99120112 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 12.011
CITY OF CUPERTINO APPLICATION/PERMIT BUILDING-ELECTRICAL ERMI1 FNO.
HUILIING DIVISION PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
LIIING AIIIIKESS: SANITARY NO. APPLICATION SUBMIITAI.DATI
?�
1 WNER'S IPHONE: CON' ACTOR'S NAME: LIC NO:
/
iCHITL T/ENGINEER: LIC NO: l •0 try" p ea 6n.. L11e ❑
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTLDM II MECH
❑ ❑ ❑
LICENSED CONTRACTOR der previsions DECof'ION QTY ELECTRIC PERMIT FEE
1 hereby afbmt mm I nm)f eeBu nnder olf ss of Chapter 9 myticenwia JOB DESCRIPTION
A0.'Z wilollia inn ndeftef UivisinnJnf the Bminas and Professions Code.and my license ix RF_SIDENTIAL:
WOO PERMIT ISSUANCI!
F-W- in famiCceansl ellict. ❑SFDWI. ❑KI'fC1HEN REMODF,I.
aVF Liccnsc Clnss Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
F-Z a Commcmr
NCN ARCH]IECTS DECLARATION PANELS ❑MULTI-UNIT ❑SIRUCTURAL
I undenland my glare shall be used as public records M DIFICATION
pz-0 UP TO 20 AMPS
❑INTERIOR IMNCY REPAIR
F4I_'nud Licensed Professional 2nl-IIHOAMPS IMPROVEMENT MING POOLS
OWNER BUILDER DECLARATION OVER IINOAMI'S ❑BATH kEMODEIJRCPAIR :h .ITION
p,C 6 I hereby affirm lhal I mm excnspt Illinois,Contractors License Low for the
x O d V following reason.(Seelian 7031.5,Business and Profession,,Code:Any city or comay SIGNS ELECTRICAL ❑OTHER
LL7 3 fa.� which requires a permit to constrict,alter,improve,demolish,or¢pair any structure
0-5 poor it)its issuance.also requires the applicant for such permit to rile a signed statement SPECIAL CRCUITIMISC.
9 of thlll he is licensed pursuant m the prvvi.,,mo,of He Conmesumi,License Law(Chapter9
W�'0 (commencing with Section'/gOU of Division3ofthe Ousines.,,and Pndessinnv Gde)or TEMHMETEROR POLE INST. COMMERCIAL:
G ly ca C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION D 01. ION
�f 4• Section]U3 L5 by any applicant for a permitsubjects the applicant to a civil penally of POWER DEVICES
lar-y ❑TENANT 'OI�D ICE
not more than five hundred dollen(S500),
El Las owner of the property,or my employees wirh wages as their side compensation, SWIMMING POOL FLECTRIC s P .N7Y
F�G will do the work,and the structure is not branded or offered for sale(Sec.7I ,Business T
CWC and Professions"a:The Contractors Licemse Law does not apply to an owner of OUTLETS-SWITCHES
-F RES �
progeny who mild,or improves thereon and who does such work himself or through
his own employees,provided that such impmvemm�ts am not intended or offered lie NEW RESIDENTIAL 1AX, FT.
sole.If.however,the building or improvement is sold within one year afcomple0oo,the SQ.FT.PLOOKARFA VSQ.FL
er-builder will have the human of proving that he did nm build or improve for par-
El 1 of sulci).
1.as owner of the Sec.7Comedy,out excessively cofies kog with licensed combooars i- O'1'ALI
command the project apply
to an Business and Professions Carel Tho Contractor's Li-
cerise
i- q
seontr ticeor such plyman with
who builds mimproves the Contractor's QTY, PLUMBING PERMIT @/
who contracts for such projects with a cnmmcmrts)IiccnscJ pursuant to the CnnlranoBs
License Law. PERMIT ISSUANCE
❑ Iamesemptunder See .B&PCfielhismaon
ALTER-DRAIN&VENT-WATER(I!A) VALUATION
(loner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.D17VICE
I hereby af0roe under penalty M perjury,one of the following declarations:
r-]Ihaveand will maintain a Criificate of Consent to self insure for Workers Compcm DRAINS-FLOOR,RWR AREA,COND. STORIES
TYPECONSTRUCI'ION
nation,a,provided for by Section 3900of the LOMn Cale,far the pfom
ertance of the
wod,for which this permit is issued. FIXTURES-PER TRAP O�
❑1 have and will maintain Workers Compensation Insurance,as required by Sectien
3900ofthelsbm Gde,for the perf rmaaeeof Neworkfnfwhichthispemnitisisaued, GAS-EA.SYSTFM-1 INC.4 OUTLETS { C. IROUP 0 APN
S
My Workc' oto Incur ce wnicr and Policy number ore:^^ _
Caoncc • cnsa' Policy No.: t �'NL� GAS-IiA.SYSTEM OVER o \
CERTIFICATE OF EXEMPTION MOM WORKERS' `X
COMPENSATION INSURANCE: GREA,SEANDUSTRL WASTE INTERCEPTOR 7
(Thiswelion readmit be completed it the pl+Mr is 1'orone handled dollars(SI00) E l GDI VISIOry EEL'S
GREASETRAP I A2 \
or less) PIA ECK FEE
Ioya,thatmine
any mailofs 1fivese aich this permitisis.suad.lehaller- SEWER-SANITARY-S'fORM EA.200 FT.
net employ any Terson in any Bonner so as to become xubjcct to the Workers'Charter- F.NEItG Eli
O Z satitn Laws mf California.Dale WATER HIiATER WNENTIE:LEC R GRADINZApplicantNOTICE TO APPLICANT:If,after making this Certificate of Exemption,yon should WA1'I!R SYSI Ewl REATING $OIL Sbecome subject to the Workds Compensation provisions of the Labor Cale,you mustforthwith comply with such provisions or this prmil shall be deemed revoked. WATER SERVICE
CONhem is a IONLENDING AGENCY NEW RESIDENTIAL PLMU. SQ.t9'. PAIU
U 0Thereby atlinnlhauhere isaconxwnion lendin6 agency for the perfomtanre of Receipt If
r list wed I'of which this lemni,is iouid(Sec.3097,Civ.CJ
Q U Landon Name TOTAL:
�-r Lenders Address TOTAL:
L. I certify that I have mad this application and slate that the above information is BUILDING FEE
..i (0!) correct,l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U building construction,and hereby aohorim reprewmatives oflhis city tocramupontbt SEISMIC FEE
ahavemcntioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hmonlea the City of Cupertino against ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way¢cane against said City ALTER OR ADD TO M ECIL
in emocymerse of the'tuning of This permit. PLUMBING 12E
APPLICANT U RSTAN AND WILL COMPLY WITH AL1,NON POINT AIR HANDLING UNIT(To 10,000 CFM)
SOURCES MECHANICAL THE
is-�Y f^9 AIR HANDLINGIINIT(OVER 10,000CPM) CONSI RUM ION TAX
Sig eo pplicamucom Tato Data EXHAUST HOOD(W/DUCO 14OUSTNG MITIGATION FET!
HAZ RI U MATERIALS DISCLOSURE
Will thea adding occupant store or handle hareadaus material HEATING UNIT(TO I Widen BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade.Section M532(a)^. HEATING UNIT(OVER 100 olat if X)
[IYes E]No VENN'l1.AT IONFAN(SINGLE RESID) PAID --
Disc Rcwga#
Will the applicant ter future huildi rg secupma use equipment or devices which
nit hnrordous air contaminants as defined by the Bay Arco Air Quality Management BOILER-COMP(3HPOR 100,0X0 BTI))
TOTAL:
DWrivil
E]Yes 11 No BOILER-COMP(OVER 100.00 BTU)
I have d,ha hamNoas oscdmq
als uinmems under Chapter fi95of The Cali- AIR CONDITIONER ISSUANCE DATE
fomia health&Safely Cade,Sections 25505,25533 and 25534.I understood and if The NI!W RESIIIEN'rIAI.MECH. SQ.FT.
building des not comnlly have a mount,that it is my responsibility m notify the occupnm
of the requirements which must be mel prior to issuance of a Certificate of Occupancy.
Owner m iental sed agent Date TOTAL: ISSUEU BY:
OFFICE