO: - ADDRESS:
CONTACT. PHONE
BUILDING PERMIT INFO
❑ Consultant Fccs Paid by Applicant (Initial)
BfLDDG ELECT PLUMB MECH
TY ❑ ❑ Cl
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
hereby affrrn that 1 am nerved order provishms or chapter v teammencing
QMZ1
with Section]00umf Division Sof NC Business and Pmfecrians Cude.andmy licensee is
RESIDENTIAL'
WCO
F-�B
in lull force and effect PERMIT ISSUANCE
❑SF IWL ❑ KITCHEN REMODEL
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HGW
License Class Lic.p APPLIANCES - RESIDENTIAL
Date Co...,
❑ADDITION CIPLUMBING RF.PIPE
C3 MULTI-UNIT []STRUCTURAL
F,Ow
1 ARCHITECT'S D17CLARATION PANELS O
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k' . 1 undcrnwnJ mY plans eM1Cll bd used as public records C i
MODIFICATION
Oy—,
UP'M 200 AMPS J
❑INTERIOR E3 CHIMNEY REPAIR
IMPROVEMENT
F4t:mLijnsN
Pmfessiunul 201-100OAMPS
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a. OWNER-BUILDER DECLARq'1'ION OVER ❑NXmAMPs
❑ RATH REMODEL/REPAIR ❑ DEMOLITION
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r 1 hereby, zffirrn that 1 am exempt from the Comracors License Law for me
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following reason. (Section 7031.5. Business and Processions Code: Any city or county SIGNS ELI-.0 L
[]OTHERYl
LL N
which requires a permit to conslmel, alter, improve, demolish, or repair any structure
Nim'n its issuance. also requires the applicant for such permit o file o signed statement SPECIAL CIR'UIT/M C.
f y"
mTbeis]ieemed pursuant to the prrvisionvol'the Contractor's License Law (Char
Is C)
(commencingwlm Section700(bof LAM,ion3of1he Imoress and Profisoona Cordo, TEMP.MLTER RPOLE INST.
COMMERCIAL:
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X
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
y]--m
Sectors9031.5 by any applicant an a permit subjecp the applicant m a civil penalty nl POWER DEVICES
five hundred dolours
b.....
❑FOOD SERVICE
~=G
not more Nun
SWIMMING POOLELECTRIC
f
6 IMPROV
IMPROVEMEN]'a��`
q
y empl cum tion.
❑ Pmpe Y YcmP Y g sorsa
the n,nrm lodes wiewa <fil
Lathe
❑OTHER
p.�
rsalei(Sole
work. Curia rots Business
will dothewons Coded
owdoesnot
L2
and he License apply to an
Code.lesor the Qmhacmh License Law does not apply
elf owner of Of1TLlTS-SWITCHES-FIXTURES
who miles or thereon, and who does mch work hi or through
erty whom
his own empbyms, provided ohm pooh improvements thin not intended offered for NEW RESIDENTIAL ELIiCTN SQ 14.
his own tided that deed or
SQ FT. FLUOR AREA
&SU. PI'.
or -.sat hdid none
for the
enpmvvmenl
ild or improve
owner-builder will have the bather of proving that he did not build or improve for Fur-
owner--hawevemllhave the bur
pose of sale.).
TOTAL:
C] 1. as owner of the property. am exclusively contracting with licensed enmraclors or
instruct the project (Sec. 74H4. Business and Professions Cnde:)The -mur-our'a Li-
ns, Law does not apply to an owner of property who builds or impnnes thcmon.and QTY. PLUMBING PERMIT FEE
who contracts forsuch ptokcts with C cmaacor(s) licensed pursuant to the Comment's
License Low. . PERMIT ISSUANCE
❑ I am exempt under Sec. . B & P C for this rcamn
ALTER - DRAIN & V17NT- WATER (EA)
VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTEGE'. DEVICE
1hereby under pettyofperjuryoneofthe following
Cr
illi eCcrti37W of Workers Compere DRAINS -FLUOR, ROOK A0.EA,COND.
❑Ihavc and will main toLabor
STORIES
TYPE CONSTRUCTION
for the inarric
theCause.,
Code,
ration, as provided for by Section 3]00 of the Labor Coec, for the perfo,mance of me
by
work for which suis permit is issued. FIXTURES - PER TRAP
❑ 1 have and will mrimain Wnrkel's Ct do, nsnlion Inmrance, as required by Section
3EW of the Labor Cede, for the performance of the work for which this Permit is issued GAS -EA. SYSTEM-I INC. J OUTLETS
OCC. GROUT'
APN
My Workers Compensation Insurance carrier and Policy number we:
Carrier: Policy Nor GAS -EA. SYSTEM OVER J (EA)
CERTIFICATE-. OF EXEMPGON FROM WORKERS' GREASE%INUUS'1'RL WASTE INTERCEPTOR
BUILDING DIVISION FT-ES
COMPENSATION INSURANCE
fThis section need not be completed if the permit is forone meadreddolltrs(510) GREASE TRAP
or less)
PLANCHIiCK PEI?
licit that int he Ferfnnnarrceofstein work for which this permit is issued. Ishii l SEWER-SANITARY-STORM EA. 20117.
not employ any person in tory manner - as m bemuse subject to the Workrri Conmpen.
ENERGY FEE
Z
Z
satian Laws n1'California. Date WATER HEATER W/VENT/ELECTR
Applicant
GRADING FEE
NOTICE TO APPLICANT: If, after necking this Certificate of lixemptiom, you should WgTIiR NYSTEM/1'REATING
hewnne wbjen m the Wo,ke,'a Cona,mition Fmviomrs of the Labor Cade, you mast
SOILS FEE
forthwith comply with such Provisions or this Permit shell be deemed revoked. WATER SERVICE
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CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL PLMN. SQ. FT
PAID Date 'prp
C.J
agency for the ce,fortnanee of
isxCscuolns(Swcce.30
rsunil
u" H
dl]e.nCdinvg
national, udich5stpermir C.)
Lenders Name
I'AL:
Lenders Ae TOTAL:
BUILDING 'C
1 ccnify that I have reed this application and stole that the shave information is
d
correct I agree to comply with all city and county ordinunc s and slate laws relating es QTY. MECHANICAL PERMITPE
V Z
building construction, and herby aumnrire representatives of suis city were, open the
SEISMIC FEE
IiLEC'FRIC FEE
above-mentioned property for inspection pmixtures. PERMIT ISSUANCE?
(We) agree to save, indemnify and keep harndew the Cay of Cupertino against
holohnics,judgmcnts,costs and espenms which may inany wiry accme against mid City ALTER OR ADD TO MECO.
in consequence of the granting of this permit.
MECHANICAL FEE
APPLICANT' UNDERSTANDS AND WILL COMPLY WITH AI.NON-I' NT AIR HANDLING UNIT TO 10,004 CFM)
SO' ULATIONN.
CONS'TRUCUONTAX
AIH HANDLING UNIT(EVER 110,000 CFM)
Signature of ApplicanVContractor Da EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
11111 DOUS MATERIALS DI LOSURE
Will Neti,heant or future buildingmneop.amt s or handle haeardommated.1 HEATING UNIT (TO 100.000 BTU)
as defined by the Cupertino Municipal Cede, CM1aper 9.12, and the Health and Safety
COTe, Section 25532(a)7 HEATING UNI'[' (OVER Hk).000 B'FU)
E3 Yea ❑No
VF.NTIIATION FAN (SINGLE RFSIU)
PAID
Ualc Receipt X
Will the applicant or future building occupant use equipment or devices which
TOTAL.
emir huaafduus air contmniumas as defined by the Buy Area Air Quality Management BOILER-COMP(JHPOR 100.000 BTU)
DUtricfl BOILER -COMP (OVER I(I IUM BTU)
F1 Yes C] No
I have read the haznNom mccdab requirements under Chnper b 95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
Trio Ilealth & Safety Cede, Nocuous 25505. M533 and 2553a. 1 understand that if the NEW RESIDENTIAL MECH. SQ. 17.
building dads ren correctly have a lewno. than it is my responsibility to notify the occupant
of the equiminen s which mnsl hr me prier In iesuanre of a Ceniliaate of 0.capancy
ISSUED BY:
Owner or authorized agent Done TOTAL:
OFFICE