S 1864 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE\V T NO. 1864
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS'. SANITARY NO. APPLICATION SUBMITTAL DATE
1CX 30 Cis+lne, c'.
O NER'S ME: PHONE: CONTRACTOR'S NAME: I' LIC NO'.
_ 1 1 1 9qC,— 5465 (meq Vqpr rv/c CONTROL«
ARCHITECTIENGINEER: LIC NO: AD RES �l A ,p a ❑
7 c� • Qi-N-K2.c O�IbC, -
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG, EL[CT� PLUMB_ MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE LdJ
1 hereby union that 1 am liccnati under provisions of Chapter 9 hevmfachimg JOB DESCRIPTION
WOO with Section 7000)of Division Sof the Bodowsand Prof e..io:ss Code,add my license is
XI— PERMIT ISSUANCE. r(� RESIDENTIAL:
F� L ane Class
effect. / ❑SPDWL ❑KITCHEN REMODEL
CUV License Class Lie.k
yZW Dme Comment APPLIANCES-RESIDENTIAL ❑ADDITION [_1 PLUMBING RE-PIPE
ARCHITECT'S DECLARATION
[IMULTI-UNIT ❑STRUCTURAL
r o,z I understand day plans shot be used as puhlierer d, PANELS MODIFICATION
p Z14- UP ID 200 AMPS ❑IMI'ERIOR El CHIMNEY REPAIR
i,4tJ.W] Licensed Pudessimetl 201-IOWAMPS IMPROVEMENT E]SWIMMING POOLS
y'YYYY OWNER-BUILDER DECLARATION OVER IOOOAMPS
0.f��6 I hereby aft IMt 1 am exempt faradic Ib
Cmnmena,License Law far e ATN REMODEIBEPAIR E)DEMOLITION
6 U following mann.(Section 9031.5.Business and Pmdes.ions Code:Any city nr county SIGNS ELECTRICAL ❑OTHER
which y ' Lapmll.consuara.'L pd I',h p' nY.uncture
poor to itsane,also requiresthe pplic t for suchp II No a:Ked statement SPECIAL CIRCUIT/MISC.
!bar he is licensed. I to M1 p f the Contractors License Law(Chapter 9
se (commencing with Section 7000)at Division 3 cribs Bmsineesand Profmssano Cade)or TEMP.METER OR POLE INST. COMMERCIAL'
d p,o a that he i,exempt thuefrem and the harts for the alleged exemptionAnysioletion of ❑NEW BLDG/ADDITION ❑DEMOLITION
WSection HH LS by any applicant far a permit subjects the vpplicvm n a eivi l penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
net mem thin five hundred dollars($5(X1).
- IMPROVEMENT
Q ❑Lasowner mfthe property,arnryemntendes with wages,atheir Sce.compensation,4,Busiess SWIMMING POOL IiLECI'RIC
F� wall do tfiewmk,ande he Coreismol intended nr ffeed Law
apply to an.Puniness ❑OTHER
W ro and Professions Code:The Contractor's License Law done not apply to if owner of OUTLETS-SWD'CIIES-I>IXTURES
his o ny who builds or improves thereory and who docs tech work himself m Nrougb
has own employeesprovided that such improvements um nm imendW or offered far NEW RESIDENTIAL ELECTS SQ FT.
sale.IL however the
building or improvement is sold within one year dfwmplction,the - SQ.FT.FLOOR AREA $/SQ.FT
owner-builder will have the burden or proving that he did nut build or improve for pur-
pose of sale.). ,
❑T.as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
ensure the project(Sec.7EU,Business and Prttmssaom CMc:)The Cmmmcmr's Lr-
cease Law does not apply toanowner of praper,who hands or improves thereon,and QTY. PLUMBING PERMIT FEE
who emmarels forsuch projects with a contractors)licensed pursuant to the Contractor's ,^
License law. PERMIT ISSUANCE. V 0
E]I an cxnmpt under Sec. ,B&P C far this reason V V
Owner Dam ALTER-DRAIN&VENT-WATER(EA) V ION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby uHim under penalty of perjury one of the following declarations:
s ❑ I have and will maintain a Ceniticmc of Consent o self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCT ION
sation.as provided lin by Section 37N)of the Labor Cede,for the Perf,,M nCc of the
work for which this permit i.issued. FIXTURES-PER TRAP ,
❑I have and will mainmio Worker's Compensation Insurance,as required by Scotian
37M of the Lamar Code,for the performance of the work for which this permit i.issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCCGROUP APE
My Work CmmP nsatj, nl mac v 'or and Policy n
Cassias: Policy Nm.: 9le�� GAS-EA.SYSTENUOVER 4(EA)
CERTI CATEOFE' MPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not so emipleted ifthe permit is far one hundred dollars P6 100)ter leu) GREASE TRAP PLANCHBCK PEE
I certify than in the performuneeafthe work for which this permit is issued,I shad SEWER-SANITARY-STORM EA.21X)FT
not employ any person in any manner so as to become subject the Workers Compact- ENERGY Ej
Zz saran Laws of Coroner.Dec WATER HEATER W/VENT/ELECTR
Applicant I 4P FEE
tZl NOTICE TO APPLICANT.If,aft,,making this Counteract of Excelsom,you should WATER SYSTEM?REATING
E^ ? became subject name Worker's Compensation provisions of the Labor Cade,you most SOUS FBR
QLathwib,sharly with such provisions arras himad,hall he decmedrevoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ.PT ID •�
=).Z Dglm. ReceiplM
off
U0 Iherehy rte the ww
there is agenc
construction lending y forth¢performance of
the work f a which this permit is issued(Sec.3097,Civ,C.)
O ULender's Name TOTAL.
WLender's Address TOTAL:
I certify that 1 have mad this application and state(hill the above information is BUILDING FEE
fro Zl correct.1 agree to'comply with all city and county crdinaoces and state laws relntang to QTY. MECHANICAL PERMIT FEE
V SEISMIC FEE
z bnlldangcupmand h
nctlme- cmhy ama honzemp...crtmavof 11h,uly to color upon the
manemeatirned proper y fur inspection purlmaex. PERMIT ISSUANCE
Wo)agree to save,indemnity and keep harmless the City of Cupertino against P.LP.CTRIC PEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADDTO MECH. PLUMBING FEE 0
I.c
onscgnence of the granting of thnis per 1.
APPLICANT UNDERSTANDS COMPLY WITH At.[.NON-POINT AIR HANDLING UNIT(TO IBWB CPM)
SOURCE REGU MECHANICAL, FEE
O - -
AI R HANDLING UNIT(OVER 10,000 CFM) CONSTRUC'1'IONTAX
Slgmat Appli nt/Cant ! /Dec EXHAUSTI100D(W/DUCT) HOUSING MITIGATION FTE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(To 100A00 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety'
Cordo,Section 25532OL HHATING UNIT(OVER 100,0010 BTU)
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID -
. Data R 'eipIM
Will the applicantorPoore bullring occupant Arcse o
Air equipment Management
aces nawhich BOILER-COMP(3HP OR 100,0(10 BTU)
emit hazallous air cantamin:mts ns defined by the Bay Area Air Qudliry,Management L.
I District) BOILER-COMP(OVER 100,NX)BTU)
❑Yes F7 No
I have rend the hazardous materials mamremenis under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fa:nis Health&Safety Code,Sectians 25505,25533 and 25534.1 undersand Chet if the NEW BESIDES PIAL MECH. SQ.FT. -7button,doesnet chathave a tenant.than it is myrespnnobility to maifythcacer am /
of the requniu ents which must he mel prior to issuance of a Cenificate of Occupancy.
Owner or authorized agent Date TOTAL ISSUED BY:
OFFICE