29945 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING . ELECTR
BUILDING DIVISION APPLICATION/PF.RNIT PLUMBING. MECHA
BUILDING PROJECT [DEN
CONTACT:
❑ Consultant Fees Paid by Applicant (Initial)
WO O OZ
aacUU
tiZW
ZOy?
O Z 4 O
F .N..F. a1
C Q
L 06 U
3 R'y¢
F'LL0.4
to
ily
fydC�0
ILK e C
,MV,
L=<
p. Q
T 3 m
lhcmb Term 'hat lam licensed entero provisions of Chapter (commencing ues.lnoav
y a
with Section 7010)of Divldon3 ofare Businessland PonfessionsCode,andmy licensees
in full furca end c[fat.
License Clan. Lic.p
Dam Contractor
QTY. ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES — RESIDENTIAL
ARCHITECTS DECLARATION
I understand my plana shall he used us public records
PANELS
UPT0 2M AMPS
LieneeP
,[ mfeasional
OWNER -BUILDER DECLARATION
1 hereby vffrnn that 1 ant exempt from the Contract.'. License Law for the
following moson. (Section 7031.5. Business anal Profevame, Cade: Any city or county
which centric, a #email m co luenct, race Improve, demolish, or repair any stmcture
prior to its issuance, also requires the applicant for such permitto file a signed damment
that by is licensed pursuant it) mm
the pvrsnsi of the Commerce's License Law (Chapter 9
Bnmmencing with Section ]IKKgnf Division 3 ofthe Business and Professions Code)or
that he is exempt Iherefmm and the basis for Ne alleged exemption. Any violation of
Section 7031.5 by any applicant fire a permit subjects the applicant to a civil penafy of
n more than five hundred dollars ($50 ).
❑Las owner ofthe pmpcny, or my emplmyen wilt surges ns their sole compensminn,
wN Jo the cions and the he Corr s not eme, Law doesof apply to an Business
Code: The over dwhrt.. Llama Law does urn apply s if owner of
end enyProwho
property who builds or improve. thereon, and who does such work himself or through
2111-1(X18 AMPS
OVER HXMAMPS
SIGNS ELECTRICAL.
SPECIA L Cl RCUIT/MISC.
` TI7MP METER OR POLE INST
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-5WITC .S—FIXTURES
FEE
his own employees, provided that such improvements arc not intended or offered for
NEW RES A i 1 ELECTS SQ FT.
able. If, however, the building or improvement is sold within one year of camplcumn, the
ownwintoulder will have the burden of proving that he did not build or improve for par -
pee of sale.).
TOTAL
❑ 1, as owner of the property, am exclusively contracting with licensed contractors u,
mramort the project (Sec. 7014, Business and Profession. Code:) The Contractor's Li-
QTY. PLUMBE
censeLaw does red apply ill unowner ofproposy who build or impmvcs thereon. and
who contracts for such projects with a commissions) licensed pursuant to the Commences
PERMIT ISSUANCE
License Law.
❑ I vat exempt under Sec. ,B&PC for Nis mason
ALTER — DRAIN & VENT —W
Owner Doc
WORKER'S COMPF,NSA'1'ION DECLARATION
1 hereby offer under pastry of perjury one of the following decloralma :
BACK FLOW PROTECT. DEVICE
DRAINS— FLOOR, ROOF AREA. GOND.
❑ Ihxve and will mainaina Certifcam ofConsen, to.ell'-encore Tia Worker's Compen-
codon, as provided far by Station 37M ml the lab,. Cdr fee the performance of the
FUTURES — PER TRAP
work for which this penal, is issued
1 have and will maintain Workers Compensation Insurance, ns required by Section
3710 offle Labor Code, for the performance orthe work for which this permit is issued.
GAS — EA. SYSTEM -I INC. 4 OUTLETS
My Work roppee k�p,N :yan<e carrier and Polmyq ^py
z' GAS — EA. SYSTEM -OVER 4(EA)
,
Currier:O.Ness ls.�aJ. Policy No: �Y{ Cn,'k�
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE(INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE
(This section lived not be completed iffle permit is fur one hundred dollars ($1 W)
W less.)
GREASE TRAP
O Z
z �
I certify hat inthe performance ef,hc walk for whichthis prom, i.s,swell, Is hall
not employ any person in any manner m as to become subject to the Workers' Compere
cation Laws if California. Date
Applicant
SEWER—SANITARY—STORM EA. 200 FT.
WATER HEATER WNENOELECTR
sN..
D.1
NOTICE TO APPLICANT: If. after making thin CeniEs:ue of Exclusion. you shoat,[
become subject to the Worker's Compensation provisions of the labor Cork, you must
forthwith comply with such provisions or this permit.hall he deemed revoked
WATER SYSTEM/TREATING
WATER SERVICE
0. Q
�Z
V O
LL H
CONSTRUCTION LENDING AGENCY
(hereby affirm that there is a construction lending agency for the performance of
the work for which this preen is issued (See 3097, Civ. C.)
Lenders Name
NEW RESIDENTIAL PCMB. SQ. FT.
Q L)
F 0.
N
L) Z
Lenders Address
1 certify that I have read this application and state that the above information is
correct. l agree m comply withal) city and county ordinances and slate lows relating to
building construction. and hercbyauthoriu representatives ofthis city tocmerurym the
TOTAL.
QTY, MECHANICAL PERMIT
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless ,he City of Cupertino against
PERMIT ISSUANCE
"'.,'cel t.,n..rsandexpense, which may in any may accrue against said City
inconsequence e6rianin, of this permit.
ALTER OR ADD TO MECH.
APPLICANTUN STANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGUL, TI NS.
AIR HANDLING UNIT(TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,00(1 CFM)
Signature 'ontranor Date
c HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD OYMUC)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (QVIiR IW,000 BTU)
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chirpier 9.12, and the Ilevlth and Safety
Code, Section 25532(x)'!
❑Ycs ❑No
VENTILATION FAN (SINGLE RESID)
Will the applicant or future building occupant use equipment or devices which
emit transitions air contaminants as defined by the Bay Area Air Quality Management
BOILER—COM(' (3HP OR W,(Xp BTU)
District?
BOILER— COMP (OVER 100.000 BTU)
❑Yea ❑No
AIR CONDITIONER
I have read the hazardous materials requirements under Chimer 6.95 ofthe Cali-
Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that if the
building does not currently hove a tenant, that it is my mrponsibility to notify the occupant
of the requirement which must be met prior to isof a Certificate of Occupancy.
L:
NEW RESIDENTIAL MECH.
Uwner or vuthmnred agent Dam
TOTAL:
OFFICE
1 DESCRIPTION
„.29945
❑SPOW.
SANITARY NO.
APPLICATION SUBMITTAL DAT
Z1q�
❑PLUMBING RE -PIPE.
El MULTI -UNIT
BIC
CONTROL#
MODIFICATION
El INTERIOR
BUILDING PERMIT INFO
IMPROVEMENT
BLDG ELECT PLUMB MECH
❑ ❑ ❑
FEE
1 DESCRIPTION
RESIDENTIAL:
❑SPOW.
❑ KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE.
El MULTI -UNIT
❑STRUCTURAL.
MODIFICATION
El INTERIOR
El CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑ OTHER
COMMERCIAL
❑ NEW BLDG/ADDITION
❑TENANT
IMPROVEMENT
❑OTHER
❑ DEMOLITION
❑ FOOD SERVICE
f .a
FEE MAY 28 1996
Gil yUr_
STORIES TYPE CI
OCC. GROUT'
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGYFEE
fFEFG FEE
EF,
I Receipt#
'TOTAL
PEFEE
FEFC 'E' , FEECALFEE MITIGATION
PAID
Date Rectips4
ITYIAL:
/1ISSUANCE E
ISSUED BY:
$/SQ. IT.