30412APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PERMIT NO. /I
BUILDING DIVISION APPLICATION/PERMIT PLUMPING - MECHANICAL
1
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:
SANITARY NO. I
APPLICATION SUBMITTAL DATE
�G
OW ERN E: PHONE:
.Tpty%I ZDS' 3Za�/
ACTORS A t LpI[ NO:
1 1 3
NC
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PEPERMIT TIINFO `
\RCHITE /ENGI ER: LIC NO:
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pvt—ps us
CONTACT: PHONE:: I CI •
BUILDING
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Consultant Fees Paid by Applicant (InHia1)
can
T
-pG PLMECH
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Nal 1 am licensed under provisions of Chapter 9 Uommeucing
with Section 7") of Division 3 oflhe Businessand Profepssipons Code, andmy license is
in full force and effLs11/_3,
License Imo LIC.M L P
Date Conitm
QTY. ELECTRIC PERMIT FEF.
JOB DESCRIPTION
RESIDENTIAL:
CSFDWL ❑KITCHEN REMODEL
❑ADDITION [I PLUMBING R6PIPE
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECTS DECLARATION
1 understand my plans shall be usedns public records
❑MULTI -UNIT ❑STRUCTURAL
PAI'MODIFICATION
❑INTERIOR 0CHIMNEY REPAIR
IMPRO ENT
❑BATH I�E R ❑DEMOLITION
PANELS
I at
l UPT02alAMPS
Licensed Professional exempt
OWNER -BUILDER DECLARATION
I hereby affirm that I am eexempt from the Contractors License Law for the
201.10WAMPS ��
OVER IM)AMPS
SIGNS ELECTRICAL
following main.(Section 7031.5, Business and Pmfemians Code: Any city or county
which reasons a permit to contain, alms improve, demolish, or repair any structure
��%L1�fvwlLJ�7
COTTH/ER
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SPECIAL CIRCUIT/MISC.
prior to its issuance, also neauiresshe applicant fm such pe me, to Bit, a signed mete...
that he is licensed pumusnuo the provisions of the Contractor's License Law (Chapter 9
t/it•,, v�
�Ilfi
TEMP. METER OR POLE INST.
V
COMMFRCIAI� V
C NEW BLDG/ADDITION C DEMOLITION
NANT [I FOOD SERVICE
IMPROVEMENT
[]OTHER
gammemingwith Section 701 .1 Division 3 of the Business and Professions Code) or
that he is exempt IhereRsm and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars(SSW).
C1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the lomem. is not imendeciorolfered forsale (Sec. 1049, Bus
POWER DEVICES
SWIMMING POOL ELECTRIC
and Professions Code: The Convector's License Law does not apply m are owner of
UTLETS- SWITCHES - FIXTURES
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 aflened for
NEW REST ENT] FLECfR SQ FT
-
-$/SQ.
sale. If. however, the building or improvement is sold within one yearofcompletion,the
SQ. FT. FLOOR AREA
FT.
owner -builder will have the burden of proving that he did not build or improve for pub-
pose
I,mowner ofthe property. amexclusively amtioicng with licensedannwor's m
gL•�a` y
C a/l'111TWy1`
1
e onslrvm the projttt (Sec. 1044, Business end Ihofessions Code:) The Contractor's Li.
QTY, PLM&WefRmrr FEE
cense Law does not apply to an owner of property who builds or improve,% thereon, and
who contracts for such projects with a cunlmmm(s) licensed Futstmm to the Contmames
PERM ANCE
License law.
Iamexcmptunder5ec. ,B&PCforthi,m.n
ALTF. - &VENT- A R(E
Owner Date
VAL ATIO
WORKER'S COMPENSATION DECLARATION
.Ihemb firm udder puully of
yes perjury one of the following dalualism:
7 have and will maintain 0 Certificate ofConsem to self-insare frWorkds Co.,. -DRAINS-
Milan, m provided for by Section 37M of the Labor Code, for the performance of the
-
RACK FLOWP DEVICC
�/t�
R, ROOF, AREA, COND. 2V
STORIES
TYPE CONSTRUCTION
FIXTURES -PCR
w for which this Permit is issued.
ko
I have and will muintvn Workels Cnmpcnnetion Insurance, .,,.!,cd by Section
31 of the labor Code, for the performance of the work for which this permit is issued.
My Work y' C nMti nand PNicynondsmate:
GAS -EA. Mirm. IINC. OUTLET$
OCC. GROUP
APN
GAS-EA.SYST 4(EA)
' Ca_T %k'XA S _Policy No.:
rtier.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
section interim, be completed ifthe permit is for one hundred dollars ($1(10)
or less)
I certify that in the performance ufthe work for which this pemtil is issued l shall
not employ mNome rson in mm m y manner so as become subject the Workers Compen-
GREASFANDUSTRL WAST JCEPTOR
BUILDING DIVISION HIS
GREASE TRAP
PLANCHECK FEE /r
SEWER -SANITARY TORM' OO PI'. I
ENERGY FEE
WATER HEATER WNENT/ELECfR
motion Laws of California. Date
Applicant
GRADING FEE
NOTICE TO APPLICANT. If, after making this Cenifcate of Exemption, you shouldWp'IER
become subN
ject to e Wcomi's Compensation Provisions of the Lubar Code, ym must
forthwith comply with such provisions or this permit shall be deemed revoked
SYSTIiMl1'REATING
SOUS FEE CN
WATER SERVICE '
CONSTRUCTION LENDING AGENCY
Ihereby off that there is a construction lending 49MY for the pedOMMce of
PAID
i"Ji
NEWRESIDENTIALP1,109. SQ, FL
the work for which this permit is issued (Sec. 3091, Civ. C.)
Lender's Name
TOTAL:
Lender's Address
V
1 eci ify that 1 have read this application and state that Ne moose information is
BuTifix FE G•
QTY. MECHANICAL PERMIT FEE
correct. l agree to comply with all city and county ordinances and mile laws misting to
building comlrvction, and hereby anthorire representatives of Nis city to enter upon the
above-mentioned property for inspection purposes.
(We) agree m save, indemnify and keep hamtless the City of Cupertino against
SEI
' PERMITISSUANCE
F .E
ALTER OR ADD TO MECH.
PLUMBING 7
liabilities,judgments, costs and expenses which may in any way secom agaitut said City
in consequence fine granting of this permit
AIR HANDLING UNIT(TO 10,004 CFM)
AMC LFEE I�
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
1R
!VCR REGULATIONS
� lo�b8 �£6
AIR HANDLING UNIT (OVER I0,"CFM)
STRUM TAX
Signet APPIicmlDem
HAZARDOUS
US MATERIALS DISCLOSURE
EXHAUST HOOD (W/DUCI)
HOUSING MITIG ON FEE
HEATING UNIT (TO It]B,INI) BTU)
Willy e building Occ ore or and
Cupertinorom Muni
as defined i. the 32(a)? nn Municipal Code, Chvpmr 9.12, and the Health and Safety
t Chapter the Health and Safety
Code. Section 235321e)?
C] Yes _�Na
Will the air contamicer ornants
future building occupant Bay AequipmentaAivality Management
mit hazallous dr amtaminmta ns def red by the Boy Arta Air Quality Management
OisWcIR
E] Yes 'gl N�/o
HEATING UNIT (OVER 104,00) BTU)
PAID
Date aeiplp
VENTILATION FAN (SINGLE RESID) �'
BOILER -COMP
OT
I 645
BOILER - COMP (OVER 104,004 BTU)
J
I hove tend the hazaNuus materials reyuirermnu under Chapter 695 of the Cal,
AIR
AIR CONDITIONER
IS
DATE
NEW RESIDENTIAL MECH. SQ. PT.
M96I
forma Health & Safety Cale, Swim 25505, 25533 and 25534. 1 undersand that if fire
bo ildingt m have mnmt. that it is my rmMlibility to notify the Occupant
es�mre whic nun meepriami sof a Cenitreal aj'A4ec pariaY. h
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ISSUED BY:
Owner th nzed engem
au o
OFFICE ..