B 0324 (2)APPLICANTTO FILL IN INFORMATION WITHIN REO LINES - USE BALL POINT PEN ONLY '
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CITY OF CUPERTINO BUILDING - ELECTRICAL,
BUILDING DIVISION t APPLICATIOWPERMIT PLUMBING-MECHANICAL
BUILDING' PROJECTIDENTIFICATION
PERMIT NO.
50001 o$0324
BUILDING ADDRESS:
SANITARYNO.
APPLICATION SUBMI ITAL DATE
WNERS NAMH: PHONE:
CON' 1' RAC I' ORS NAME: LIC NO,
N/C
CONTROL#
❑
CHI'1'ECT/ENGINEER: LIC NO:
ADDRESS: -
iJtwlb � c'-2076
CGNTAC'I PHONE:
Y - BUILDING PERMIT INFO -
�,;,d 4toi7246-389(,
❑ Consultant Fees Paid by Applicant (Initial) '
13LDG - ELECT PLUMB MECH
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LICENSED Co RACTDR'S DECLARATION
1 hereby alirm that 1 am licened under provisions of Chapter 9 (commencing
with Section 7000)of0ivision 3 ofthe Business and Professions Code, and my license is
in full force and effect.
License Class Use, #
Date Contractor
QTY. ,= ELECTRIC PERMIT = FEE
_
JOB DESCRIPTION
RESIDENTIAL'
❑ SFDWL El KITCHEN REMODEL
DDITION El PLUMBING RE-PIPE
❑MUM '[-UNIT ❑STRUCTURAL
MODIFICATION
11 CHIMNEY REPAIR
IMPROVEMENT' -
❑DEMOLSWIMMING FOOLS
ElNATH REMODEVREPAIR 0 DEMOLITION
❑ OTHER
PERMIT ISSUANCE
5 APPLIANCES - RESIDENTIAL
Z O,��
OZ-,
ARCHITECT'S DECLARATION
-
I understand my plans shall he used ns pontic recoMs
PANELS
UP T02(10 AMPSINTERIOR
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Licensed Prnfessi.nel
OWNER-BUILDERDECLARATION
I hereby affirm that 1 am exempt from the Comreanr'c License Law For the
following reason (Section 7031.5, Business and Professions Code: Any city or ammy
which require., a permit In conswct, alter, impfuve, demolish, or repair any ewdure.
prior,. it, issuance, also requites the applicant l'or sn.M1 pnmitmfil.aslgned smmment
that he is licensed Former,.. he pmv3si.nsnf the Chmtmchr's License Law (Chapter 9
(cnmmemiug with Section 7000)of Division 3 of the Businc,sand Profession, Cale) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500). ,
as owner of the property, or my employees with wages as their sole compensation,
will do the Casale (Sec 70D4; Business
and Profession, Code: The Contra hica, License Law dues not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
- 201-1000AMPS
OVER 1000 AMPS _
SIGNS ELECTRICAL
$ SPECIALCIRCUIT/MISC.
_
TEMP. MHTER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
[]TENANT L1 FOOD SERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
-
SWIMMING POOL ELECTRIC
6 OUTLETS-SWITCHES-FIXTURES
NEW RESIDENTIAL ELECTR , SQ Fr.
sale. If, however the building or improvement is said withinoue year.fcentpletirmon,
SQ. FT. FLOOR AREA
$/SQ. Ff.
ser builder will have the burden of proving Nat he did ant build or improve for par-
pose .eta).
asst owner fineProperty exclusively contracting N
ongw licensed contractors m .
TOTAL: �,7�a
co
.acthe pr jen (S. 7044 B . sand Vrofessioae Cad :) TT C m t � In-
n:e Law deasmtapplyt fpropetly who bunds.improve, m d
ow
on¢acn for sucM1p J elwith a crntreemr(s) licensed pursuant m the Contractor's
QTY: PLUMBING'PF. 'FEEson
PERMIT ISSUANCE 35x6
License Law. '
❑lam order Sec. B&PCfnr thl.sre...n
ALTER - DRAIN&VE '_ (EA
•
net Dme
VALUATION
�7
D00 W
W tKER' MPENSATION DECLARATION,
1 hereby affirm under penally of perjury one of the following declareti.ta:
BACK FLOW PRI TLCT. D F 0
(have and will ofaCertificam of Consen0o self-Insure for Worker's Compen-
cation, as provided for by Section 3700 of the lobar Code, for the performance .f the
DRAINS-FLOOR, ROOF, AREA, CO
STORIES TYPP. CONS9'RUCTION
' FIXTURES -PER TRAP
work for which this Permit is issued.
"'I'j-� . 1
1 have and will orWorker's Compensation Inauaoce, as required by Section
JC N
3700.f the Labor Code, for performance ofthe work for which this permit is issued,
My Worker's Compensation Insurancew- a
and Policy number rc:
GAS-EA. SYS TEM-I INC. 4 OUTLETS
OCC, GROUP
.
APN
Carrier: Policy No
GAS- EA. SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' `
O
%.
ZO
p�j
F
[ak1
�z
U
W �+
C)F
L)
H a
h
COMPENSATION INSURANCE
(This eecd.nn.ed not hemmpleted if thepennit is tomos hundred dollars($100)
or less.)
perany manner-mance stohadhe kforwhich bject to permit ikesued, I stall' Conalsom
not stn Ie an
toy any pershat on in unuerso asmbec.me euhjenmthe Workers'
suum Lawsof California.tany
Applicant )
GREASEJINDUSTRL WASTE INTERCEPTOR
`=BUILDIN DIVISION FEES
GREASE TRAP
PIANCHF.CK FEE 9
H 70
SEWER-SANITARY- STORM EA. 200 FT.
ENERGY PEG110
WATER HEATER W/VENT/ELECTR /0,00
GRADING FEE
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
heemoo suhject t. the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed men ked.
CONSTRUCTION LENDING AGENCY
whicby h thi that pthereissued(Sunlull. Civ. agency for the performance of
the work for which this )omit is issued (Sec 3M7. Civ. C)
work
Lenders Name
WATER SYSTENVI RENDNG
SOILS FEE
WA'1'Ek SERVICE '
PAID
Dna Receipt#
NEW RESIDENTIAL ELSE. SQ. F-I'.
-
TOTAL
Lender's Address
I certify that 1 have mad this application and state that the above information is-
correct, I agree m comply with all city andeonry entrance, condone lawsrelating to
construction, and
building covsetion, and hereby authorize representatives of this city to corn upon the
TOTAL A
BUILDING FEE (fii
QTy', "ry.ECHANICAL PERMIT'.*
SEISMIC FEE
r
above mentioned property for inspection purp.,ea.
(We) agree reserve, indemnify and keep harmless the City of Cupensts id
PERMIT ISSUANCE
q #x
ELECTRICF E !. I
City
may in any way acerae against said City
expenses thispermit.
in of s. costs the granting
' consequence of thegmming of this )omit.
ALTER OR ADD TO MECH.
PLUMBI GF
AIR HANDLING UNIT (TO 10,000 CFM)
�
SUMBCONST 1 FEE
APPLICANTTTTTT//////��������44DERSTANDSANI)WI COMPLY WITH 'ALL NON-POINT
SOUR ATIO
AIR HANDLING UNII'(OVER 111,000 CFM)
CONSTR ION'1'AX
Signature ofAppli t/ ..unci Date
HAZAR 5 MATERIALS DISCLOSURE
Will the applicam.r future building occupant tram.rhvndlehazardous matnial
EXHAUST HOOD(W/DUCf)
HOUSING MI GATION FEE
_
I HEATING UNI 'P(TO 100,000 BTU) ww
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)'1
HEATING UNIT (OVER 100.000 BTU)
i
❑Yes Fl No'
Will the applimm or Pomrc building occupant use equipment or devices whin,
rt hazardous air conmminants as defined by the Bay Area Air Quality Managemenl
District? ❑Ves ❑No
PAID -�
Date keoeipt # -
VENTILATION PAN (SINGLE RESID) �� /
BOILER-COMP CUP OR 100k000 BTU)
& ZIP 5-2-
BOILER- COME(OVER 100,000 BTU)
CONDITIONER
I have read the hazardous materialsAIR
requirements undo Chepmrfi95 of the Call-
forma Heald, & S fay Cole, Seaioos 25505, 25533 and 25534. I understand that if the
million neatly haveatenanh th I I spone belity to notify the occupant
ISSUANCE DATE
NEW RESIDENTIAL MECH.
none cut,which tetpne,1.i a of a Cenificea of Occupancy.
�
ISSUEDBY.
_1 Date
Owner or anhortze gn
TOTAL: J.S.
OFFICE