99120041C
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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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CITY OF CUPERTINO BUILDING- ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL.�ppp
BUILDING PROJECT IDFNTIF'ICATIIIN
P +IT No.
BUILDING q(>URliti& //
�n7 60 POR 11 ev�w►, MI
SANITARY N(1,
APYLICA'1'ION SUBMITTALDATf
Z—G�Q
OWN 'S AMB: �PIIQNI?: ��� \
6,l {
CONTRACTOR NAME: LIC NO:
N/C
❑
CON'IROLN
tCHITF.CTIENGINEE LIC NO:
ADDRESS'.
CONTACT: PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILUING PERMIT INFO
RLDGG HLEC'I' PITA —M1 BB MECH
R 2 ---LY ❑
LICENSED CONTRACTORS DECLARATION
1 herehy ellirm that 1 am licensed n ander provisioof Chepier9 hwom rwing
with Section ]1XXB of Division 3 of the Rosiness and Professions Crde, and my liana is
in full force and ef(ca
License Class' Dr.N
Y Date Contractor
QTY F,LEMIC PERMIT FEE
JOB DESCRIPTION
RESIDF,NTIAI:
y�.am.+{
❑SFDWL ya,Kl'1'CIIPN RHMODL'I.
El ADDITION El PLUMBING RI PIPE
❑MULTI -UNIT El STRUCTURAL
MODIFICATION
INTERIOR ❑SWIMNEY MING EPAIR
IMPROVEMIiNT SWIMMING POOLS
El' POOL
BATH REMOOIiI./Rf?PAIR (] OI3MDUTTON
❑ O'I'HEk
PERMI'1'ISSUANCE
APPLIANCES—BESIDES HAL
ARCHIT1:CTS DECLARATION
_ 1 understand my plans shall M used as public records
5
PANELS
UP TO 200 AMPS
Licensed Professional
j OWNER-IIIIILDERDE he ComrION
g - I hemby uflirm that I nm eaentpt from the Cnntracurr's hlcemso Luw Tnr the
following reason, (Section 7031.5, B.,eas and Pndecvions Code: Any elq (around,
which rcyuircx n permit m construct, alter, improve, Demolish, or repair any atmemrc
prior w it,issuance.wso ma iinesthe applicant for such permit,, lileasignegslammeat
that be is laterad pbuantpthe,mokinns ofthe Counselor., License Ww(Chapter 9
(commenting with Section]IX)a)n(Uivisinn3 of the Business anJ Prnfesxinns Crxlq or
e that he is exempt therefrom and the basis for the alleged co ;eption. Any violation of
Section 7031.5 by any applicant for a panuitsubjeas the applicunupurist Norltyof
not com than him hundred dollars ($510),
Lasocenwofthepmpeny,tnny...... eta with wages us their sale eompntxatian.
will Jo the work, anJ mr_cweure is nm inended proffered lbrs:Je (Sec. ]IN4, Business
and Professions Cele: The Contractors License Law does not apply to an owner ofOUTUTS—SWITCHES
propeny who builds or improves thereon, and who does such work himself or imaugM1
his own employees, provided that such improvements are not intended or offered for
sale. If. hpwaven the building or improvement is sold within one yew afcompletinnnhe
Ir will have the burden of proving that he did not build or improve b¢par
ppsaa a.).
as owner of the progeny, ,it exclusively comraming with licensed mmractom In
Antrum me pmjem (Sea. ]814, Businan and Profession, Code:) The Contractor's Li -
verse lawdoes net apply tp ad aammefpropeny who miles., impmvesmempn, and
whocanuacts forsuchp Projects with a comracmr(s) licensed pursuant to the Contractors
License Law.
E]I am exempt under Sec. B& P C for thiser..vn
201-I0X0IAMPS
OVI3R IINXI AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INSIt
COMMERCIAL:
❑ NEW BLDC/ADDITION ❑ UFMOLITION
❑TENANT ❑FOODSERVICE
IMPROVP.Ir,; F
❑OTHER
POWER DEVICES
SWIMMINGPOOL ELL'CT C
NEW RE4IDENTIA . 'R SQ FT.
SQ, IT, FLOOR AREA
/i � 5 ft
`T
$ISQ. tT.
TA L:
QTY PLUMBING PERMIT FEE
PERMIT ISSUANCE
AI:TI?R—ISRAIN&VBN'1'—WA'I13R IRA)
Owner Dutc.{Z' -
VA CATION
yyy
1
{ l KF.R'. COT. SATION DECLARATION
emhy ulBrm under penal) ofperjuty one of the following declarations:
,-] I heveend will maintain aCeni&ate of ConsemmalGinsum for Worker's Cmmpem
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work far which This permit is issued
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
370(lofihe Latin Code, for the pert imnan. of the work for whlclt this permit is mined.
My Worker', Conipmeation Inam'ance carrier and Policy number are:
Camay: Policy No.:
. CHRUFICATE OF EXEMPTION MGM WORKERS'
COMPENSATION ININSURANCEGREASI%INUUSTRL
(This sedan madam Is, completed Bite permit is for one hundreddollms ($100)
or less.)
I canil'y that in the pcd'armeme of the work for which is this (be W is issued, Idial l
not cm to xwrin on manner na na In hacpmc,uh'uotbo Wprkws'Com
p gong per y Ia pen-
sation Laws of California. Date
Applicant I
RACK PLOW PROTECT'. DEVICE
DRAINS— FLOOR, ROOK. AREA, COND.
STORIES
TYPE CONSTRUCTION
FIXTURES — PER TRAP
GAR -13A. SYSTEM -I INC. 4 OUT LETS
OCC. GROUP
gy PN/
p
O O�
GAS — EA. SYSTEM -OVER 4 (IS)
WASTIi INTERCEPTOR
HOILDING DIVISION M. tS
GREASE TRAP
PLANCHECK FEL?
SCWI?R— SANITARY —S'IY)RM 13A.2001rf.
IiNI?RGV FE[
WATIiR HEATER WNEM'/ELECTR
GRADING ME
NOTICE TO APPLICANT. IL aper making this Cenifcme of Exemption. youshould
become subject at the Workers Com ismanion provisions of the Labor Cade, you must
fanhwim comply with such provisions or this permit shall he deemed weaker,
CONSTRUCT ION LENDING AGENCY
I hereby want thntthere lsaamumeion lending agency for the performance of
the work far which his permit is assn al (sea 3097, Cm C.)
Lenders Name
WATER SY.YTEM/TRG'1'ING
SOILS FEE
WA'I UR SERVICE
PAID
Date Receipt#
NEW RESIDENTIAL PLMII. SQ. EF
TOTAL:
Lenders Address
I certify that 1 have read this application and state that the above information is
emet.I agree to comply with all city and county ordinances unit state laws relating to
building consmuchon, and hereby umhnriz.c repreeentmives of this city m inner upon the
above-mmmionedpmpeny ka-mapecdon poromas.
(We) agree to save, indemnify and keep harmless the City o[ Cupertino against
liabilities,judgments, costs tied expenses which may in any way accrue against said City
' ono ence nine grunting ofthis Permit.
APPLICA �INDERSTA' S AND WILL COMPLY WITH ALL NON -POINT
SOU RE UL ONS,
�Z r6 /
TOTAL:
BUILDING FEE
-
QTY. MECHANICAL PERMIT,, FEE
SEISMIC FEE
PERMIT' ISSUANCE
ELECTRIC FEE
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT (TO 10.000 CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10,00CFM)
CONSTRUCTION TAX
sure of Applinmt onract Dae?
HA9.A US MATERIALS DISCLOSURE
Willtheapplicant tore huilJing cecupwv more nrhandlc hazsNous nmtetiul
as defnN by the Ci. Municipal Code, Chapter 9.12, and the Health send Safety
Code. Section 25532myl
E] yes E) No
Will the applicant or ntsa building occupant B sew Area Air Qu or devices which
Fruit hazwdon' air contaminants w UcfincJ by the Bey Arw Air Quality Management
ilisvicfl
E3 Yes E] No
I have read the haemlous materials aradomems under Chapter 6.95 ofthe Cal i-
romia Health & Safety Code, Sections 25505, 25533 and 25534, 1 understand that it the
hui)ding more cu ntlyh.e(y�o etcnunl, that His my respansihility wordy me aceupam
al'm qulrcmc vhich met prior to issuamccnfu Ccniafewta'o'Owupancy.
g
EXHAUST HOOD(W/Durr)
110USING MITIGATION FF.E
HEATINGUNITOU100,00013 FI)
,
HEAPING UNIT (OVER Haddad BTU)
PAID _
Dale Receipt #
VENTI LAI ]ON FAN (SI NU LH RES I D)
BOILER —COMP (3HP OR IIXhOW BTU )
TOTAL:
BOILER — COME (OVER 100,000 B'IV)
AIR CONDITIONER
ISSUANCE DATE
6 /
/
ISSUED BY:
NEW RESIDENTIAL. MF,CH. SQ. 11
ot itredegerf I Date
TOTAL:
u
OFFICE