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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO - - BUILDING. ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL
+:'Tat • r" BUILDIN(;PROJECTIDENTIFICATION`_'i„td':YiR
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J 4 3 5 5
6UILDING ADDRESS:
cpe1210
SANITARY NO.
APPLICATION SUBMITTAL DATE
R' M �' )
CONTRACT(] AM LIC NO:
NIC
❑
CONTROL of
ARCHITECT/EN EER CNG:
ADDRESS:
O CT: PE NE: �f
I/ �c•-.J ��J
I
❑ Consultant Fees Paid by Applicant (Initial)
ILDIAOPERMIT•INFO s'
BLDG ELECT PLUMB / MECH
IJA o�.7C /
❑ ❑ Elf ❑
LI SED CONTRACTOkS )ECgnsof CON
I oreh affirm gnat 1 vin licensed ander provisions of Chapter 9 (comms g
TY, {) [ CCL'GTRIC PERMIT•+tit T ( 'PE4d IIS.
QTY
..,.,,. fir., . • .. ,f ax± .S.xy ....: ..
JOB DESCRIPTION
PERMIT ISSUANCE
with Section]000)of Division 3.ftbc Businessand Professions Cale, andmy license es
In full force and effect.
RESIDENTIAL:
❑ SFDWL ❑ KITCHEN REMODEL
APPLIANCES -RESIDENTIAL
License Claes Lia#
Uate
❑ADDITION El PLUMBING RE -PIPE
[I MULTI -UNIT [I STRUCTURAL
MODIFICATION
MODIFICATION
❑CHIMNEY REPAIR
IMPROVEMENT []SWIMMING POOLS
ARCHITECTTSDECLARATION
'S DECLARATION
I understand on, plans shall be used as public nand,
_
PANEL S
UP T0200 AMPS
Licensed Professional
201-1000AMPS
OWNER-BU1I.DERugGe RATION
firlimvI here.. aBbm that 1 am exempt from the fesntmslCo Licence Law dodge
ima remora (Secilon 7031.5, Business and Professions Cafe: Any city orounlyLure
❑ BATH REMODEUREPAIR El DEMOLITION
[]OTHER
OVER 1000AMPS
SIGNS ELECTRICAL.
which requires permit hat clmo'ueL aha, Improve, demolishi or repair any twnure
which
SPECIAL CIRCUIT/MISC.
issuance, requires provisionamfor such
pdornnnensepursuant Licensfile asigned shaptert
that he is licensed pureuam to the of the Contractor License Lew (Chapter 9
TEMP. AFTER OR POLE INST.
COMMERCIAL:
of Division
(commencingsexempt Sonsion of Divisioor a%he Nosiness andon.Ayvi Code) or
a Business
and
gM1ad he is exempt therefrom and the basis for the allege) exemption. Any violation of
El NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
nog more than five hundred doll .¢ (55 W).
0 Las ownerofing props..,.' on, employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. AvEL Business
[]TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES -FIXTUR
_-
and Poressionc Code: The Congruence, Latin. Law does not apply to an ..or of
-_
property who builds or improves thereon, and who docs such work himself or through
his own employees, provided that such improvements arc net intended or offered for
sale. IL however, the building or improvement is sold within one year ofeompletion.the
NEW RESIDENTIAL ELECTS FT.
i FLUOR AREA 5
I 9T
-builder will have the burden of proving that he did not build or improve for per-
owner -builder
of the p am exclusively contracting with licensed contractors i-
❑yl so o0,
l " JUN 2 8 19 9
TO L.
704 C
const/ IN p J t(So,,]044 B. dP [ Cade)TTe Contractors L
p
e . I d i pplyt n n rp pony n n -1a or mpr.vns mpreo e
who ted forsnah prjanw onimnC(s) licensed parauongmthe Ciarmar ,
❑ImLicenso uxentpt Sec ,B& P C for this reason
jjjj fly
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� � � � �( �- qd � #; '1
QTY.,` PLUMBING PERMTT 4 iii". P4E'll I.
+ +
�'
PERMIT ISSUANCE
ALTER-DRAIN As VENT- WATER (EA)
Owner Dam
VALUATION
BACK FLOW PROTECT. DEVICE
ORK N DECLARATION
I hereby nfri oder penalty of perjury ane of the following deelamtions'.
DRAINS- FLOOR, ROOF, AREA, COND.
I have a.d-i".,.intainaCenificatecf Conseiittoself-insureftr WorkerSComCn-
Bion, .s provided for by Section 3700 of the Labor Cade, for -the performance of the
STORIES
TYPE CONSTRUCTION
ork for which this permit is issued. -
FIXTURES -PER TRAP
-
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3801 ofthe Labor Coro, for the performance addle work for whichud, permit is issued.
GAS - RA. SYSTEM -1 INC. 4 OUTLETS
OCC, GROUP
APN
My Worker's Compensmion Insurance carrier and Policy number are
Cardec Policy N.,
GAS -EA. SYSTEM -OVER 4 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COM PENSAI'[ON INSU RANCF;
(Thisswdonneed not hecnmpletsd ifthe permforms hundred is formhundred dollar, G 100)
or Iv".)
GREASE/INDUSTRL WASTE INTERCEPTOR
, ': - y IDN I ON FENS} $ �' gi
GREASETRAP
PLANCHECK FEE
SEWER -SANITARY -STORM EA. 200 FT.
I certify that in the pedormanceorlhe work for which this permit is issued, I shall
not employ any person In any manner so as to become subject m the Workers' Comn- pe
ENERGY FEE
WATER HEATER WNENDELECTR
satin Laws of California. Date
Applicant
GRADING FEE
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
beams supl,pd to the Worker's a ndo'e'adoa provisions of the Labor Coda von mon
WATER SYSTENVI'REATING
SOILS FEE
It -
WATER SERVICE
forthwith comply with such provisions or this permit shall b, deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them ise consumption lending agency for the performance of
NEW RESIDENTIAL PLMB. SQ. FT.
PAID
Dam Receipt#
the work for which this permit is issued (Sec 3097, Civ. C.)
Lenders Name
O
TOTAL'.
.
Lead Add
TOT
BUILDING FE VV
I certify that 1 have read this application and state that the b f at'
correct. I agree to comply with all chtyrold county ora nences and state laws cannot g
buildin, conswuinn and herebyauthono, representatives of the citym enter uponthc
.. .. o
QTY . ' " I`. MECHANICAL PERMIT FEE � r
td, .i; i
SEISMIC'
PERMIT ISSUANCE-
ELECTRIC FE
.bone -mentioned property for inspection purposes.
(We) agrce to save, indemand nify keep harmless the City of Cupertino against
ALTER OR ADD TO MECH.
PLUMBING E 9, 0
lial"Ites,judgmards, costs and,�^^f arcs whichmayinanywayaccme againsisaid City
ansequ may/if IgEg3 ti9hod his permit.
gIRHANDLINO UNIT(TO It1,000 CPM)
MECHANICAL F '
APPLIC ( DESS (ND A ILL COMPLY WITH ALL NON -POINT
SOU ,ULATIO S.
AIR HANDLING UNIT (OVER 10.000CFhH
CONSTRUCTION TA
I
EXHAUST HOOD(W/DUCT)
nature d Cn meat Data
HAZARDOUS MATERIALS DISCLOSURE
HOUSING MITIGATION FEE
HEATING UNIT (TO UV,000 BTU)
WIFE, applicant., fair,, building eccupantsm,e., handle lmmN.us optimal
as defined by the Capeninc Municipal Code, Chapter 9.12, and the Health and Safety
Cade, Section 25532(1)9
HEATING UNIT (OVER 100,000 BTU)
E:1 Y” EIN.
x Wil l the applicant or future building is .... of use equipment .r devices which
mit harardous air contaminants as defined by the Bay Area Air Quality Management
svicdP
❑Yes LIN.
PAID
Date Receipt#
VENTILATION FAN (SINGLE RESID)
BOILER-COMP(3HPOR 100,000 BTU)
TOTAL:
BOILER -COMP (OVER 100,000 BTU)
^
,./
.us t vmnels rcqulrcmenw underChnpt,r fi95 of the Gli-
fi,95o
Cthe
AIR CONDITIONER
LONERMECH.
ISSUANCBforni,
NEWRESN SQ. FT.L
c 2550 5533 and25534. 1 and that if
and, ti mnrypa,mosibillrymnmifythcoccupent
CE (�bueat
"h.vop.dthoha�ou,,
ofst mer cofoC Inst of Ocupancy,
7
Datc
ISSUED BY:
TOTAL:
OFFICE