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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
IIUILDING PROJECT IDEXI'IFICNI ION
PEK`p1ITNO. --
V 1216
BUILDING ADDRESS:
all4/'
SANIIARYNO.
APPLICATION SUBMITTAL DATE
qA
OWN". NAME:
A
I'HONl'.:
CONI'RACTOR'SNAME; LIC NO:
NIC
CONTROLk
❑
ARCHITECT/ENGINEER: LIC NiO:
ADDRESS:
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
I.ICFNSI?DCOSnRd amIc SDECL'ra`CmN
I hereby err m mm ;air Imenxra under pmvisiin.a it enapter 9 (cimmneneing
QTY, ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE
with sction]IXNp of Uivision3of the Nosiness and PmfessionsCNe. and mylicense is
in full fnrccted effect.
RESIDENTIAL:
0SFDWL O KITCHEN REMODEL
APPLIANCES—RESIDENTIAL
License Class Lie.p
Dae Conaomor
❑ADDITION El PLUMBING RF: -PIPE
EI STRUCTURAL
MODIFICATION
❑INTERIOR O CHIMNEY REPAIR
IMPROVEMENT ❑SWIMMING POOLS
ARCHITECTS DECLARATION❑MULTI-UNIT
1 understand my plans shall be used as public records
PANELS
UPTO gal AMPS
LicenuJ Professional
201-1000AMPS
OWNER- BUILDER DECLARATION
1 hereby affirm that I am exempt from the Counicam'x License Law for the
following reason. (Sectors 7031.5, Business and Professions Cute: My city or county
O BATH REMODF.IIREPAIR ❑DEMOLITION
❑ OTHER
OVER Iax)AMPS
SIGNS ELECTRICAL.
which rcquim. a .am conswe, afar, impmve, demolish, or repair any nmetme
nor
poor o its issuance, also requires the applicant for such panni, to file a signed waremenl
SPECIALCIRCUIT/MISC,
,bathe is licensed pursuant o the pmvLrlos of the Contractor's License Law (Chapter 9
(commencing with Section ]0a,)of Division 3 ofthe Business and Professions Code) or
TEMP. MIUTROR POLEINST.
COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption, Any violation of
0 NEW BLDG/ADDITION 0 DEMOLITION
Section 703 IS by arty applicam fora Permit schic,asom npplicanuo a civil penalty of
not mare than rive hundred Jolles(45(10).
'. 01, as owner oflhe property, or my employees with wages as their sole compensation.
I will du work, and the structure is not intended of offered for sale (Sec. Business
ut
POWER DEVICES
[I TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
SWIMMING POOL ELECTRIC
and Profusions Cove: The Contrrearrs License Law does not apply in an owner of
property who builds or improvers Neuron, and who does such work himself or Through
his own employees, provided that such impmvemems are not intended or offered for
code. If. however. the building or improvement is sold within one year ofeemplation,the
OUTLETS — SWITCHES — FIXTURES
NEW RESIDENTIAL ELECTR SQ PT.
SQ. Fr FLOUR AREA
8/SV. FT.
owne,latilder will have the burden of proving that he did not build or impmve for pu,
Faw of sale,.
1, at owner of the prorcny. am exnnsively cunfacfng with Itemised contruuns or
PA
D
TOTAL
xtmet the project See. IIW4, Business and PmBsinns Crude:) The Contract
came Use docs not upply to on owner of property who builds or improves thereon, and
QTY, PLUMBING P• MI FEE
who contracts for such project+ with a contractions) licensed Pursuanuothe Cnmrenor'e
License Low.
01am pt under. .R&PCfonhis reasonOc
�� ^ry0
PERMIT ISSUANCE
ALTER — DRAIN & VENT —WA .
/- fVYLUA'1'ION
Ch U
Owner Dam
WORK17R'S COMPENSATION DECLARATION
BACK FLOW PROTECT. Of
I hereby affirm anter penalty of Perjury one of the following declaration"
0Ihave and will maintain oCertihwm of Cumenuosclf-Insure for Workers Contpen-
DRAINS— FLOOR, ROOF, ARfA, COND.
S'T'ORIES
'I YPII CONSTRUCTION
came, its provided far by Section 3700 of the Labor Code, for the Performance of the
work for which this Permit is issued.
FIXTURES — PER TRAP
❑ I have and will maintain Workers Compc rsation Insurance, as required by Section
3900 of the labor Coic, Pio the performance of the work lin which this Perini, is Issued.
GAS—EA. SYSTEM -I INC. 4 OUTLETS
OCC. GROUP
APN
My Workers Compensation Insurance cancer and Policy number are:
Cartier: Policy No.:
GAS — F.A. SYSTEM OVER 4 (EA)
GREASEIINDUY11RL WASTE INTERCEPTOR
CERTIFICATE, OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FRES
(Thisseclionneed nm hecompicted if the Penni, is forone hundreddollan(SlaO
or Ies.)
GREASETRAP
PIANCHECK FEE
SEWER — SANITARY — STORM EA. 200 FT.
ENERGY FEE
Icertify that in the performance offs, work lot which this permit isissned.I shall
nm employ any person in any manner m as in become subject to the Workers' Camper-
WATER 1117ATER W/VENT/ELECfR
GRADING FEE
' sation laws of Califomia. Date
Applicant
NOTICE TO APPLICANT: If, after making this Cmdricac of Exemption, you should
become subject le the Workers Compensation provisions of the IaMn Cale, you must
WATER SYSTEM,TREATING
SOILS FEE
WATER SERVICE
forthwith comply with such provisions or this pemtilshull be deenaJ revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that is a constmetine lending agency for the performance of
tt
PAID
Dae R"ceiplN
NEW RL•SIDENTIAL PLMH. SQ, FT.
1^1'
the work for which this permit is issued (Sec. 3097, Civ. C.) '
Lender's Name
TOTAL'
LendersAddress
1
BUILDING PIiE
I aniry that I Imer rend this opplicaron and time that the above information is
I cone". l agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby authorize reprresenmlives of this city m enna men the
QTY, MECHANICAL PERMIT FEE
SEISMIC FEIi
PERMIT ISSUANCE
mr,woaroured Property far inspection pmm v,.
(We) agree m xava mammary and keep harmless the City of Cupertino againstB_ERIC
PIIS
ALTER OR ADD TO MECH,
PLUMBING FEE
ems. costs and which may in any wnynece egounu.mid City
liabilities,judgmry
of the granting if this permit.
AIH HANDLING UNIT (TO I0,000CPM)
MECHANICALFEE
UNDERSTANDSAND WILL COMPLY WITH ALL NON -POINT
SOIIRC REGULAT .' .
2
1112
AIR HANDLING UNIT (OVER 10.000CFM)
CONSTRUCTION T
Si,maJoeof A,licam/Contureamr Data
EXHAUSTHOOD(W/DUCT)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT 00100,000 BTU)
Willthert,hem, nr furore building occupantnoreor handle hamrdous material
as defined by the Cupeamm, Municipal Cede, Chapter 9.12, and the Health and Safety
Cede. Section 25532(a)9
HEATING UNIT (OVER 100.000, BTU)
VENTILATION FAN (SINGLE, RESIDE
Yes No
� �
PAID —Date Recciptk
Will the applicant or future building necup to use equipment or devices which
emit hardous air contaminants as defined by the Bay Area Air Quality Management
m
ROLLER—COMP (31iP OR lal,txx) RTU)
TOTAL;
n
Dmcl^
O Ycs ON.
BOILER — COMP (OVER 1110,000 B'HJ)
AIR CONDITIONER
1 have read the hamrdous ma¢rials requirements under Chapter 6.95 of the Coli.
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. IT.
forms Health & Safety Gyle, Seen... 25505, 25.533 and 25534. 1 understand that if the
building does not currently have a small, Nat it is my responsibility to notify the remains
of the requincrat which most he met prior to issuance of a Cenificale of Exempt.,
�.�/L
"�/Ja�(I`J�\/1�
ISSUED BY: ��
TOTAL:
Ownerorn ffirrozed agent Data
OFFICE