99070045AaaucANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY V 47,407 0 04 *
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERNIIT PLUMBING -MECHANICAL.
BUILDING PROJECTIDENTIFICATION
PERMUNO.
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
/03 afF t yie,Gu �.
9
OWNER'S NAME: PHONE:
CONTRACTOR'S NAME: LIC NO:
N/C
❑��
CONTROL
A�F�IL_'NGINLC LI NO:
AOOftFSS:
PHONE: l
BUILDING PERMIT INFO
I
/ / -/- ` /
IT al( GOL�1 $/Gly J� �8(G
Consultant Fees Paid by Applicant (Initial)
B,�DGf ELECT PL�U�MD/� MECH
LJ � Z
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions mf Chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
P17 tM,1' ISSUANCE
with Section 7000)of Division 3elthe Businessnnd Professions Gde, andtny license is
in full oriental enter.
RESIDENTIAL;
❑SFDWL ❑ KITCHEN REMODEL
APPLIANCES -RESIDENTIAL
License Class Lic.g
Dam Contractor
El ADDITION [I PLUMBING RE -PIPE
❑ MULTI -UNIT ❑ STRUCTURAL
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
ARCHITECTS DECLARATION
I understand my s shall be used as Vublic remNs
' PANELS
UP TO 2s)AMPS
Licensed Professional
201-I00IAMPS
OWNER -BUILDER DECLARATION
1 hereby M. that I on exempt from the Contractors License Law for the
fallowing reason. (Section 7031.5, Business and Professions Code: Any city or county
[I BATH REMODEUREPAIR ❑DEMOLRION
C1 OTHER
OVER ItN1UAMPS
SIGNS ELECTRICAL
which requires o permit to construct. alter, improw, demolish, or repair any structure
SPECIAL CIRCUIT/MISC.
'
prior for.huuancgaHn requinestbi,applicam for such troad to fifeasignedemmrmal
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(commencing with Section 711007 of Division 3 alum Business and Professions Code) or
TEMP. METER OR POLE. INST.
COMMERCIAL:
that he is exempt Ihemfmm and the basis for the air col exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
.❑ LN�EW BLDG/ADDITION El DEMOLITION
/ENANT ❑ FOOD SERVICE
POWER DEVICES
not more than five hundred dollars (1500).
❑Las owner of the pmpeny.onny cmployea with wages aslMirwlecompensation,W
will do the work, and the structure, is not intended or offered for sale (Sec. 7816, Business
IMPROVEMENT
❑OTHER
SWIMMING POOLELECTRIC
+ OUTLETS - SWITCHES - FIXTURES
and Professions Care: The Contractors License law does not apply to an owner of
property who builds or inmproves thereon, and who does such work himself or through
his own employees, provided that such intprovemems are not intended or offered for
sale. If.however, the building or impowem,nt is sold within one ycar.femn,letim.the
NEW RESIDENTIAL ELECI'R SQ Pf.
FT. FLUOR AREA
S/SQ. PT.
owner -builder will have the burden of proving that he did not build or improve for our-
owner of the prnpant exclusively contracting with licensed contractors to
Weeny,
trio smuct the protect (Sec. 7061. Iusiness and Professlonc Co.., The Contra xor'c Li
rr-7 Jr
TOTAL:
cense Law does not apply loan owner of property who build,or improves thereon,and
QTY. PLUMBING PERM 'TFEE
who contracts for such project, with a contractors) licenced pursuant In the Ciu mneto2s
PERMH ISSUANCE It
License Lit.
❑lam cxcm oder Scc. ,B& P C for this reason
Owner Date
ALI'1iR- DRAIN & VENT -WAE E)
yx
VALUATION
BACK FLOW PROTECT. DEVICE
ORKER'S COMPENSATION DECLARATION
I here . ift under penalty of perjury one of the following declarations:
I hmaune will maintuinaCertifcamofComent toself-insure for Worker, Comoem
sution, as provided for by Section 37W of the tabor Code, for the performance of the
work for which this permit is issued.
DRAINS- FLOOR, RUDE. AREA, COND.
STORIES
1'y TgUCT N
�J•CG/(K—//`HA[P/��
FI%TURES - E'ER TRAP
14
❑ 1 have and will maintain Worker's Compensation Insurance, in rer,mom by Section
37W of Ste Labor Cure. lit the prKeamanee ofthe work for which this Permit is issued.
OCC. GROUP
GAS - EA. SYSTEM -1 INC.4 OUTLETS
My Workers Compensation Insurance carrier and Policy number are:
Currier: Policy NO.:
GAS -EA. SYSTEM OVER 6 (EA)
GREASEANDUSTRLWASTE INTERCEPTOR
CERTIFICATE OFE tpIP ION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(Ilmissurrom nerd nm W completed if the permit is moron, marthd out]. is IW)
or less,
GREASETRAI'
PLANCHECK FEE
I certify lha in the perurmanceii the work for which this .if is issued, IdadI
not employ any pawn inany manner so ax to become subject ro the Wmkers' Compen-
SEWER - SANITARY - STORM EA. 200 PC
ENERGY FEE lit
N'Al HEATER WNENT/ELECTR
WATER SYSTENWREATING
cation Laws of California. Dam
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject lo the Workers Compensation provisions of the labor Care, you must
GRADING ffA
SOILS FEE
WATIiR SERVICE
forthwith comply with such provisions or this Permit shall W deemed mini
CONSTRUCTION LENDING AGENCY
j I herby oflimm that there iso conduction lendlngugency bribe perortmcarc of
NEW RESIDENTIAL PLMB. SQ, PC
PAI
¢ Receiorp
t the work for which thi, parnit ,,mrd (Sec. 30)7, Co, C,
Lender's Name
TOTAL:
'TOTAL:
Lenders Address
information Is
BUILDING
m
1 cenily that 1 have read this application and state that the above
correct. 1 agree m comply win all city and coumy oNinanccs and stoat laws remtlng m
huilding c'onsvunion, and hereby umharirc representatives of this city to enter upon the
QTY. MECHANICAL PERMIT FEE
51315MIC FE
PERMIT ISSUANCE(We)
ELECTRIC SEE
uMvcm,nninned property for inspection pugmses.
agree m orm. indemry toand keep harmless the City of Cupertino against
PLUMBING 'I
habiliti,s,judgmenrs, costs and expenses which may in anyway accrue against said City
in asequence of the graining of this permit.
/ ALTER OR ADD DO MECH.1 '� G
AIR HANDLING UNIT(TO IB.00 CFM)
MECHANICAL NIE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
S tRCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
Sigm of Applicant/Commuselor Date
HAZARDOUS MATERIALS DISCLOSURE
V `
HEATING UNIT (TO 100.088 BTU)
Will the applicant or future building occupant store or handle harardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and now Health and Safety
Cede, Sertion 2553200?
HEATING UNIT (OVER 100,00) BTU)
EJ Yes ❑No
VENT ILATION PAN (SINGLE RF -SID)
PAID Date Rewriter If
BOILER -COMP GHP OR 100.1188 BTU)
Will the applicant or future building occupant use equipment or devices which
mil h rrardous air contaminants as defined by the Bay Area Air Quality Management
TOTAL:
�1
II 2
BOILER - COMP(OVER I00100.00d BTU)
DismieR
C3 Yes C3 No
AIR CONDITIONER
1 have headline harmdu is nnmrials requirements under Chapter ti 95 of Bate Cali-
ISSUANCE DATE
NEW RESIDENIHAL SUCH. SQ. FT.
forma Health & Safety Ccxle, Sections 25505, 25533 and 25531. 1 understand muff the
�ji5 3 O .�47
building does not currently have a tenant, that it is my responsibility to notify the occupant
quire a hii h alptIF met prior nm iaxuwce ala Certificate of O,cupancy.
TOTAL:
rind agcnr Date
ISSUED BY:
OFFICE