30045APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
PROJECT IDENTIFICATION
PERMIT NO. ^ s
30.;
4 ® JJ_.;BUILDING
145
BUILD[N A R
O C-6kIPUS CAW,
SANITARY NO.
APPLICATION SUBMITTAL DAT
OWNER' NA E: PHONE:
CONTRAC R'S NAME: LIC NO:
N/Cf
❑
CONTROL #
ARCHITECT/ENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
It 9�41_0_
❑Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
HA 04 Z
W
U U
F Z W
F-< a
O Z
A
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) ofD' 3 of the Business and Professions d and my license is
in full force a eff _
License Clas Lic. #
Date Contractor
AR CT'S DECLAR ION /
I understand my plans shall be used as public records
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
El SFDWL ❑KITCHEN REMODEL
E] ADDITION ❑ PLUMBING RE-PIPE
❑ MULTI-UNIT ❑ STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEL/REPAIR ❑ DEMOLITION
❑ OTHER
PERMIT ISSUANCE r O
APPLIANCES -RESIDENTIAL
PANELS
UP TO 200 AMPS
E,
W
a
W W Q
3 a EU-
w0 V
aprior
G� A
o �
W ^ n
F Z
W oo
Licensed Professional
OWNER-BUILDER fr DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property 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
sale. If, however, the building or improvement is sold within one year of completion, the
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
El am exempt under Sec. , B & P C for this reason
201-1000AMPS
OVER 1000 AMPS
` SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
IF
TEMP. METER OR POLE INST.
COMMERCIAL:
El NEW BLDG/ADDITION El DEMOLITION
El TENANT El FOOD SERVICEIMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR SQ FT.
SQ. FT. FLOOR AREA
$/SQ. FT.
TOTAL: rfif Q 0
QTY, PLUMBING P FEE
PERMIT ISUAN .J
ALTER - DRAIN & VENT - WATER (EA)
ZZ
O
r.r V)
E"t ?
WH
Z
U O
L>~ H the
O U
0 U
HVI
U Z
0-4
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
MyWorkaffr1l ante carrier and Policy n e a
Carrier: Policy No.: , O
CERTfFICATEO EXEMPTION FROM WORKS S'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Workers' Compen-
sation Laws of California. Date
Applicant
VALUATION
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOF, AREA, COND.
STORIES
TYPE CONSTRUCTION
FIXTURES - PER TRAP
GAS - EA. SYSTEM-1 INC. 4 OUTLETS
OCC. GROUP
APN
GAS - EA. SYSTEM -OVER 4 (EA)
GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE TRAP
PLANCHECK FEE
SEWER - SANITARY - STORM EA. 200 FT.
ENERGY FEE
WATER HEATER WNENT/ELECTR
GRADING FEE
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, )'on should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
WATER SYSTEM/PREATING
SOILS FEE
WATER SERVICE
PAID
Date Receipt #
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
TOTAL:
1 certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTAN ND WILL COMPLY WITH ALL NON-POINT
G — J I -
r
QTY. MECHANICAL PERMIT FEE
BUILDING FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL ECHANICAL FEE
AIR HANDLING UNIT (OVER 10.000 CFM)
CONSTRUCTION TAX
S' ure of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes ❑ No
Will the applicant or future building occupant use equipment or devices which
nit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes ❑ No
I have read the hazardous materials requirements under Chapter 6.95 of the Cali-
fomia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the
building does not currently have a tenant, that is responsibility to notify the occupant
of the requirements which must be me[ prior to issuance of a Certificate of Occupancy.
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID
Date Receipt #
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR 100,000 BTU)
TOTAL:
BOILER - COMP (OVER 100,000 BTU)
AIR CONDITIONER
ISSUANCE DATE
//�
`/
�J�-
ISSUED 134 - �= ` -
NEW RESIDENTIAL MECH. SQ. FT.
Owner or authorized agent Date
TOTAL:
OFFICE
BRAIN POWER SIGN ELEVATION: 191'i0 5TEVEN5 CREEK BLVD. ORCHARD VALLEY CENTER CITY OF CUPERTINO
BRAIN POWER
5" THICK INDIVIDUAL CHANNEL LETTERS, NEON FOR INTERNALLY ILLUMINATION. /49 --
ORANGE #2119 PLASTIC FACE WITH GOLD TRIM -CAP, RETURN PAINTED ORANGE
5CALE:3/&"=1'-O" PATE:6-(5-96
uvu�•n �
I vJi,no..
--DPI AN110WER uccr.u. --
19710 5TEVEN5 CREEK BLVD
20'-O"
STORE FRONTAGE
#10a'SCREW
'W
Rif
1408/280-6500
MIN. 3 PER
fAx408/280-8700
APPiIOV'0 \
PLASTIC FACE
HOUSING \y_
sAN _ - -F cA. 95125
NEON TUBE
SHEET METAL
TRANSFORMER
RETURN
ii
— l✓
■no1sY
ponos o.uos �
uvu�•n �
I vJi,no..
--DPI AN110WER uccr.u. --
19710 5TEVEN5 CREEK BLVD
20'-O"
STORE FRONTAGE
#10a'SCREW
'W
Rif
1408/280-6500
MIN. 3 PER
fAx408/280-8700
APPiIOV'0 \
PLASTIC FACE
HOUSING \y_
sAN _ - -F cA. 95125
NEON TUBE
SHEET METAL
TRANSFORMER
RETURN
INSTALLATION DETAIL
APPROVED �I
ORDANCE WV.- L,
NO CODES AND ORDINANCES BUILDING ELEVATION:
this set of
pans and specifications MUST
be kept on the job at atl times and it is un
lawful to make any changes or alteration
)n same without w' 11161) permission from
he bul,ding Dept,, City Of Cupertino.
i
rhe stamp;ng of th.s Pel ttno.
SHALL NOT be tie P.r,n `1)d specification
Ipproval of th , ,• d .t� Pe mit or to be Ory
TIG= ..n Of any prokisiM
APPROVAL: DATE: Pk&EtP 1181 re 1)r c#.+„ 1 _�—
All dcoigr-, & art works belong to Allen 5ign5 any duplication i5 prohibited. COPY RIGH 1T 996
'
1408/280-6500
-
C
fAx408/280-8700
1932 ST'OA'E AVE.
sAN _ - -F cA. 95125
StatE ' : se # 505655