00010119 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY b 6Q l V I
CITY OF CUPERTINO - BUILTNG-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB MECHANICAL
BUII,DINGIIROJECTIDENTIFICATION
BUILDING ADDRESS: SANITARY I. 1
A [CATION UBMITTALI DATE
V � -2 / 'Za-D dal
OWNE " AME: P[ NE: NTRACTOR'S NA E: LIC
NO
NIC COST ROL#
IHITIiCT/ENGINE[R: LIC NO; ADDRESS: 1r ❑
CONTACT: PHONE: r BUILDING PERMTF INFO
❑ Consultant Foes Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
210 ❑ ❑ ❑ w,LICENSED CONTRACTOR S DECLARATION •.
1 hereby affirm fort l.,it ee,aed coder trot a moa r.r Chapter 9 for QTY ELECTRIC PERMIT FEE,n ne,e ng ,.-. JOB DESCRIPTION
FW-=woZ with Section of Division J of the Business and Professions Codd and n license is PERMIT ISSUANCE RESIDENTIAL,
h S
in full force and df
CF b BS'FDWL ❑KITCHEN REMODEL
<UyV L License Clnss Lich Conuactor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RIiPIPE
h 4 Dom
'Dan ARC]IITECT'S DECLARATION PANIiI.S ❑MULTI-UNIT ❑STRUCTURAL.
Z p y Z 1 understood my plans shall be records MODIFICATION
town as public
N in UP TO 2M AMPS
Z p ❑INTERIOR 0 CHIMNEY REPAIR
H W Licensed Professional 201IIHMIAMPS IMPROVEMENT E]SWIMMING POOLS
Fg F a OWNER-BUIIAER DECLARATION OVER best AMPS ❑BATH REMODEL/REPAIR El DEMOLITION
CC< I hereby affirm that I nm exempt from Ne Cnmrvamr'S Le vase Low fur the �
kL U following mason.(Section 7071.5,Business and professions Code Any City or county SIGNS ELECTRICAL ❑OTHER
W 3 k y which mquhcs a pencil to construct,alter,improve,demolish,or repair any mruaure e' (�
prior to itsissuance,also requires the applicant lot such permit o file a signed ntatemem SPECIAL CIRCUI'PMISC.
9999' } that he is licensed pursuant to the provismns of me Communes License Law(Chapmr9
�OC (etmmmteing with Section 700t1)nf Division 3ofthe Business and P..fsoiom Cn let or TEMP METER OR POLE INST. COMMERCIAL,
Q.6 e that he is cxcmpt theierrom and the basis far the alleged exemption.Any violation or 0 NEW BLDG/ADDITION 0 DEMOLITION
Section 7031.5 by any applictmtfor a permitsubjects the applicant o a civil penalty or POWER DEVICES
than five hundred dollars($51K1). ❑TENANT ❑FOOD SERVICE
F'Z} not mote IMPROVEMENT
60Lolliew Owner of the property,nr my employed withered as their sole mi4.R mos, SWIMMING POOL ELECTRIC
� ❑ will do the wnrk.rndthexwemmis nnlimendW ornfferel fnrsolc fSw,7(W4,Buxinecs ❑DTHI'.R
a3$ and Professions Code:The CaronLicense Law does not apply to —act t of OUTLETS-SWITCIIF.S-hIXTCaronipnperty 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 NEW RVSIDENq'IAt,E,tiC9'R
Coe
sale.If,however,the building or improvement is sold obtain one year of completion.the Q.FT. ORAREA $/SQ.FT.
own
er-hullder will have the burden of proving that he did not build,,r improve forpmr-
pnu
1,mew. of the pmpeny,am exclusively comooda,with licensed contractors to TOTAL:
construct the projea(Sec.9(94,Business and Professions Code.)The Contractor's Li-
cense law does not apply to an owner of property who builds or impmvd thereon.and QTY. PLUMBING PERMIT FEE
wIv,contracts forsucb projecla wim mamelcroo licensed purstnmt to the Conbactors
License law. PERMIT ISSUANCE
0 1 am exempt under Sec ,B&P C for this reason
ontrAINER-DRAIN&VENT-WA1ER EA) VALUATION
Date
WOR KERS COM PI7NSNI I ON DECLA RATION BACK FLOW PROfECT.DEVICE
1 hereby affimt under penalty of se jury one of the following declarations:
I have and will mainmine Certificate of Consent,,self-insure for Wodrs Compete DRAINS-FLOOR,ROOF.AREA,COND.
sation,as pcouled for by Section 3700 of the Leh...Code,for the performance of the STORIES CONSTRUCTION
work far which this permit is issued, FIV URFS-PER'TRAP
and will maintain Worker's Compensation Foriumee,toss required by Section
J of the lab,,Code,for the pcafrmancec,f Ne work for which this permit is issued GAS-EA.SYSTI3M-IINC.4OUTLE'IS OCC.GROAT' �� A9Ne7
My We
Cnmpeneauon nwrance carrieran
oli Policy ryynl iriyj�w.� GAS-EA.SYS"rEtvTovf 4(IiA) 1 G�
Cameo Policy No.:FI 7��i0a{O y
CERT'IFICA'TE F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
1'Dtis section neeJnot hecontplowl ifthepmait is foronehundmildollan(5100) >,a . ' +BUILDINODIVISION PERS a
nr less,)
GREASETRAP PLANCIIECK ME
I certify threat the ped.roccuse.ofthe work for which this permit is issued lshall SEWER-SANITARY_Sr FORM LA.2W FT.
call employ any person in any manner,,as to become subject to the Worker,Compen- ENERGY FEE
,z sation laws nl'California.Dom WATER DEALER WHEN DELECTR
7�0 Applicant GRADING FEF.
q ti NOTICE TO APPLICANT:If,alter making this Certificate of Exemption,you should WATI7R SYSTEM/IREA'1'INO
a ' become subject In the Worker',Compensation prov,mr,or the Labor Coale,you must SOILS FHE
forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
CONSTRUCT is a 1lONLENDING AGLNCY NEW RESIDENT IAL p1.MB. SQ.fT. PAID
C_) p lhereby farwhiaffirmht this
that isaco (Site 3nlending agency for the performance n( Date ReceiptM
thewnrk for which this permit is issued(See.7097,Ci,CJ
IIUttder,Name TOTAL
,ca :
W lender's Address TOTAL:
1... fy T certify that 1 have rcnJ this application and state that be above information is -. BUILDING PEE
C. m correct,I agree to comply with all city and county ordinances and state laws relating ,, QTY , MECHANICAL PERMIT -FEE
`f. building constmnion,and hereby outhonze representatives or city to enter mann the SEISMIC FEE
above mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m eve,indemnify and kccp harmless the City of Cuperfro ngnim, ELECTRIC FEE
liabilities.judgments.costs and expenses which may in my way accrue against said City ALTER OR ADD TO MECH.
nseyuence of the graining oft permit -'PLUMBING_FEE _
In CO
APPLICANT UNDBRS \NDS WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 10,004)CPM) I
SOURCER IfLAT10 / A11iGHANIGAI.FEE
AIR HANDLING UNIT(OVER III,(toII CFM) l CDNSTBUGTIQN'TAX U
IN
Signature or ApplintMComrmtor Drum EXHAUST FOOD(W/DUCF)
HAZARDOUS MATERIALS DISCLOSURE MO tAl'
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 1 f111A00 B'rU)
un defined by ibr Cupertino Municipal Code,Chnptvr 9.12,and the Ilmthh and Safety
Crile,Section 3553200 HEATING UNIT(OVER IW.OW BTU) -
0 Yen
VEN FILA'I'[ON FAN(SINGLE RESIDI •, FAID-
--f>n -kesei in_
WII the applicant or furore building by the Bt use co Air u or devices which BOILER-COMP(3HPOR 100,000 BTU)
it huzard0mn'air comuminums as define)by the limy Arco Air Quality Management TOTAL:
)imrinO Y� - / BOILER-COMP(OVER 10)(1.000 BTU)
1� zit
I have read the ha orkms materials requirements under Cha for li 95 of the Cali AIR CONDITIONER
quircmcn p ISSUANCE D TF.
fnmie Health&Solely tlyhaea crica255115,ismyend sp25534.I to notify the
tbal Bthe NEW RP.SIIIEN'fIALMliCfl. SQ.Pr.
of thengdoes
ume, hick haveamnet promo ismyrcipmsiiilirymnotifythupant,m zC�p
or the tryuimnsnts which roust be amt prinno isocentre of n Cenifiente of Occupancy. ( F'
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE