S 2017APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. iiUECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING In OJKCT IDEN'TIF'ICATION
PHISI INo 2 O 1 7
L /
BUILDING ADDRESS,,
SANITARY NO,
APPLICATION SUBMITTAL DATE
Cu
OVIR:S AMC: J PHONE �n CO H:ti A :: LIC NO
L. V` `T V 1
. -(9-49
NIC
❑
-ONTROLM
ARCIII' iCl'/ElNGI 7ER: LIC NO:
D E.SS: .}��
T
CONTACT. PHONE:
BUILDING PERMIT INPO
De 1 `h li ^ s,,. �` 71 Q
tvts
El Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMS BB MECH
LICENSED CON' TRACTOR'S DECLARATION
I herehy c0irn Nm I am IicensN under Prnvi,inn, of Chapter 9 (commencing
QTY. Ei,F-CTRIC PERMIT FEE
.TOB DESCRIPI'ION
PEiRMTE' ISISSUANCE
with Section TlxgB of Division l of the Business and Prefexsions Cele, and my license is
in full t ette
RESIDENTIAL
❑SFUWL KITCHEN REMODEL
APPLIANCES - RESIDENT[At,
7,.,nd
Licenu Cf Ito N _
Ume—S Contractor w t
AltClll'IECTS DECLARATION
I j,I �yp hullo meati .,public records
s;alL
C1 ADDITION ❑PLUMBING RE -PIPE
[I STRUCTURAL
MODIFICATION
❑IN'['FRIOR QCHIMNEY REPAIR
IMPROVEMENT E]SWIMMING POOLS
PANELS❑MULTI-UNTp
lll'T02011AMF5.
Coat. I'mfexsinntd
201-III0IAMPS
GWNI?It-IIUILDIRIIt!CI,ARATION
I Immby off nn thin I ani exmn,a Tran the Cnntramor's L,,rn,a Low for the
following reason. Scar 1703 1 5, Business and V lv,,ma, Gavle: Any city or county
❑ BATH RCMODFI./REPAIR ElDEMOLfI'ION
Elm
�T�2 !✓.�
OVER In00AMl'S
SIGNS III.I!C'I'RICAL
which require, .'colt m construct, idler, improve, demolish, or repair any stmemre
SPECIALCIRCUI'I'/MISC.
priorm its issuance. also requires the applicant!orsuch permit ofle asigned statement
that he Is licensed It arra mthe pmvi,ion,ofthe Corthwea, License Low (Chapmr9
(commencing with Section 7000) of Division 3 ofthe Business and Professions Code) 'It
TL'MR ME' TBR OR POLE HINT.
COMMERCIAL:
that he is cxntnry tbcrefnnn and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section THIS by any applicant for a permit subjects the applicant to a civil Penalty of
POWER DEVICES
❑TENANT ❑ FOOD SERVICE
nounom than five hundred dollars ESSEX)).
❑l, as owner of the pmpenY, or my employees with wages as their sole compensation,
will du 0e work, and the anionic is not intended or offered for sale (See ]TWA. Business
IMPROVEMENT
❑OTHER
SWIMMING POOL FI.IiLT
and Profeminns Come: The Contactor', license Lw does resat apply m an owner of
OUII.GI:S-SWETCIIES- '
NEW RISIDEMIAL ELECTN FT
proPeny who build, or improves thereon, and who does such work himself s through
his own employees, Provided that such improvements are not intended or offered for
sale. IL however,the building or improvement is sold within one year ofeampletioadre
SQ, FT. FLOOR AREA
5/SQ. IT.
ncobuilder will have the burden of proving that he did not build or improve for pur-
TOTAL:
pose of sale.).
1, as owner of the prupeny, am exclusively contracting with licensed commmors to
QTY. PLUMBING PERMIT FEE
construct the project (See. TIM3, Business and Professions Cade.) The Cotnrabl s Li-
cerve Law does ma apply to an owner of onlEeny who builds or improves flivecon. and
me Cont..r's
who contracts for such projects with a curbacmgs) licenwd Carburetor's
PERMIT ISSUANCE
License Lw.
❑ 1 am exempt under Sec. . B & P C for this reason
Owner Dole
ALI'Ik - DRAIN k VENT- WATER (EA)
VAL11600N
WORKER'S COMPENSATION DECLARATION
BACK Iq,OW PROTECT'. DEVICE
I hereby anion under Penalty of perptry one of the fol lowing deelaatioms:
uvcund will muinwln nCenlfcatcnTCnmem mwIf-insure for Worker's Contpen-
sation, ns Provided ter by Seton 3700 ol'the lath... Code, liar the Performance of the
DRAINS- FLOOR, ROOF. ARG, COND,
STORIES
TYPE CONSTRUCTION
work for whgclt This pooh is I".rd.
FI X'TURES - PER 'I'RAI'
I have Inti will TaininhoW ..ka'a Compca,mio i Insumnac, a, myuimd by Seelmn
3700 of the Labor Code, or the perbmmtnee of me work for which this permiti,issued.
GAS-HA.SY$'I'EM-I INCA OU'II.ETS
OCC. GROUP
APN
My WnrkyyYY's �Com nsnlinn lnsumn.<.--u''rticr oli Policy lyt arc:
Currier:,V'QQ �]x.�l'and Na:I+ Ng7N77�_
GAS -IiA SYS'1"IiM-OVCIt4(IiA)
CIiR'I'119CATli( PT ]ON FROMWORKERS'
COMPENSATION INSURANCE
GItEAM%INDUSTRI, WASTE INTERCEPTOR
BUILDING DIVISION FEES
('ITi,scedon need mtbecomplcted it thopemril i'houne hundmddolUrs(3100)
or Iesx.1
GREASE TRAP
PLANCHECK FEIi
- —
Icenifythm in the pedurnanecofthc work for which this permit is issued. I shop
net employ any person in any norma. m as to became ,abject to the Wcakeri Contpen-
SEWER -SANITARY -STORM HA. 200 FP.
ENERGY FRE
WATER BEATER WNEN TIELECTR
GRADING EEE
,.Iran Laws of Colifnmiu. Date
Applicant
Not ICH TO APPLHCANI:If, after nuking this Certificate of Exemption, you should
keome subjmt home Wnrsees Cmmpensubon provisions of the Lothar Code, you vi
fanhwith comply with such provisions or this permit shall he deemed revoked.
WATER SYSTHNVERPATINC,
WATER SERVICE
Soils 19E?
CONSTRUCTION LENDING AGENCY
1 herehy affirm tom there is. construction lending agency for the performance of
NEW RF.SIDENT'IAI. PLMB, SQ. ET.
PAID Eat
Dae
,he work for which this permit is issued (Sec. 3097, Co. C.)
I.eadet's Name
L'
Under', Address
A
-
BUILDING NE
I canny that 1 have mad this application and state Nat the akve information is
QTY. MECHANICAL PERMIT FE
Sep1,I ,F p O
'}'1i'/ U v Jill
sect. l agree to comply with all city and county eminences and state laws relating to
huildingaaastruainn and hetchy amhnoc represemativesofrhis city mercer upon the
ELECT RIC FEE
above-mentioned prop ry, for inspesaion purposes.
(V10 agree rearm, indemnify and keep huntdess the City of Cupertino against
PERMIT ISSUANCE
PLUMBING PF.E
Iiahilities,judgmems,crisis and expenses which muyinunywayaccmeagain,teaid Cily
in consequence of line grunting at this Farren.
AMHRORAUDTO MHCH.
AIR HANDLING ONE P('10 10,000 C-111
APPLICANT' UNDERSTANDS AND WII.I, COMPLY WITH ALL NON -POINT
SOURJ1 iCG—ULAI'IUNS
AIR HANDLING USEI'(OVER 10,000CFM)
CONSTRUE N
�W
T:XHAUSI'H000(W/DUCT)
H IJSIN( GAl'ION PIiIi
Sf nu rc of Applirmt/Gmwetor U:ne
HAZARDOUS MAI ERIALS DISCLOSURE
I IHA'I'END UNIT' (l0 100,000 BTU)
Will the applicant or fumm building occupant store or handle hazardous material
as defnul by the CuPenino Manleipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(x)'1
H1381 INC. UNIT' (OVER 100,000 BTU)
VENTILATION PA N ISI NGLE BESIDE
❑Yes r_1 No
.IU
Dan. Receiprp
BOB.HR- COME' (31411 OR 100.000 BTU)
will rhe applicant or future building iscupa n oto equipment or devices which
emit maindiu, in roarrionsnts in, defined by the Bay Area Air Quality Management
TOTAL:
HOILER-COMPU)VER 100,00 BTUI
District?
❑Ye, C3 No
AIR CONDITIONER
Ihwc rcSolel h are, Sisiam., ls5, 15533 aunder Chapter 495af Ne if he
femia Huhb .F Safety Crede, Sections ]SSU5. 85JJ unJ 25533. I understand chat if the
I$$UANCE DATI' /I
NEW RESIDENTIAL AIECII. SQ. Fr.
building does not ly leve a umant, rhm it is my responsibility m ratify the oecupam
.fine teyuirenemw.hixwhich moa heal prior m issuurce of a CeniMam of Occupancy.
ISSUED BY: 9 F
TOTAL:
Owner or iuthori/ad agent Date
OFFICE