S 2153 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUR.DwG.ELECTRICAL PESIT No. 2153 153
BUILDING DIVISION APPLICATIONIPERMIT PLUMB NG-MECHANICAL \J
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'PI'AL DATE
OWNER'S AME: (� f:: — CONT ACTOR'S NAME: LIC NO: /
XpfY N/C CONTROLp
y SR ITEC[/ENOIbl LIC NO ADI FSSL]PH
CONTACT: ONE: I BUILDING PERMIT INFO
❑ Consultant Fees Pard by Applicant(Initial) BLDG ELECT PLU�M(1j MBCA
❑ ❑ YJ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 herehy affirm that I am licensed under provisions of Chapter 9(commencing JOE DESCRIPTION '
❑aZ with Section 9000)of Divi.von3.1 the Business and Professions Code,and my License is
Op in fall force and¢Bear PERMIT LSsugrvcE RESIDENTIAL,
�UV License Lica# ]SFDWL [I KITCHEN REMODEL
F 7jW Dam Cnnlraar APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
pN.,S¢p ran ARCHITECT'S DECLARATION PANELS ❑MULTI-UNI1' LI STRUCTURAL
OZ.`n+z l underecndmy plans shall be used as publicsmtc n
IJPT02W AMPS MODIFICATION
❑ El El CHIMNEY REPAIR
a
Licensed wnxd Professiomd
- 201-1000AMPS IMPROVEMENT SWIMMING POOLS
p, OWNER-BUILDERDECLARATION
ereyorteohm 1 at warrant fail.the ConrmetuLicense Law fr rhe OVER IOW AMPS - E:)BATH REMODEUREPAIR ❑DEMOLITION
3 toy Er Tallnwing reason.(Semis.9031.5,Business and Potassium,Cado:Any city or county SIGNS ELECTRICAL ElOTHER
❑
sip .Inch requires a perms to construct,ulna intpmve,demolish, ,,repair any immune Q
o" primm as iA...ce,oleo wrong,the applicam(mithpumJr m file so,aedsmrement SPECIAL CIRCUITIMISC.
rbar he is licensed pursurnt to the provisioneofiM1e Contractor's License Low(Chupwr9
(mmmatci.g with Section 7000)of Dmvmston 3 ofthe Businessand Professions Crit TEMP.METER OR POLE INST. COMMERCIAL'
that he is exempt therefrom:mJ the basis far the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑U-MOLGUON
iC^V. Section 01131.5 by any...licam fora Isamusubjects rheupplimnt mnenalpenaltyin POWER OHVICHS
❑1 rc'y . ors than five hundred dollme($500). El TENANT ❑FOODSERVICE,
arm
Q I,mownerof rhe mann
IMPROVEMENT
❑ ❑ trope y yemntendes withroffered for 044,Bsiiess SWIMMING POOL ELECTRIC
will dorhework,and tueamamreistor's Livens Lawdosnotl apply to
owner of ❑OTHER
"m and Professions Code The rose,fewer,License Law docs not apply ro on owner of OUTFurs-SWI"[COBS-FIXTURES
properly who builds nr imprdvth thereon,and who docs such tint¢himself or through
his own empbyem,,Provided obit such improvement
issold
within are nor intended or pd'cred lar NEW RESIDENTIAL.HhECTk S
Bale.LLlnwevegrheve th.burden fprovint ithalheidoneyen ildoriprovetfogrhe SQ.IT.FLOOR AREA $ISQ.FT.
nwneofare.) will have the burden of paving that he did not build or improve fitrpur-
pose of sole.),
❑ Las owner of she property,am exclusively Pontrnaing with licensed urtra cars m TOTA .
01
mss La the es not (Sec.9(140,Business a end ny who Potassium.Codei no Gmwaon, Li-
sscLawJtsforsapply roaswithaofpncpenywhosedporlmpmveethereon,and QTY. PLUMBING PERMIT P.
who nsacorea for such projects with a contractions)licensed pumuamm the Contracmr'e
License Law. PERMIT ISSUANCE
❑ lam exempt under Son. ,B&PCfor this reason
I Owner DoleALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTE �V CE
I herehy affirm under penalty of perjury one of the following declarations:
I have and will maintain a Centeare of Comenuo self-insure for Worker's Compere DRAINS-FLOORR ). RE.A,C �, FJ STORIES TYPE CONSTRUCTION
,mi.n,as provided far by Section 300 of rho Labor Code,far the performance of the
far which this permit is issued. FIXTURES-PER TR
w I he-and will malnumn Worker's Compensation loomerce,as required by Section
-]W rfthe Labor Cad0.for the Ferformnnceohbe work rnr whicM1 Ibis pemtil is isued. OAS-HA.SYSTEM- .4 SIJQnnJLJJ OCC.GROUP AM
MY Werkcmwm � µn �
GAS-EA.SYSTEM- FR4(HA)GrPolicyN / o
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMP17NSATION INSURANCE GREASIINDUSTRW SIE INTERCEPTOR
(This secriro nerd nor be complasd d the Femur is[Drano hundred della ns($100) BUILDING DIVISIQN FEES
or less) GREASE TRAP PLANCHECK FEE
I wnil'y that in the performance ofthe work ter which this permit is issued,L shall
not employ an y SEWER-SANITARY-STORM EA. FT.
p of California.
in an mennersu as mheusmeauhjecnothe Workerx'[oaten- ENERGY FISH
,7., smisn Lvws r[Celifomiu.Date WAI RE HEATER WNENT/HLF.COO
OZ Q NOT(am GRADING FEE
yNOTI
CE TO APPLICANT If,otter making this Certificate of Exemption,you should WATER SYSTEM/1'kF.AI'INC
become suompyrhe Worker's Corns or the, arouse.of theLabor Cade,you must SOILS FEE
L11 forthwith comply with such provisions or this permit.hull be deemed revoked. WATER SERVICE
Q
_ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT PAID
UQ (hereby affirm rhnuhueis econhwction lending agency fw tuc Isal rmvncc of Date ipo#
fL Hthe work for which this permit is issued(See 3099,Civ.C)
Loaders Name TOTAL
O W Leader's Address TOTAL, a
FFFf��� 1 certify that 1 have read this xpplicauon and score tsar rhe mage information is BUILDING FEE
Fr ul merger I.,rcem comply with at]city ad warty mdlnanmsand state lasrchnin,m QTY. MECHANICAL PERMIT FEF.
buildirgmastrucriom and hereby aathnrize rcpmsemtives of bischy locale,upon the SEISMIC FEE
above mentioned property for inspection purposes.
(Wed agree to save,indemnity and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
Iiabilities.judgmenrs,costs and expenses which may in any way same against said City gl:fliR OR ADO TO MECH. PLUMBING FEE
in rusequence of the gaming of this permit.
its Vc) "10
APPLICANT NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO 10,000 CPM) MECHANICALFEE
SOURC .S /J' AIR HANDLING UNIT(OVER 10,00 CFM) CONS TRUCI'[ON'I'AX
mreofN tcaM6.On¢amrr 2 '-Date % EXHAUST HOOD(W/DUCU
HAZARDOUS MATERIALS DISCLOSURE. HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hozeNous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)p HEATING UNIT(OVER 10,000 BTU)
E]Yes ❑No VEN"ORATION PAN(SINGLE RESID) PAID
Dom Receipt#
ssmousll the applicant orruture building y the rl Buy Area
AirQntotdevice, huchManaement BOILER-COMP(3HPOR 100,000BTU)
air hazardous ait comvminanrs as defined by the Bay Area Air Quality Management /rk
DixrricrP
XK
❑Yex ]Nu BOILER-COME(OVER 00.00IBTU)
I have wad fee hanardous materials requirements under Chapter 695 oft alr AIR CONDITIONER ISSUANCE DATE
forme Health&Safety Cade,Sections 25505,25533 and 25534.1 undenied that if the NEW RESIDF.N'FIAL MECH. SQ.FT.
building does not is which have a tenant,tsar o i,s ua ce minsCertiy re notify tuc mcupam
.rise requirements which mustMma prior rr issuance min CcrtiErare of upon y. � z�r9 ,
Owner or authorized.gem m TOTAL: ISSUED BY: 7-!q
OFFICE