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APPPjJCANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ` l q /20/ `4Z
CI* OF CUPERTINO BUILD NC - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMDING- MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO. to
SOOO1
BUILDING ADDRESS:
333 va�� eo Pa.¢.e�.ry COAM49Q cb- e/
/9 a
SANITARY NO.
APPLICATION SUBMITTAL DATE
�2 28
/All
OWES S NqE: sPHONE:
C/-,VA0nm
CON'rRACfOR'S NAME'LIC NO:
NIC
❑
CONTROL It
R HITECT/ENGI EER' LIC NO:
oAA60 y A1114oL GiS 9e 3
ADDRESS:
coNTACT: PHONE:
❑ Consultant Fces Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
El ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hand tirm that I mm licenxd under f Chapter 9 rourni cin
yh nd Pononso p ( g
with Section and 7") of Division 3 afthe Business and Professiad Caleja hyliccnsets
Licenfull e Cis and effect. — /// �, Itpa
License Clas Contractor fI V
Date Commnor
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RR NIF DFNTI
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION El PLUMBING RE -PIPE
El MULTI -UNIT L1 STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT []SWIMMING POOLS
❑ BATH REMODELJREPAIR (]DEMOLITION
❑OTHER
PERMITISSUANCE
APPLIANCES - RESIDENTIAL
ARCHIT[CTS DECLARATION
1 undersand my plans shall W used as public records
PANELS
UP'T02GIAMPS
Licensed Professional
OWNER -BUILDER DECLARATION
1 thereby alum that 1 am exempt from thee CConmaravenor's License Law for the
Code: Any city or county
following reason (Section ]onstr Business add Professions demolish. repair any awnure
which requuea a permit to coaswa. altar,Mfic improve, demolish, file
daor to teheslits censcgalso mano to resthe
omencis Liccenseigmal ow(Ch statement
nvisiosoftheand for such Commences
(co menccenxd Oursnote me of Division 3 the Commnor and Professions
(commencing with Section ]IXMOof Divisionlof the Business unit Pmfessinns Csde) o
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 Permit subjects the applicant o a civil penalty of
not mom Nan five hundred dollars 15500).
❑1, as ownerof Ne property, or my empinytts wiN wages as thcirwle compenavtion.
will Bothe work, sJ Weawcmmis nut imendcd aroiemdfor agile lSec.7(I4L Business
and Professions Code: The Command's License Law doe, nm apply to on owner of
peopeny who builds or impmeas therron, set who dies such wed himxlf or through
his own employees, provided mm such imptomeramua are nm intended or offered fnr
sale. If. however. Ne building or improvement is sold within one year ofaomphninn,the
owner-hoildea will have the burden of Paving that he did not Wild or improve for pur-
pose of sale.).
❑ I, as owner of the property, sm exclusively contracting with licensed con moors m
construct the project (Sec. 7014, Business and Professions Code:) The Command, Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
wh rroatmov for such projects with o convenor(,) licensed pursuanno the Convenors
License Low.
El Iam exempt under Sec. , B & P C for this mass
201-Iqp AMPS
OVER IfI(I(IAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC. /
TIiMP. MITER OR POLE INST.
BLDG/ADDITION ❑ DEMOLITION
TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER UIiVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
Baa
v W
NEW RESIDENTIAL ELECTR SQ FT.
SQ. FT. FLUOR AREA
VSQ. Fr.
TOTAL:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
Owner Data
VALUATION
��f ^
( V
WORKER'S COMPENSATION DECLARA'I'[ON
line
I hereby aunder Penalty of perjury one of the following declaration:
I have and will maintain a Certificate ofComent m.sell -insure for Workers Cempen-
tion, as Provided for by Section 3700 of the labor Code, for the performance of the
work for which this permit is issued
I have and will mstatute Worker's Cnmpamminn Insurance, as mgaimd by Section
3 Wofthe Laor Code, for the Performance ofthe work for which this permit is issued
My Wmke' Compe ration insuranceSu JPolicy umber am:
CarrieiZ7//�fjl�f�/� Policy No o 10
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section modern be completed ifdmpennit is fnr one hundred dollars 1S1 D0
or less.)
I candy that in the performance of dic work fnr which this permit is issued. Island
not employ any person in any mannereco as it) become subjvcnot he Workers'Conipcn-
smion Laws of California. Data
Applicant \
BACK FLOW PR(TEC'L DEVICE
DRAINS- FLOOR, RUDE AREA, GOND.
STORIES
OCC. GROUP
TYPE CONSTRUCTION
FIXTURES -PER TRAP
GAS-HA.SYSTHM-I INC.4OUTLETS
GAS -P.A. SYSTEM -OVER 4(HA)
GRBASGINDUSTRL WAS TE INTERCEPTOR
-
BUILDING DIVISION ILLS
GREAS I: ]'RAI'
PLANCHECK FEE
RhWER-SAN19'ANY-STORM HA. 2q1 FT.
ENERGY PEE
WNI ER HHAI'ER W/VEN'T/lil.l?CI'R
GRADING FEE
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
beende subject to the Waders Compensation provksions ol'the Lecher Code, you nasi
forthwith comply with such provisions or this pcmtitshall be deemed revoked
CONSTRUCTION LENDING AG17NCY
I hereby affirm that hem is u construction lending agency fnr the perfiemmtccof
the work for which this permit is issued (Sec. 3107, Civ. C.)
Lender's Name
WATER SYS] 'LM/1'REATING
WATER SERVICE
SOILS FEE
PAID
NEW RESIDENTIAL PLMB. SQ, PT.
Date Receipt If
TOTAL:
Lander'; Address
TOTAL:
BUILDING FEE
1 comfy that 1 have read this application and state that the move information is
rod. l agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby manna, reprexmutives ofthls city to enter upon the
above-mentioned property for inspection purpnxs.
(We) agree to save, indemnify unit keep handless the City of Cupcninn against
Iiabilldes,judgmenls. costs and expcnxs which may in any way accrue against said City
in onscquence of Ne granting of this permit.
APPLICANT UNDERSTANDS AND WILT. COMPLY WITH AL1, NON -POINT
SOURCE REGULATE) S.
1����(,�a/yAIR
QTY. MECHANICAL PERMIT FEF.
_
SErMICPBE ��
I'IiRMIT ISSUANCE
S e ' 1
RIG FEES, LJ
1n
ACT ER OR ADD'rO MECH.
ING FEE
IC
ICIRUCTION
AIR HANDLING UNIT (TO 11t"CFM)
HANIl1.ING UNIT (OVER IO,(gl CPM)
TA%nature
of A11Imn nntmc r Dae
MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store orhandle hazardous material
as definN by the Cupertino Municipal CMe, Chapter 912, and the Health and Safety
Cade. Section 25532(a)?
❑Yes ❑No
Will the applicant or future Wilding occupant use equipment or devices which
T haurlous air connotations 0 derined by the Ray Area Air Quality Management
stria?
Dyes ❑No
I have read the hazvdws materials requirements under Chapter 6.95 of the Cali-
fomia Health & Safdy Code, Scatters; 25505, 25533 hal 25534.1 understand that if Ne
buildingdnot currently have a m, that it is my responsibility to notify the occupant
oes oat
of the requbemcnts which must be mer prior m issuance urn Ceniicare of Occupery.
EXHAUST HOOD IW/DUCDHAZARDOUS
NG MITIGATION FEE
_
HEATING UNIT (TO ffiff H1 BTU)
---
HEATING UNIT (OVER 1011.0i BTU)
PAID
--
VENTILATION PAN (SINGLE RESID)
Date Receipt a
BOILER -COMP PHP OR 100,000 B'rU)
TOTAL:
�s
V .
BOILER-COMP(OVER100,01JOBTU)
AIR CONDITIONER
ISSUANCE DATE
/ Z-..� 2-1 p
0 /
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. IT.
Owner m i uNoriud agent Date
TOTAL:
OFFICE