B 0147ICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-MECH ELECTRICAL MICA
BUILDING DIVISION APPLICATIONIPERMIT PLUMB R OJECTEGHANIFIC
BUILDING PROJIECI'IDENTIb'ICATION
PERMIT NO`— 0147
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BUILDING ADDRESS:
a 1 R 1 CoL_u rh a Li s A-
SANITARY NO.
APPLICATION SUIT MI'ITAL pgfl
I,
DI? 'P A ; PHO &
ONTRACfOR'S NAME: LIC NO:
N/C
❑
FT
CONTROL p
ARCHI'IECT/EIJGINEER: LIC NO:
ADDRESS:
CONTACB PHONE: �I •f �7�BUILDING
l��r ASP -Oki S'U �j S7 K"1I
❑ C9nsallan4Fee, Paid byApplicant (Initial)
PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ ❑
QTY ELECTRIC PERMiT FEE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section"K010tof Division3ofthe Businessund Professions Cale, and mylicen.se is
in full farce and effect.
JOB DESCRIPTION
R SIDDENTIAL'
❑SFDWL El KITCHEN REMODEL
PERMIT ISSUANCE
APPLIANCES- RESIDENTIAL
License Class IJc.I
Date Continuant
❑ADDITION 0PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR [_1 CHIMNEY REPAIR
IMPROVEMENT OSWIMMINGPOOLS
❑ BATH REMODEUREPAIR ❑DEMOLITION
El OTHER
ARCHITECTS DECLARATION
1 undendeal my plans shill he used as public records
PANELS
UPTO200AMI'S
1 Licensed Professional
- OWNER -BUILDER DECLARATION
1 hereby affirm that 1 an exempt from the Contractors License Law for the
t following reason. (Section 703 L5, Business and Pedmiumns Code: Any city or county
201-1DBBAMPS
OVER IBRD AMPS
SIGNS ELECTRICAL
which requires a permit to corsnal, alter, improve, demolish, -or repair any structure
-
primtoitsissuance, also requires the applicant for such Permit o file o signed statement
SPECIAL CIRCUIT/MISC.
thin he is licensed puramnuo the provisions of the Contractors Lacnu Low (Chapter Y
(commencing with Section7") of Division 3 of he Business and Prrofeuiom Costs) or
4 that he is exempt thercfmm and the basis for the alleged exemption. Any violation of
+ Sestian7031.5 by airy applicant far u permit subjects the applicant o a civil penalty of
nm inure than five hundred dollars ($50%
C I, os srvner of the pmpety, or my employees with wegesaz their sole compensation.
will do the work, and the structure is not intended or offered for sale (Sm. 70,D, Business
and professions Cdc: The Cmdourne, License Law does not apply m an owner of
TE -MIP METER OR POLE INST.
COMMERCIAL;
❑ NEW BLDG/AUDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OOTLETS-SWITCHES-FIXTURES
NEW RESIDENTIAL ELECTR SU Il'.
+ property who builds or Improves thereon, and who does such work himself or through
his own employees, provided that such improvements arc not intended or offered for
sale. If, however. the building orimpro einem is sold within one year of completion, the
SQ. FT. FLOOR AREA
5/SQ. FT.
ovener-builder will have the burden of proving that he did not build or improve for per.
TOTAL:
poseafsalen)e r of Ohc pnOpeny, am cxdusively coneacting with licensed commgtory no
_,.miner the prnjttt (Pec. 9844, Business and Prole,,ras•Counc) I he loomemr'a Li
cense Low does nm apply to M owner of properly who builds or improves thereon, and
QTY. PLUMBING PERMIT FEF.
who commie s for such projecu wird. cnnveemar) licensed pumusuit to the Convectors
License lsw.
I um caem t oder a �. H& P C fonhis o
PERMIT ISSUANCE
ALTER - DRAIN & VENT -WAI ER RA)
VALUATION '
Owner De
WOR ER'SCOMPENSATIONDECLAATION
BACK FLOW PROTECT. DEVICE
'
I here sy affirm der penalty of perjory one of the following dtt amdons:
❑ 1 hnveand willmoinmina Cenificauof Conxm to self-msum for Worker's Camper-
DRAINS- FLOOR. ROOF AREA. GOND.
STORIES
TY PF.CONSfRUC11Ot
nation, as provided for by Section 3900 of the Labor Code, for the parramunce of the
work for which this permit is issued,
FIXTURES - PER TRAP
GAS -EA.SYSTEM- I INC.4 OUTLETS
❑ 1 have and will maintain Workers Compensation Insurance, es imitured by Section
37M of the Labor Code, for the performance of Ne work for which this permit is issued.
OCC.GROUP
APN
GAS - EA. SYSTESTOVE R 4 (EAI
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
,
CERTIFICATE 017 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASEINDUSTRL WASTE INTERCEPTUR
BUILDING DIVISION FEES
GREASETRAP
PER
(This urian red not be, completed if the permit is for one hundred dollars (S I IXB
or les'.) Mix
I mitifythat in the perfarmarrecifthe work for which this permit is issued, Inha0
not employ any prison in any manner so as to become subject to the Workers'Contpon-
SEWER -SANITARY - STORM F.A.200FT.
17 ERGY FEE
WATER BEATER WNENT/ELEC R
GRADING FEB
ammer Laws of Califomia. Date
Applicant t
NoHCE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation previsions of the Labor Code, you must
y forthwith comply with such provisions art this permit shall W domed residual.
WATER SYSTEM/TREATING
WATERSERVICE
SOILS FEE
p. CONSTRUCTION LENDING AGENCY
I herebyaRmtthatthere isacximume on lendingagercyfor the performance of
the work for winch this pumll is issued (Sea 3097. Co. C.)
PAID
pate Rttcipr M
NIiW RESIDENTIAL PLMH. LII 1SQ.RI'. sir u r r ua
TOTAL
Lender's Name
Lender's Address
T(y1'AL:
BUILDING FEIi
y� I certify Nat I have read this application and gate that Ne above infsmtmian is
correct. I agree to comply with all city said county ordinances and slate laws relating to
Wilding consw<tion, and hereby authorize representatives of this city toemer operate
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
ISSUANCE
OR ADI( TO MECH.
ELECTRIC FEE
above-mentioned property for inspection puryases.
(We) agree m save, indemnity and keep harmless the City of Cupertino almost
liabilities,judgments, costs and caprnses which may many way acerae ngain9 said CityER
in nmui nam of the graining of this pcmtit,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
PLUMBING FEE
AIRHANDLING UNIT (TO H'ah" CFT17
MECHANICAL FEE
SOURCE REGULATIONS.
J"UT
HANDLING UNIT(OVER 10.000 CFM)
CONSTRUCTION TAX
Signature ofApplianUCouacter Date
HAZARDOUS MATERIALS DISCLOSURE
WiII the applicant or future building occupant store or handle harardons aroundTING
as defnd'by the Cupertino Municipal Code, Chapter 9. 12. and the Health end Safety
Cdc, Section 25532(u17
AUST HOOD(W/DULT)
HOUSING MITIGATION FEE
UNIT ITO Ip(IOM BTU)
HEATING UNI'IYOVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
❑Yes ON.
PAID
Date Itemipt#
Will the applicant or future building occupant use equipment or devices which
' emit hazardous air contaminants its defined by the Bay Area Air Quality Management
BOILER -COMP (HIT OR 100,0(0 BTU)
TOTA e E
HOILER-COMP (OVER 100,100 BTU)
Diane@
El Yea Fl No
AIR CONDITIONER
ISSUANCE DATE
n pr
1
I have read the haurdaon maeriols"mamems under Chapter 695 of the Cali-
fomia Health & Safety Code. Sections 25505, 25533 and 25534.1 understmd Nan if the
building does not rumatly have it union, that d is nay nsponsihility o -o nctify the occnpent
NEW RESIDENTIAL MECH. SQ. ET.
of the requireme nta which must be met prior to issuance of a Curnfirme of Occupancy.
/Y
ISSUED BY: (9T A �'tV/----
(
TOTAL
Owner or antiradical agent Date
OFFICE