S 1450 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PESIT NO. 1450
BOILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. PES
tlUILDING PROJECT IDENTIFICATION -
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Cil C'f !o o- -1080 157-7
NA T PHONE C T 0� yAyIEC_ ,r — LIC NO:
�1/1 rI I gGp. NIC- CONTROL#
ARCHITECT/ENGINHER: LIC NO: A RESS: ❑
CONTACT: PHONE:
BUILllINC PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I nm licensed under previsions of Chapter Y(commencing JOB D85CRIPTI N
I-WZ with Section9000)afDivision3 of the Rosiness end Pml'essiom Cade,sail mylicenseis RESIDENTIAL;
F k7� is full force and of t. PERMIT ISSUANCE
�UZV License Lp If ❑SFUWL ���❑,,,,,,KIIIITCHEN REMODEL
yds ate " `��Comradorl� APPLIANCES-RESIDENTIAL ❑ADDITION D4'LllMBING RE-PIPE_
ARCHITECT'S DLCLARATION El MULTI-UNIT ❑S UCfURAL
Z p Z 1 understand m l pec PANELS
OZ.- YP ono shall be used as hila swords CHIMNEY
UP T02fNlAMPS
F s4-F.u Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
C, 201-1000 AMPS. IMPROVEMENT 1DEMOLINGPOOLS
OWNER-BUILDER DECLARATION OVER'MOAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
G C I hereby afErm Not I um exempt front the Contract Cis License Law for the
W3 F following rwmn.(Section 90315,Business and Professions Code Any city or county SIGNS ELECTRICAL ❑OTHER
N¢ which requires a pout m eaaaaact,alter,improve,demolish,or repair any xtnemre
["..V,O.i priarm itsissuance,alsnrequires the applicantforsuch permit to file asigned,rammenl SPECIAL CIRCULUMISC.
WNthat he is licensed pursuant m lbopmva.mnsafthe Contmators License Law(Chopler9
(commencing with Section]gH)ofDivi.vion 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INS'll COMMERCIAL;
tL{y m 4 that he is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W..y Section 90315 by any applicant for a permit subjects the applicant In a civil penalty of POWER DEVICES
Zy not more tban five hundred dollars($500). ❑TENANT ❑FOODSERVICE
b 6 1,as owner of the IMPROVEMENT
SFQ ❑ th-li ages emmandeswithwiedfur Nei rsolec0mpenwness SWIMMING POOL ELECTRIC
will dothework,andthe The
isoatintended Law dofar sale(Sea.inan Business ❑OTHER
m andProfessionswho
Cad or The Cnsthereo Lind who
Lawdoesnalapply unownerof OU'i'LE'TS-SWITCIIHS-PI TURES
property who builds or improves thereon,and who does such work der himself orNrmgh
hie awn employees,e provided that arev improvements within arc nnl intended nr 0B0rcd for NBW RESIDENTIAL .N R SQ PT.
sale.IL howevw,ll have idingod n or pro int ithat heid one year(it improve
the SQ IT.FLOOR AREA $/SQ.FT.
nerf,.Ic.cr will have the harden of proving that he did not buil)ar improve for pur-
pas0ofsowne TOTAL: P d
❑ I,as owner of the property,,B exdusi and Pro essi ns with licensed enactors i M
construct the project(Sec.9044,Business and Professions Code:)The Commemra Li
curveLaw does not applyln on owner ofpmperry who builds or improves thereon,and QTY.- PLUMBIN P IT FEE
who contracts for such projects with a contractors)licensed pursuant o the Contractors
License Law. PERMIT ISSUANCE ��� _s Afl�t
❑rare exempt nail,,Sec ,B&P C fns this reason C
14 I
Owner Date ALTER-DRAIN&VENT-WATER( ) _ LIu
WORKERS COMPENSATION DECLARATION , ~�_�II��I
PACK FLOW PROF ECT.DEVICE
. � Iherehy affirm under penally of perjury one of the following declarations:
I have and will maintain a Cenificate ofConsem In seldireare for Workers Camper- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3900 of the Lahor Code,for the performance of the ts
work for wh di dd5 permit is issued FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation lmurance,as required by Section
3900 afthe Labor Cole,for the performance of the work for which this parent is Issued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCCGROUP APN
My Work is refund onInst a c ca d Policy nu her
Carti": es Policy No in
GAS-EA.SYSTEM-OVER 4(EA)
CF.RTIFICAT4 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This aced em be a,mpleted,t heperson is foram hundred dollars($100) GREASE TRAP
or less.) PI.ANCHECK FEE
I cenify that in the performance radio work for which this permit is issoed lshull SEWER-SANITARY-STORM EA.20d FT.
not employ any person in any manner so as In became ae subject In the Workery G,mpem- ENERGY FEE
0 Z mhmp Laws of Cnlifnmia.Data WATER HEATER W/VENT/ELECTR
Z Applicant a GRADING FEE
fq NOTICE TO APPLICANT:If,after making this Certificate of Exonprinn,you should a WATER SYSTEM/TREATING SOILS FEF.become subject Bathe Workers Compensation provisions of the Labor Cade,yea must
W forthwith comply with such provisiam or this permit shall bo deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.FE PAID
V C) I hereby affirm that there is acnnstruction lending agency for Neperoamence of Data Receipt If
"sH theworkfor which this permit is issued(See 3(199,Civ.C.)
Q H Lenders Name TOTAL:
wLender's Address TOTAL:
I cenify that I have mad this application and state that the above informotion is BUILDING N
aF-a VJ comeet.I agree m comply with all cityend county otdinancw and ante law,palling to QTY, MECHANICAL PERMIT FEE
building construction,and hereby authodre representrivesofthis city banter upon the SEISMICFE
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against - PBRMI'1'ISSUANCE ELECT I E
liabilities,judgments,costs and expenses which may In any way accrue against said City ALTER OR ADD TO MECH.
In consequence of the granting of this permit. PLURANG
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANI LPBB
SOLIRCf :011LAT�N /i / -
�/JJy�� -/�/ AB HANDLING UNIT(OVER HOW CFM) CONSTR TION TAX
fV
it
Signature, Applmmn/tmarac m Date P.XHAUS'I'HOOD(W/DUCT) HOUSI G MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hamNnustneleaial HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the I Iwlth and Safety
Cale,Section 25532(a)9 HEATING UNIT(OVER 100,000 BTU)
F1 Yes E]No VENTILATION FAN(SINGLE RESID) PAI -
Date Receipt#
Will the applicantotaorfunre definedding occupby
nt Buseequipmentof Management
BOILER-POMP(3HP OR 100,000 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Manabement TOTAL:
Dls¢ImP
E]yes No
BOILER,_COMP(OVER 100,000 BTU)
I]
1 Rave fwd the hazardous materials requirements under Chapter 695 of the Cali- AIR CONDITIONERUA CE DATE
Total.Health&Safety Code,Sections 25505,25533 and 25534.1 understand Net if the NEW RESIDENTIAL MECII. SQ.FI'.
hullding does not currently have a Ieaanl,that h is my responsibility in nobly the occupnon
of the requirements which must be met prior to istuance of a Cenificam ofOmupancy.
Owner or auNnrized agent Date TOTAL: ISSUED BY:
OFFICE