29930❑my
Z00
�n6o,
oz --
0
Z -O
�0 U
U°a
:off
yyy
X�LL
LLS>
tT'
i C
00
h
a�
UO
4. OV
[r d
uz
C
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
PERMITNO. ^ ^
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
L 9 0
BUILDING PROJECTIDENTIFICATION
BUILDINGADDRFSS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
Z� 6
OWNE'S Mm' PIIONE:
Q ne
C ITECf/ENGINE?R: V LICNO:'
cf.
CTINTRACfOR'S NAME: LIC NO: '
ADDRESS: - -
NIC
❑
CONTROL #
CQXTACT PHONE:
BUILDING PERMIT INFO
(TwI/ffii 2 I i;M I
❑_.Consultant Pecs Paid by Applicant (Initial)
e ECf PLUMB x
LICENS11b CONTRACTOR'S DECLARATION
1 hereby affirm that I amn licenud under provisions of Chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
' JOB DESCRIPTION
with Section 7") ofDivision 3 ofthe Business and Professions Cole, and my license is
in full farce and effect.
License Class Lh.k
Dam ContractorAPPLIANCES
PERMIT ISSUANCE
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT C3 STRUCTURAL ,
MODIFICATION
— RESIDENTIAL
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
PANELS
UPTO200AMPS
❑INTERIOR ❑ CHIMN17Y R17PAIR
IMPROVEMENT
❑PATH REMODEIIREPAIR ED DEMOLITION
❑ OTHER
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I ata exempt from the Connector's License Law for the
following meson. (Section 7031.5, Business and Professions Code: Any city or county
201-I0W AMPS
OVER IIgp AMPS
SIGNS ELECTRICAL
which requires a ennil to con.stsuct alter, improve, demodsh or repair an structure
P P P Y s
SPECIALCIRCUIT/A115C.
for
it) slits cesedpalso requires previsions Licensle ae ned
that heor
o Contractuch or Law
thatheiecing
the previsions of the Contractor's License Law (ChaptersCase)
purstion
TEMP. METER OR POLE INST,
OMMERCIAL:
COMMERCIAL-
7to
it the se)9
exempt Professions Code) or
engwipr5ereinne ad tof he bassion30f
that he e,cal
that
Shatio is exempt therefrom anJ the basis traffic cReged exemption. Any violation of
'W NT ADDITION ❑ DEMOLITION
POWER DEVICES
ad ber7t31.5 bynfive any
ardestapplicant delta. apennit subjects She applicammacivil Penalty of
Sol more Nen five hundred Jollan ($500).
❑1, In owner ofthe Foolery. or my employees with wages as their sole compensation,
will do the work, and the suucrure is no,imendednroffered formle(Sec. 7044, Business
ANT ❑ FOOD SERVICE.
PROVE T ,
0
SWIMMING POOL ELECTRIC
and Professions Code: The Cmana tars License Law docs nm apply to an owner of
JOUTLET5— SWITCHES — FIXTURES I�
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one year ofcompletion,the
ownenbmlder will have the human of proving that he did not build or insprove for pur-
NEW RESIDENTIAL ELP.CTR SQ Fr.
NT. FLOOR AREA
S/SQ. FT.
paxarsale.).
sines and contracting with licensed mm ittees i.
❑ f vs owner of ct proper,, , Business Li-
the projectpplytoan Businessand Professions Codex The
cause
2f Od
II r,
nxlawdoes vestheram,
Lo who
lymts
QTY. PLUMBING PERMIT FEE
sedpurrimpmvcs]hereon,and
r such ith alfprnpeny
who commmx for such projects with u contmctor(s) licensed pursuant to the Comemnr's
License Lu
❑ I um t oder , e & P C fortis reason
MAY 21 19
PERK SDANCB
Own Du¢ Goa IAL
W R'S C PENS ION DECLARATION
DRAIN VENT—WATER (EA)
My VALUATION
I I s [ '. S�
�j
BACK FL TE . EVICE
I hereby affirm under penalty of perjury one of the following declaration..:
DRAT —FLO RAREA, GOND.
❑ I have and will maintain a Cenilicateaf Camcm to ml&mmm for Worker's Copper-
nation, as provided for by Section 3700 of the Labor Corfu, for the performance of She
STORIES
TYPE CONSTRUCTION
work for which this permit is issued.
FIXTURES ERT
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
371X1 ofthe Labor Code, for the performance ofthe work for which Nis permit is issued.
GAS—EA.SYS UTLUS
OCC. GROUP
APN
My Worker's Compensation Insurance eerier and Policy number tutu
Carver. Policy No.:
GAS —GA. SYSTEMOVER 41 )
CERTIFICATE OFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
GREASFJINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thissation need oat be rompieted if She permit is forme hundred Jollarn(81(X)
or )as..)
GREASETRAP
PLANCHECK FEF;
Loy my penin in anymannrof the work for which this themitisissuedrnEve-
not employ any person in any manner so as m become subject m the Workers' Cnmpen-
SEWER—SANITARY-STORM CA. FT.
ENERGY FEE
walla Laws of Celifemio. Dam
Applicant
WATER HEATER W/VENTIEiLECTR
GRADING FEE
NOTICE TO APPLICANT, If, after making his Certificate of Exemption. you,dmild
become subject to the Worker's Compensation provisions of the Labor Code, you must
WATER SYSTEMGTEATING
SOILS FEE
fmrthwitbcnmply with such pmvisiansar this permit shall he deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I herebyaffrre thomere isu connotation lendingagency for pafomwnttof
NEW RESIDENTIAL PLMN SQ. FT.
PAID
Date R2�Al,�
the work far which Nis permit is issued (Sce. 3007, Civ. C.)
Lenders Name
Lender's Address
TOTAL:
BUILDING FEE
1 scarify that I have read this application and state that the abrwe information is
correct. l agree to comply withal] city and county tmmences and state laws relminger
building conswction, and hereby authorize representatives ofthis city to enter upon the
QTY. MECHANICAL PERMIT FEE
t/a�
SEISMIC FEE 4
PERMITISSUANCC
ELECTRIC FEE
abeeve.nom used proper, for inspection pct xvies.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
PLUMBING FEE
liabilities.judgments, costs and expenses which may in any way sceme against said City
in consequence of the granting of this permit.
ALTER OR ADD TO MEC,h
AIR HANDLING UNIT LTO 10.000 CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,0011 CFM)
CONSTRUCTION TAX
Signature of ApplicenUConractor Data
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO I W." BTU)
Will the applicant or future building occupentstore or handle huzamons material
as defined by the Catawba. Municipal Code, Chapter 9.12, and the Health end Safety
Code, Section 25532(x)'
HEATING UNIT (OVER thin 0BTU)
❑Yes ❑No
PAID
Date Receipt p
VENTILATION FAN (SINGLE RESID)
BOILER—COMP(3HP OR 1W,I1W BTU)
Will the applicantorfuture defined occupantuse equipmentordeviceswhich
;mit hvzumous Sir nmmminams us Defined by the Buy Ata Air Quality Management
Uirnctp
❑ Yes ❑Nu
TOTAL:
BOILER —COMP (OVER 100,000 BTU)
AIR CONDITIONER
I have tend the hmnmous matenaN requirements under Chapter 6.95 of the Cali-
ISSUANCED
NEW RESIDENTIAL MECH. SQ. Fr.
boom. Hath & Safety Cmc, Sections 25505, 25533 and 25500. I understood that if the
building dues not currently have a tenant, that it is my responsibility to notify the occupant
'
of the requirements which must lx met prior to issneo'a of a Certificate of Occupancy.
sa,
ISSUED BY:
Owner or authorised agent Date
IAL:
OFFICE