The URL can be used to link to this page

S 0011 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITN BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.NECHANICAL Ci.dyy� 1 BUILDING PROJECT IDENTIFICATION ILDINGADDR ISS: SANITARY NO. APPLICA'T'ION SUBMI"ITAL DATE NER'S fqA .© PHONE: CTOOR'S NAME'FS��/TLA I/ NAC/ ILJ E .C1� N/C CONTROL# 000lAgg RCHITECTIENGINEEk: LIC NO: A REss: V.Bl a W/f{Y a L)4 ❑ CONTACT: PHONE: "3:W9, BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLQG ELECT PLUMB MECH !F V ❑ ❑ LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE I hereby affirm Nat I con licensed under previsions of Chapter 9(commencing JOB DESCRIPTION pOo with Section 700))of Division 3 ofthe Business and Professions Coca,and my license is PERMIT ISSUANCE RESIDENTIAL in bill foneand effect /�� 1'// ❑SFDWI. [I KITCHEN REMODEL GUj License Class _ Lic.# �/ APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE NZ Dam Comracmr El MULTI-UNIT ❑STRUCfURAL YPanss To ARCHT rECT'S DECLARATION PANELS Z 1 understand m 1 hall he used as public recons MODIFICATION OZ � UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR �l Licensed Professional 2(H-11X0 AMPS IMPROVEMENT SWIMMING POOIS Ss; OWNER-BUILDER DECLARATION I batch,arm thin I am exempt from the Contractor's License Law for the OVER!"AMPS El BATH REMODEL/ItEPAIR DEMOLITION iqy's5�O a Ufollowing owner.(Section 1031.5,Business and PurfacUmas Coda.Any city or county SIGNS ELECTRICAL ❑OTHER B13 LL H which requires is permit to construct,alma improve,demolish,or repair any structure �0 prlorto it,issuance.also nquireslheapplicaroforxuch permitm file asignel smmntent SPECIAL CIRCUIT/MISC. that he is licensed pursunnt to The Provisions ofthe Conmacmrs License Low(Chapter 9 $q0 (commencing win Sxtinn1fM10)nf Dfvisian3 of ohe Business and Professions Code)or TEMP.METER OR POLO INS'll COMMERCIAL G y m eG that he is exempt therefrom and the basis for the alleged exemption.Any vi ilm nr of ❑NEW BLDG/ADDITION ❑DEMOLITION YXI 4y Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES jElTENANT ❑FOODSERVICE � 6 not mare than five hundred dollars($500). IMPROVEMENT E] Los mvnnofiheproperty,or my emplo,cas with wages an lasumlecmmpensmion, SWIMMINGPOOLELEGTRIC will do The work,and The someone is not intended nroRerd farsale(Sm.7044,Business ❑OTHER and Professions Code:The Commences License Law does not apply to an—act of OUTLETS-SWITCHES-FlXTUR[S property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvemems art not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. sale.If.however,the building or improvement issnld widtiumayeal-fromidefon,the SQ.FT FLOOR AREA $ISQ.IT. owner-builder will have the burden of proving ohm he did nm build or improve for par- D gsse of sack.). .. [:]L as owner of the pmPeny,am exclusively contracting with lannoted cmarint rs m TOTAL: cnnrtmct the project(Sec.1044.Hosiness and Professions Ccsi The Contractors Li- rsfL`"IR arms,Law does net apply to an owner of property who bunds or improves thereon,and QTY, PLUMBING PERMIT FEE 4,9 who contra's fur such projects with a contractors)licensed,momm m the Contractor's pp License Law. PERMIT ISSUANCE 1 on exempt under Sec. ,If&P C for this reason rl, ALTER (EA) !x VALUATIDN Owner Data V WORKER'S COMPENSATION DECLARATION BACK FLOW PROTIiCf.DEVICE 2pp G'r I hereby affirm under penalty of perjury one of the following de'Iamtions: J I have and will maintain a Certificate ofConsem m self-insure oWorkers Com pen- IXDRAINS-FLOOR,ROOF AREA,CONED. WORIPS TYPE CONSTRUCTIO! suman,ns provided for by Section 31W of The Labor Cede,for the performance of the work for which this permit is issued. FTURES-PER TRAP C]I have and will maintain Workers Compensation Insumnce,us required by Section 31W of the labor Cash,for the parmorrance or the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP APN My Workers Compen nation Insurance carrier and Policy number are: Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERSGREASBINDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE ITU .DI VISION ETES L'Iissatiimneednotbe£mpleledifNepermitkforonuhundrWdnllam($IW) GREASE TRAP Unless.) PLANCHECK FEE I certify that in the Performance ofthe work forwhich this permit is issued,I shall SEWER-SANITARY-STORM EA.2110 FT. not employ any person in any manners ltre as to c me sy�(,co the Workers'Cooper. ENERGY PGE 0 Z cation Law f C I folniUDa�,t �N `A�V"a WATER HEATER W/VF.NT/ELECTR Z Q Applicant Jl GRADING CgNOTICE TO APPLICANT.if.after making this Certificate of Exemption,you should WATER SYSTEMORGTING SOILS FEE f,�^' become subje<nn the Work<rs Compenmtion pmvisiom of the labor Csale,you must C n : forthwith comply with such provioaroor this demit shall be domed evoked. WATER SERVICE Cil Q z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.FT. PAID Dm Receiptp I hereby ofm firthm therelsa comminution lending ageouy for the perfonoa..of LJaO are work for which This Permit is issued(Sec.3091,Civ.C.) TOTAL: O E"' Innders Name Lenders Address TOTAL: y I certify that 1 have read this application and suite Nat the above information is BUILDING F G Il"!) correct.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE SEISMIC F3 V Z building construction,andbereby authorize representativesedide city umnterti The above"mentioned property for inspection puHmms. PERMIT ISSUANCE ELECTRIC (We)agree to save,indemnify and keep hornless the City of Cupertino against liabilities.judgments.costs and expenses which may in any way aceme against said City ALTER OR ADD TO MECIL PLUMBING PGI? are onreque erof the grantingof this perrou. APPLICANT UNDERSTANDS ANI)WILI.COMPLY VI'I'H ALL NON-1'01NT AIR HANDLING UNIT(TO WANT CFM) MECHANICALFEE SOURCE N —� $+ AIR HANDLING UNIT(OVER 10,000 CHAT CONSTRULTION'I'AX Si ' lure of ApplicanUCoatmensr Date l EXHAUST H00D(W/DUCfI HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle Intruders orders] HEATING UNIT TO IIyd,(XXI BTU) as JeOned by the Cupertiw Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I(IH,(p0 BTU) Code,Section 25533(n)'t E]Yes IK VENTILATION FAN RGSID) PAID /� Date RxciplN C WII the applicant or future building Occupant use equipment or devices which BOILER-COMP(3HP OR I W,000 BTU) emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL: District? BOILER-COMP(OVER I00.(XX)BTU) C]Yes I have retedthe brommus materials m,mumnams under Chapter 695 of the Odb AIR CONDITIONER ISSUANCE DATE Words Hea ter&Safety Cade,Sections 25505,25533 and 25531.1 mnarsmnd That if the NEW RESIDENTIAL MECH. SQ.ff. s building does not comaddy have a a nam,than it is my resEmnsibilhy 10 notify the..,at of Ne mr,drements which most be met prior to issuance of a Cenilicate of Occupancy. Owner or truth nriud agent Date TOTAL: ISSUED BY: � OFFICE