99110117� 4
J9
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY - 1 Cl I 10 111
GIT* OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
sCI::`.i.'iBUILDING'PROJECT,IDENTIFICATION I,"':tlI',
PERMIT NO
BUILDINGADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
M& E'
CO 'S NArf
NIC
CONTROL k
❑
\RCHITECT/ENGINEER: LIC NO:
A I�
CONI'AC'I': PHONE:
BUILDING PERMIT INFO
IA
U)
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECI1
1 _IJLkL/9 /J/�
��
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
1 Hereby afrtrm mal 1 am Lanaea ander vrov a nna of Chapter 9 (commencing
QT,Y. .S ELEGTRICPERMITf' I ":k'EE�Ftr,
:nc e s. 1.. _r.. __ -. 1 .
JOB DESCRIPTION
with Section 7000) ofDivision 3 ofthe Business and professions C de,andmylionatil
in full force and aff., In � 0
PERM ISSUANCE
RESIDENTIAL:
El SFDWL ❑KITCHEN REMODEL
ApPL1ANC-RGSNEMfIAL
License ll// Lie .H '-'—
Date C onlraalor
BICDE;CLARAq'I
I understand my plans shall be used as public .,ads
El ADDITION -1 PLUMBING RF. -PIPE
❑MUI.TI-UNIT L1 STRUCTURAL
MODIFICATION
El INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
PANELS
UPTO20IAMPS
Licensed Professional
201-1000AMPS
OWNER-BUILDERexemptDE DECLARATION
I hereby affirm on I 1 5exempt from We Contractor's License Law for the
following tress.. (Section 70315, Business and Professions Code Any city or umntY
El BATH REMODEIIREPAIR El DEMOLITION
OTHER
OVER ]Bud AMPS
SIGNS ELECTRICAL
which requires a permit m anaWU, alter, improve, demolish, or repair any swemre
SPECIAL CIRCUDEMISC,
_
prior to itv isxuuna,al.o requires the applicant for each pwnmluoflle aeigned satement
that he is licensed pursuant to the Provisions or the Conuador's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code)it
TEMP. METER OR POLE BeST,
COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
[D NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section ADIS by any applicant for a permit subjects the applicant in) u civil penally of
Hat common rise hundred della¢ ($5001).-
❑ Las owner of the property, or my employees with wages as lhelrsolecmn,matim,
will do the work, and the sbucare is not intended or offered for sale (Sec.7044, Business
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
D OTHER
SWIMMING POOL ELECTRIC
and Professions (VE: The Cwhaemr-s Lieense Law docs not apply man owner of
OUTLETS -SWITCHES -FIXTURES
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale. It, however, the building or improvement is sold within one year ofcompletion, the
NEW RESIDENTIAL ELECTR SQ FT
X
SQ. FT. FLOOR AREA
$ISQ. FT.
-builder will have the burden capturing that he did not build or improve far port -
PraHer
se of ecleJ.
0 I, as owner of the property, nm exelu.vively commuting with hamed connecmn to
TOTAL:
construct the Project (Sec. 7044 Business and Professions Cod-) TT C tat l
ase Law does not apply to an owner of,property who build' p thereon, d
QTY; t.. < y q F; r Ir,1 11
PLUMBIN
who contacts mrxuch pmlects w th. c uvea r(s) IicemW p rsaanl to the CGmanc ore lk
t r 1"FEEti'yg
PERMIT ISSUANCE
License Law.
C] Iam exemPI wader Sec. , B & P C l'orthls mason
Owner Data
UTER-DRAIN&VENT-WATER(EA)
VALUATION
/'D a -0Z4
WORKER'S COMPENSATION DECLARATION
BA FLOW PROTECT DEVI .
Iheneby affirm under penalty of Perjury one of the following deelnatinns;
VVLLJJ/ (/
DRAIN FLOOR, ROOF,
I leavened will muionlon CulifmcofCorwal to self- insure for Worker's G:mpen-
,mien, as provided for by Swine 3701 nr the Labor Code, ror the perfotmn ce, .1 he
STORIES
-
'TYPE CONSTRUCTION
,
work for which this permit is issued.
FIXTURES- �RTRAP
have and will maintain Worker's Compensation Insurance, w required by Section
`
of the Lnhar Code, fonhe parformence of the work for which this permit is issued.
GAS-EA.SYSTE-IINC.40UTLETSOCC.
GROUP
AEN
My Wer sCompensntion �y� mer and Policy �I,u�e,
Carriac_Pollcy No: UI)/SC7JZ'7J%O
GAS-EA.SYSTEM-0R4(EA)
ER' BtICATE OF EXEMPTION PROM WORKGRS'
COMPENSATION INSURANCE
.(This section nese not bo cnmplcmdifthepermitis fomnehuudmd dollars($100)
or Lev.)
GREASFIINDUSTRL WAS NTERCEPTOR
,
��� £ R•, IIr,I$INI'i DIVISI(BJAIRESd ,RgA ���
GREASE TRAP ,
PIANCHECK FEE
I certify that in the Performance ofthe work for which this permit is issued, l shall
not employ any persou in any manner so as m become subject o the Workers Camper-
SEWER -SANITARY -STORM EA.2 FT
ENERGY FEE
WATER HEATER WNENVELFCTR
salion Laws or Coldemin. Date
Applicant
GRADING FEE
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject m the Workers Compensation provisions or the Labor Code, on must
WATER SYSTEM) TREATING
SOILS FEE
WATER SERVICE
forthwith comply with such provisions or this penal shall be deemed revoked.
NEW RESIDENTIAL PLMB. SQ. FT.
CONSTRUCTION LENDING AGENCY
I hereby affinnthichane is a construction lending agency for the pew
ffomnce of
PAID
Date RecelplM
the work ror which this permit is issued (Sec. 3097, Civ. C.)
TOTAL:
Lenders Name
LemdersAddress
TOTAL
BUILDING FEE
I lenity that l have d (fit& applicationd state t that the aboveinformationl
correct.Iagree to comply with all city and county ordinances and state laws relating t
building construction, and hereby authoze m pesentatives ofthis city enter upon the
ri
t. .. „r t .. ,
QT'$% `' MP�CHANICALPERMIT '' 1'411 p
t -k.1`', .c I,
SEISMIC FEE
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
llvbllaici,judgments, costs and expenses which may in any way accrue against said City
in n nsequenaof thegablingof this permit,
PERMIT ISSUANCE t
'ECBCTJtI FEE
PLU BINOFEO LI
ALTER OR ADD;TO MECH.
AIR HANDLING UNIT (TO IB,OBBCFM)
MECHANI
U IO 'fA
HOUSING MITIGATION PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
/// /
SOUR G CATION. 8/f �
AIRHANDLINGUNI9'(OVER 10,000CFNE
Signature of ApplicanOContommr Data
HAZARDOUS MATERIALS DISCLOSURE
EXHAUSTHOOD(WIDUCI)
BEATING UNIT (TO 100,0(10 B' 1' U)
Will the applienm orfmure building wcupam atnreor handle hazallous malainl
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER In0,fg06'fU)
Code, Section 25532(a)7
Yes
Will mevpplicant arrmurc building occupant use equipment or devices which
:mit hazardous air contaminants as defined by the Bay Arca Air Quality Management
District'
❑Yes No
�
PAID
VENTILATION FAN (SINGLE. RF.SID)
Date Receip ll
-
BOILERCOMP (3HPOR IOO,000 BTU)
T
BOILER -COMP (OVER 100,000 BTU)
AIR CONDITIONER
1 have read the hazardous materials requirements under Chapter 695 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH, SQ. FT
foais Health & Safety Code, Sections 25505. 25533 and 25534. 1 understand met ifthe
buildingdoe curently have.tenant, that 11 yresponsibility m nodfyt occupant
difficult nl Inch most t 'moi eofz(. nTev qP
/1 p +
Jak
ISSUED BY 74-0
Owoer of orizdagenl Date
TOTAL:
OFFICE