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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 00 O In / ';� 9
CITY OV CUPERTINO BUILDING - ELECTRICAL
PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL
BUILDING PROJECT IDENTIFICATION'
BUILIIINGADDRESS:
1,318 -S. STS« i.�G 20. �u PF.eTi N a
SANITARY IS
APPLICATION SUBMITTAL DATE
00J
' PHONE:
A:5� _ /
CONTRACTOR'S NAME: LIC NO'.
—OWNct`/C _
we
❑
m RDLa
GTNCER: _ LIC NO:
ef
ADDRESS: -
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
Bit DO ELECT PLUMB MECH
L� !7 ❑ ❑
unORSder p DECLARATION
LICENSEDIam Braman
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
with Senon 70Okp fDivision] of Nc Business and Professions Coda and my license is
in full lbrce and effect.
Class Lich
Date—
Date ].i.#Contractor
RESIDENTIAL
❑SFDWI, ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
I PERNH r ISSUANCE
l'
APPLIANCES -RESIDENTIAL
ARCHITECTS DECLARATION
I underamad my plans shall be, used as public accords
PANELS
UP'10210AMPS
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT []SWIMMVsG POOLS
0 BATH REMODEL/REPAIR ❑DEMOLITION
El OTHER
Licensed Professional201.INw
OWNER- exempt frDECe Contractor's
1 hereby .Dion that 1 am exempt from the Cnni n, Co License Law for the
following reason (Semina 7 airless and mans Cade: Any city or county
AMPS
OVER I"AMT'S
SIGNS ELECTRICAL.
wiirM1 construct, vet de
t, Ater, improve,
a permit rc+eores mindI or repair any agned
'
r in its the h
AsorequirespooWoux.fthapplicant r sucbmiChm'mRDa comeml
Ice,(Chpter9
SPECIALCIRCUM'/MISC.
mathelsensedissuance.
that be is licensed puation7 mart of the Cnmmnm's ense Chapter9
TI!MP.SISTER OR POLE INST.
COMMERCIAL:
(kh mEhslnm
(commencing with Seainn]fK0)nf Divisinn3 of the Business and Professions Coda nr
ad Prec'sim
Nat he is exempt therefrom and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section 7031.5 by any applicam for a q:nait subjects the applicam to a civil penalty of
no lm Nun five hundred dollars(&5(10).
us owner of the proper, or my employees with wages as their sole compensation,
POW13R DEVICES
❑ TENANT ❑ FOOD SERVICE
IMPNOVEMGNT
SWIMMING POOL ELECTRIC till
will do the work, and the urumure is not imended crocheted forsale (Sec. 7044* Business
THER
OUTLETS -SWITCHES -FIXTURES
add Professions Cade: She Contmchn s License Law docs not apply to an owner n(
properly who builds or improves Nerenn, and who does such work himself nr through
his awn cmpinyecs, provided that ouch impmvemcnE am not intended or offered for
NEW RESIDENTIAL. ELECTR SQ FP.
sale. If, hi the building or improvement is sold within one year el coati the
SQ. FT.P Oai AREA
$/SQ, FT.
ownectuilder will have the burden of proving Nat he did not build or improve for pur-
pme of sAcJ.
TOTAL:
❑ I, as owner of the properly, a exclusively contracting wiN licenced contradursto
carom the proier, (See 7044, Business and Prafcssiona CMep The Commetors Li-
cense Law does misapply to an owner 0 property who hu0ds or improves thereon, art
QTY. PLUMBINGPERMIT FEE
who contracts for such projects with a con raccoms) licensed parsuanno the Contractor's
PERMrr ISSUANCE
License lace.
El I ant eaempt andXB & P C for this res�on
ALTHR- DRAIN & VENT -WAl'BE CA)
01
G 2 Us, //J�
VALUATION
/ ���
WORKS S COMPENSATION DECLARATION
BACK 171 -OW PROTECT. DEVICE
11 rebyaffirm under penalty of perjury one of the following declarations:
DRAINS- FLOOR, ROOF, AREA, COND.
I have and will maintain a Cenifii of Consent to self -insure, for Workers Compete
chin, as provided! for by Section 37M of the Labor Code, for the performance of the
STORIES
TYPE CONSTRUCTION
work for which this permit Is issued.
FIXTURES - PCR "TRAP
1 have and will maintain Wnrker'a Cnmpemeticn Insurance, as required by Section
37M of the Labur Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
GAS -G. SYSTIiM- I INC. 40U'1'LEI'S
OCC GROUP
APN
Cartier: Policy No.;
GAS - EA. SYSTEMOVER 4 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPF.NSA'I'ION INSURANCE
(Ibis section necdna be completed ifthe permit is form, hundred dollars($IIX)
or rossJ
GRIiA$P./INDUSTRI, WASTE INTERCEPTER
BUILDING DIVISIONFEE' '
GRLASE TRAP
PLANCHECK FEE
SEWER -SANITARY -STORM EA. 200 Fr.
I reirmy Nm inthe pamfonname,.Oh,work forwhich this panni, is issued.[shall
not employ any person in any manner so as to bcrome subjcet to the Workers' ComNn-
ENERGY FEE
WKI FR HEATER WIVENTrELECTR
ration Law's of Cal i!ammo. Date
Applimtm
GRADING FEE
NOTICE TO APPLICANT: If, after making this Cenificme of Exemption, you should
become subject m the Wacker Compensation provisions of the Labor Core. you most
WAT13R SYSTEM/TREATING
SOILS FEE
fmNwith comply with such provisionsonhis pennitxhAl be deemed revoked.
WATI7R SERVICE
CONSTRUCTION LENDING AGENCY
I hereby affirm that here is a consmetion lending agency for Performance of
the work for which his peri, is issued (Sire. 3097, Civ. C)
Leaders Name
f� �•/�� +( I��
PAID
�T''++
In
NEW RESIDEMDAI. PLMB, SQ. IT.
��� It Dam "'1 `Receipt;MJ
+
LeadersAddress
TOTAL:
I certify that 1 have read this application and state that the shove infurnwtion is
IIIIt DING PEE
n
T,
QTY MECHANICAL PERMIT ; FB8
nnrect. agree N comply with all city nuW county orlinunces and nate Ines relechng to
building construction, and hereby and i¢e representatives of this city to enter upon the
t
SEISMIC
FEE
above mentioned proper for inspection purposes.
(We) agree to save. indemnify and keep harmless the City of Cupertino against
PERM! T ISSUANCE
^
EdECPRIC'FEE
Iiahi lilies, judgment,ensu and expenses which may in any way accuse against said City
n yueneeu gran go P
in cis ae f [at tin fIii coni+.
ALI HE OR ADI! TO MECH.
PLUMBING FEE
AIR HANDLING UNI ITO IB(I(N) CPM)
MECHANICALFEE
APPLICANT UNDFIJSTANDS>Nfla WILL COMPLY WITH ALL NON -POINT
SOURCERF ONS.
HANDLING UNIT (OVER 10,000CFM)
2 Qa 2zAIR
CONSTRUCTION TAX
tore til Appllcan(rCnnt m —, Data
;14
HAZARDOUS MA'T'ERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT')
HOUSING MITIGATION PEE
HEATING UNIT (TO 100.00) RTU)
Will the applicant or future building occupant store or handle haeallous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532pi
HEATING UNIT (OVER 100,000 BTU)
❑Yes ❑No
PAID
VENTILATION PAN (SINGLE RESIU)
Datc' HeceiplM
TOTAL,
Wrd the applicam m lamas building occupant use equipment Qu or devices which
i, let? us air contaminants as defined by Ne Buy Arta Air Quality Management
V cl?
❑Yes ❑No
1�
1
BOILER-COMP(3HP OR 100,(00 RTU)
BOILER - COMP (OVER II10,0008"fU)
Alit CONDITWEIR
I haveread the harmonies materials is under Chapter 695 offle Cali-
re,u 533; p
ISSUANCP. DATE
NEW BISIDENI'IAI. MECH. SQ. FT.
forHealth a. safe y CMB, Secdom 25505. I, any w, 25534.1 understand for if Be,
building ]«s no achy have a hat it is my rtsgm<ibiliry, ton tifytheoccupan,
7 — ey
/ C G O'o-p
of Nem which Ccigfimy.
Z
ISSUED BY,
Own t auNonzed gem ste
TOTAL:
OFFICE