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CITY OF CUPERTINO BUILDING -ELEC'T'RICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING .MECHANICAL.
BUILDING PROJECT IDENFIF'IC'A'FION
PS
PSAIT NO, 0922
❑TNO ADDRESS: 5
SANITARY NO, AI'1'LTCATION SUBMITTAL DATE
/OZoI yog A, P/datce CaGLr
NIC CO TROL#
❑
Fl NP NAME: I'il0 ':
w tL TO;
RC 'S'FECTA NGI EER: LIC NO.
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CO AACFOR'S AME: L NO: 'Ls
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CONT'AC'T: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initia)
BLDG Td.liC'I' 'LUMB MECI
LICENSED CONTRACTORS DECLARATION
1 herchy affirm that Ism IicenuJ under provisions of Chapter 9 (commencing
QTY. ELECTRIC PERMIT 17EE
JOB DESCRIP9 ON
PERMIT ISSUANCE
infull located eRec�tnsinnJaf the Businessand Professions Code.tandmylicemels
RESIDENTIAL
❑SFOWL ❑ KITCHEN REMODEL.
AI'I'LIANCIS- RESIDENTIAL
License Class Lic.M
DataCrmrocmr
❑AUDITION Uh1BING RE-PII'li
STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROV17MIWT E] SWIMMING POOLS
ARCHITECTS DECLARATIONPANELS❑MULTIUNIT
1 understand my plans shall be used as Public records
UPT021MtAMPS
Licensed Probasco ... I
2II-1000AMPS
OWNER -BUILDER DECLARATION
I herchy affirm that 1 am exempt Irina the Cormorant's License Law for the
fallowing inuoea. (Sestina ]LUES, Businessland! Par l'esxions Cade: Any city or county
[I BATH REMODELIREPAIR ❑DEMOLITION
❑ OTHER
OVER INK) AMPS
SIGNS ELECTRICAL
which reyaircs a permit to consumer, oiler, improve, dctool kh, or mist any structure
SPECIAL CIRCUIT/MISC.
prior to its issuuace. also requires the applicant for such permit file a signed statement
door he is licensed pursuatn to the provisions of the Com recall's License Law (Chapter 9
(commencing with Section 7BBB) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom sad Ne man, for the alleged exemption. Any violation of
'FI:M I'. MBH7R OR POLE INST.OMF'
MERCIALE'
❑ EW BLDG/ADDITION f_1 DEMOLITION
Section 7031.5 by any applicant for a pewit subjects applicant the applicano a civil penalty of
POWER DEVICES
TENANT ❑ FOOD SERVICE
not more than live hundred dollars ($500).
❑ 1. as owner n(me Pmpcny. or my employms with wvgesm their sole compensation.
will do the work, and the,comatrc is no intended or offend far sale (Sec. 70Y1, Business
IMPROVEMENT
❑ SiHER
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES -FIXTURES
and professions Coda: The Contractors License Inas does not apply to an castle, of
NEW RESIDENTIAL ELECTR SQ FT.
properly who builds or improves theman, and who does such work himself or through
his own employees, provided that such improvement arc not intended or offered for
sale. If, however. the building., improvement ixsold wihhinnne yearafmmplefm. the
Q. .FLOOR ARhA ASQ. PL
nerbuilder will have the human of proving that he did not build or improve for par
qne of sale.)
❑ L os ow r nl tiro: propeny, nm exclusively contracting with licensed contmemrs to
TGI'AI.:
come at the ocical (Sec 7044, Basime" and Pmfrsxlons Coal:, ,tae Grammars la-
Io se law does not apply at an owner of pa,sny who mtildxnr impmvea memnnund
cerise
QTY. PLUMBING PERMIT FEEp
who caramels Br such projects with a conrectods) Iicenstel pursuantIn the Cmammor's
#N
1117RMI V ISSUANCE?
License Law.
❑ 1 um exempt under Sec. . B & P C for this reason
rs VpfBpTUN
/1'/V'//�L]I]
CII i
ALTER - GRAIN & VENT -WATER (EV,
-cusall-1p-q.Dam
104— WORKER' COMPENS UIN� ATIO
BACK FLOW PROTECT. DEVICE
i hereby affirm under penalty of produry one of the following declarations:
Ur
L
❑lams and will maimaiaa Cenifcae nfCnnsenunnellinsure for Workers Compete
since, os provided for by Section 37M of the Lahr Code, for the performance of the
DRAINS- FLOOR. ROOF. AREA, COND.
STORIF_ NO TYPE CONSTRUCTION
work for which this pewit is ism W.
FIXTURES - PER TRAP
❑ 1 have and will maintain Wtowl's Conhpcustoms Insurance, as inquired by Section
3700 offal, Local Code, for the performance offhe work for which this permit is issued.
'
OCC. GROUT' APN
GAS - HA, SYSTEM-] INC.4 OUTLETS
My Worker's Compensation Insurance corner and Policy number are:
Cartier: Policy Na:
GAS - EA. SYSTEM -OVER 4 (EA)
CEItI'IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GI31?AMAINDII$'FIt I. WASTE?INTI?HCI?ITOR
BUILDING DIVISION FEES
fI his section need not be completed if11mpannir is for enenmmreddilOrs($I(Xb
or Iexs.)
GREASE'FRAP
PLANCHF.CK FCIi
of the terome suork for bjectch to permitrkers'Com,nall
I unify that in rhe any
not employ any person in any manner so as to become subject ur the Worker' Compen-
SEWER - SANI'T'ARY - STORM EA. 200 FI'.
ENERGY FEE
WATER HEATER WNF.NT/F.LECfR
---
GRADING PEE
station laws of Celifomia. Data
an
Applict 1
NOTICEI'O APPLICANT:If, after nuking this Certificate of Exemption. you should
become subject to the Wnhcrs Compensation provisions of floe Labor Code, you mush
WAA Elk SYSTF.MITREATTNG
SOILS FEE
forthwith comply wiaroch provisions m this permit shall be Jearal invoked.
WA'T'ER SERVICE
CONSTRUCTION LENDING AGENCY
I herchy affrmfhat there isacnnswefinn lending agency fnnhe performance of
NEW RESIDENTIAL PLMB. SQ, Ff.
PAID
Dam Receipt#
the work lin which this pewit is issued (Sec. 3097. Civ. C.)
Lenders Name
TOTAL:
Isatin,A kImns.
'TOTAL
BUILDING F F
I certify that I have mad (his application rad state that the shove adarmation Is
correct. l agree to comply with all city and courtly odinanecs and state laws mining to
building conswction, nod hereby emhrow mpresemutivex of this city an enter upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC P .:
move mentioned popery for inspection purposes.
(We) agree an save. indemnify and keep harmless the City of Cupertino against
ALTER OR ADD TO MECH.
PLUMBING 'E
liabilities, judgments, costs and expenses which auy in any way accrue against said City
in amsequence of the granting oftbis pewit
AIR HANDLING UNIT (TO 10.000 CFM)
MECHANICAL FL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCFt .'$IULATIONS.
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION IA
��_�''//II``//��JJ/44t/,6 �//���;\�Q��-!�1
EXHAUST HOOD OODUC I
HOUSING MITIGAT N FEE
Signslure 4Ct actnT for Dam
HAZARDOUS MATERIALS DISCLOSURE
IEFATE NO UNIT (TO 100.000 BTU)
Will the applicant or future building occupant store or handle haeamaus material
as defined by the Cupertino Municipal Code, Chapter 912, and foe Health and Safety
Coda. Section 25532(u14
HEATING UNIT (OVER 1 W," B'T'U)
❑ Ye's ❑ N.
VI?N'I'ILA'1'ION PAN (SINGLE RESE D)
PAN -
Data Itecept#
NOILI?K-COMP OR IIXLgNI BTU)
Will the applicant or future (wilding occupant use equipment or dmci s which
'sxlibueurdous air contaminants as defined by the Bay Area Air Quality Managemem
TOTAL:
BOILER -COMP (OVER 1011.000 BTU)
Dia,id4
C] Ya' ❑No
AIR CONDITIONER
I have mail the hu,zmom materialsrequiinaent under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. PC
fool. Ilealth & Sm1 y Cale, Sections 25505.25533 mil 25534.1 understand that Rahe
buildingdoes not currently have o tenant, that it is my responsibility to ramify the occupant
of The n•quiandamea which most be met prior In issuance of tl Cenillcam of Oceupaacy.
I ISSUED BY:
TOTAL]
Owner tar umhnnanl 'gem Date
OFFICE