B 0646 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, ppp�l
tlU1LpINC PROJF,GT IDENTIFICATION �.
IBUILDINGADDRESS: �j !f
M S A'�T a4l,"I �71NV SANRARY NO. APPLICATION SUBMITTAL.DATE
c� 9so/ z
OSyB73R'S NAME: PI+DNE:�.ss_237 CONTRA�R'S NAME; LIC NO:
a• �l�J\ �✓7J 11.1)„",)".U-!/t_/) NIC CONTROLp
ARCHITF.CI'/EfJGINEER: LIC NO: ADDRESS:
1
CONTACT: PHONE:
BUILDING PERMIT INFO
O��� �� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUb MECH
LICENSF.0 CO RACE 'S DECLARATION QTy ELECTRIC PERMIT ❑ ❑ ❑
1 hereby a0irm mat I am licens 'Urider provisions til Chapter 9(commencing FEC
WMZ wish Seniom703m.1Divkion3efdw Businessand Professions Cldy Andmy license is JOB DESCRIPTION
Wyw. in full fume and effect. PERMIT ISSUANCE EFSIDENTIAI'
tF�Y.U U License Class Lic,p
Va GL Date ❑SFDWL ❑KITCHEN REMODEL
Contractor APPLIANCES []ADDITION El PLUMBING RE-PIPE
ARColl be
DECLARATION ❑MULTLUNIT ❑STRUCTURAL
O Z-Z I understand my plans shall he uuJ as public records UPT0PANELS
UPT0200 AMPS MODIFICATION
Y�jl Lacnsd Professumal ❑INTERIOR CICHIMNHY REPAIR
OL
S...4I OWNER-BUILDER DECLARATION 201-1000 AMPS IMPROVEMENT SWIMMING POOLS
y o,6 1 hereby affirm that I um exempt Liam the Contruelors License Law for the OVER IM)AMPS ❑BATH RfiMO EL REPAIR ❑DEMOLITION
X 3 W F following recon,(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
F O too which regnire.x a permit to construct,alter,improve,demolish,or repair any structure
y.4 prior to its issuance,Its()minimal the applicant for such Period to file a signed statement SPECIAL CIRCUIT/MISC.
Sit y that he is licensed pursuant to the Provisions of the Qnlocro v License Low(Chapter 9
WEE o (commencing with Section TOM)o'Division 3 ofthe Business and Professions Code)or TEMP.MUTER OR POLE INST.
6 ta,n y that he is exempt therermm land the basis for the alleged exemption.Any violation of
,pec Scour.7031.5 byany applicam far u pars(subjects theepplicamma civil penalty of POWER DEVICES El BLD EDITION ❑DEMOLITION
E+ y not mare them Ove hundred dollars($50y. ❑TENANT
❑FOOD SERVICE.
REM ❑Lo the work.
.the property,structure
wire Brad ousidei(Sec.compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
will Jo the work,Aad the s o Clan a not hointended or offered outside apply A An Business ❑OTHER
and Prity who
Cade:The Com pemrk License Law does nes apply s if owner of OUTLETS—SWITCHES—FIXTURES
property who hailJs or improves thereon,and who doe such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ I7
Ads,If,however,the building or improvement is sold within one year of cnmpinion,the SQ.FT.FLOOR AREA
owner-builder will have the burden of proving n that he did not build or improve for pur- Q'FT'
KKin,
av owner of the property,am exclusively contracting wont licensed conlmcmrs to TOTAL:
compact the project(See 7014,Business and Professions Cri The Cometh m's Li- ln'-�1 !/J�•`\
cense Law docs not apply to an owner of property who builds or improves mown,and QTY, PLUMBING PERMIT U
who contracts for such projects with a cmarecmr(s)licensed pursuant m FEE
the Contractors IJ 2 6 199
License Law.
❑I am exempt under Sec. B&P C for this.,on PERMIT ISSUANCE
Owner Date ALTER—DRAIN&VENT—WATER IEA) VALUATION
WORKERS OMPENSATIONDECLARATION BACK FLOW PROTECT.DEVICE
1 hereby aRttn under penalty of pc juryAirline
one following declarations:
❑ I have and will maintain a CeniOcate of Consent to self-insure for Workers CompFly en- DRAINS—MOOR,ROOF,AREA,CGND. t,]
sation,As provided for by Section 37M of the Labor Cade,for the performance of the STORIES 'TYPE CONSTRUCTION
work far whish this permit is issued. STORIES
PER TRAP
❑1 have and will maintain Workera Compensation Insurance,as inquired by Section
37M of the LAtmr Code,for performance of the work for which this permit is issned. GAS—EA,SYSTEM.I INC,4 OUTLETS
My Workers Compensation lnsumnce carrier and Policy number am: OCC.GROUP AI'N
Comee Enlicy Nn: GAS* EA.SYST R,1-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE INTERCEPTOR
less.)
(This section need not becompletd ache permit is forms,bond”Jnllars 61X0) GREASE TRAP BUILDING DIVISION FEES
or
1 certify mal in the performance ufthe work forwhich thisPLANCHECK LEE
permit is issued,)shall
Act employ any person in any manner so as to became subject lm lite Workers'Cumpen- SEWER—
SANITARY—STORM EA.200 FT.
Q zscion laws of California.Data ENERGY FEE
O Applicant \ WATER HEATER WNENTIELELTR 00
V) NOTICE.TO APPLICANT.If,after making min Certificate of Exemption,you should GRADING FEE
f+ ; become subject to the Workers Compensation provisions of the Labor C de,you must WATER SYSTEM/1'RPATING
0.Q fmlevilh cly with.,u,h provisions or this permilxhall be deemed revoked. WATER SERVICE SOILS ME
ozCONSTRUCTION LENDING AGENCY NEW P.6 IDEN'1'IAL PLMII. SQ. PAID
L)0 l hereby affirmmal mem is a construction lending agency for performance of t Rtteiptp
4L H the work for which this permit is issued(Sec.3097,Civ.CJ
Q U Lenders Name
4 Lenders Address TO TOTAL:g
1 certify that 1 have real this application and state that the above information is BUILDINL E
zn correct.l agree m
comPly wilt)all city and county oa finances And same lows miming to QTY,
V z building construction,and hereby authonee repreamaMECHANICAL PERMIT FEE
of this city to enter upon the SEISMIC E
ahnve-mentioned property for inspection purposes.
(We)agree lm save,mccmoily And keep harmless the City of Cupertino against PERMIT ISSUANCE ELE 'FIiE
Iiabilities.indgmce s,rests and expenses which may is any way aceme agminst said City
in emax,eace of Ne gmndng of this permit. ALTER OR ADD TO MECH. PLUMBING�E
AAPPIN.,litSTT UNDEAND W,IzLL�COMPLY WITH ALL NON-POINT AIR HANIl1.INC UNIT(TO IO,gNI CPM)
lN MECHANICALFEE
AIR HANDLING UNIT(OVER X)CFCFM)— ��luareor Appliesontmnor D'— yle EXHAUST HOOD MMULT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION F[E
Will the applicant or future building weupmn store or handle hazarkma material HEATING UNIT OT)100,gMl BTU]
As icfined by me Cupertino Municipal Code,Chapter 9,12.and the Health it Safely
Coda,Sectio 25532(x)7 HEATING UNIT(OVER 100.000 BTU)
❑Yes F1 No
ift VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building reentrant use equipment Ar devices which Data Receipt p
IWemit hazallous air contaminants As defied by the Bay Area Air Quality Management BOILER—COME EUIP OR 100.05 BTU)
Planet?
❑YesAL.
❑Nn BOILER—COMP(OVER 100,000 BTU)
I have read the lamed materials requirements under Chapter 6,95 of the Cali- AIR CONDITIONER
I Ith&Safer C ISSUANCE DATE
y tons 25505,255J3 and 25514.1 understand that little NEW RESIDENTIAL MECH. S �7 [}
b ingJ murre y e enc ,mat it is my rexponsihilirymnotify me occupant Q'�' G
who ssuancc nJAC r, eof racy.
,4 k
ser or amhoriud cm ✓ TOTAL: ISSUED BY:
OFFICE