S2052APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PRO.rFVT rnFntTrFrre
BUILDING ADDRESS: 56
Ivelf.)
J
cas I
OWNER'S NAME:
PHONE:
PERMIT ISSUANCE
CONTRAC
ARCHITECT/ENGIN I
LIC NO
201- 1000 AMPS
ADDRESS
CTRICAL
IRCUIT/MISC.
TER OR POL NST. l
EVICES
rp
91, 64, tMO
LIC NO:
it,.ts
CONTACT' • / _ IA PHONE: !�e� �^ ,
Oi�
❑ ConSUltantFees Paid b} Applicant (initi l)
0 Z
F W O
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LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with SccUon 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
License Cla L Lic. #
Date Contractor if, MA is
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records
QTY ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
H 4 t: W Licensed Professional
,Wj OWNER -BUILDER DECLARATION
a L+r W d' I hereby affirm that I am exempt from the Contractor's License Law for the
�' following reason. (Section 703 1.5, Business and Professions Code: Any city or county
W which requires a permit to construct, alter, improve, demolish, ur repair any structure
prior 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
Wa Q (commencing with Section 7000) of Division 3 of the Business and Professmns Code) or
G o 9 that he is exempt therefrom and the basis for the alleged exemption. Any violation of
W r. I- Section 7031.5 by any applicant for a permitsubjects the applicant to a civil penally of
not more than five hundred dollars ($5(AI ).
Q❑ 1, as owner of the property, or my employees with wages as their sole compensation,
a o will do (he, ork, and the structure is not mended ur offered for sale (Sec 7044, Businessj
LU eo and Professions Code The C'ontractor's License Law does not apply to an owner of
who builds or improves thereon, and who does such work himself or throughlits own employees, provided that such improvements arc nut 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-
1, Pose of sale.)
201- 1000 AMPS
0 AMPS
CTRICAL
IRCUIT/MISC.
TER OR POL NST. l
EVICES
rp
G P L ELECTRIC
. WITCHES — FIXTURESproperty
DENTIAL ELECTR SQ FT.
TOTAL:
❑ 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
QTY. PLUMBING PERMIT
License Law.
❑I am exempt under Sec
P , B & P C for this reason
PERMIT ISSUANCE 1
ALTER — DRAIN & VENT— WATER (EA)
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and w ill maintain a Certificate of Consent to self -insure for Worker's Compen-
cation, as pros ided for by Section 3700 of the Labor Code, for the performance of the
BACK FLOW PROTECT. DEVICE
DRAINS — FLOOR. ROOF, AREA, COND,
FIXTURES — PER TRAP
work for which this permit is issued.
NFI 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.
GAS — EA SYSTEM- I INC. 4 OLT ETS
My Worker' 'irn ens atio�,jnnurance` carrier and Policy n n are
GAS — EA. SYSTEM -OVER 'A)
Carrier f f�� f� Pohc No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE/INDUSTRL W . TE INTERCEPTOR
( This section need not be completed it the perinu is for one hundred dollars ($100)
or less.)
GREASETRAP
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-
zZ, sation Laws of California Date
Applicant,
SEWER — SA ARY — Slq)RV EA. 200,
---- �- -.
WATER .ATER W/VENtIFLBCTR
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
a+ >; 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.
w'q SYSTEM/TREAT G�
ATR SERVICE
NEW RESIDENTIAL PLMr SQ. FT.
Z: CONSTRUCTION LENDING AGENCY
U OT I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Ci,. C.)
C) U Lender's Name
W: Lender's Address
a I certify that I have read this application and state that the above information is
,
I'
7^' '"""'�'
TOTAL
QTY, MECHANICAL PERMIT
U 4 correct. I agree lu 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
t --t above-mentioned property for inspection purposes
(We) agree W save, indemnify and keep harmless the City of Cupertum against
liabilities, judgments, costs and expenses which may in any way accrue against said City
m consequence of the granting of this permn.
PERMIT ISSUANCE
OR ADD TO MECH
VI'I'I I. A`.I 11IU IrilVAIri VAli A�II t(1AII'I1 A111it VI Ar)AOfl\I
RC1 RI(d I \IH�`.ti
NDLING IINIT(TO 10,000 CFMI
NDLING UNIT (OVER 10,000 CF
lull
!!!
Signature ofApplie (/Contractor _ Date
HAZARDOUS MATERIALS DIS SURE
STHOOD(W/DUCT)
G UNIT (TO 100,000 BT
Will the applicant or future budding occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
%0(00
G UNIT (OVER 10( 00 BTU)
Code, Section 25532(a)"
E] Yes �L':Vo
VENTILATION FAN 1, GLE RESID)
Will the applicant or future building occupant use equipment or devices which
— COMP P OR 100,000 BTU)
enut ha/ardour air contaminants as defined by the Bary Area Air Quality Management
District'?
El Yes bNo
—CO P(OVER100.000BTU)I
N TIONERfomia
have read the hazardous materials requirements under Chapter 6 9S of the Cali-
Health & Safety Code, Sections 25505, 25533 and 25534 1 understand that if the
budding does not currently have a tenant, that it is my responsibility to notify the occupant
of the reyi lents which mustlb—e7met rior to issuance of a Certificategof9t ane .
cc
SIDENTIAL MECH. SQ. 8',
AAJ
Owner or aumorize9nagent Date
- -
TOTAL:
OFFICE
FEE
FEE
PESIT NO 2052 052
1 SANITARY NO APPLICATION SUBMITTAL DA"
n
CONTROL #
o-7
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ ❑
JOB DESCRIPTION
RESIDENTIAL:
❑ SFDWL
❑ KITCHEN REMODEL
❑ ADDITION
❑ PLUMBING RE -PIPE
❑ MULTI-UNiT
[]STRUCTURAL
MODIFICATION
❑ INTERIOR
CHIMNEY REPAIR
IMPROVEMENT
❑ SWIMMING POOLS
❑ BATH REMODEL/REPAIR ❑ DEMOLITION
❑ OTHER �Fl �`iAlltr
i� Iii roti._
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑ TENANT ❑ FOOD SERVICE
SQ. 171' FLOOR AREA I $/SQ FT
VALUATION
! (o go ,ria
STORIES 11 TYPE CONSTRUCTION
OCC.
BUILDING DIVISION FEES
ANCHECK FEE
ERGY FEE
ADING FEE
FEE
Date Receipt #
TOTAL.
AP"R
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
ISSUED BY:
Receipt #
UANCE DATE