29355 ,:j •
'APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ELECTRICAL - PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT' • PLUMBING MECHANICAL. n� ��5C
BUILDING PROJEC71'IDENOFICA'1'ION G
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DAG
113-7 til iicjar1 car. Y-y-C%C.
OW�NER'S NAME: SI.I C'`l(;i r:;_ 0I I CONT1iiCIDR'S NAM / LIC NO:
Jn m..r fjf J KESS: NIC CONTROLp
4RCHG li-/ENGINEER: LIC NO: ADDRESS: �7 ❑
F.X 1D2`72 sSa �g f,In ai. pJe.L '
CONTACT: PHONE: - BIIILDINO PF,RMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY F,W?CTRICPERMIT FEE
I hmby affirm Nat 1 am licensed under provisions of Chapter (commencing JOB DESCRIPTION
-00
O'YZ with Section 9lXXBofDmoon JofNe Business and Professions Cade,and my license is PERMIT ISSUANCE RESIDENTIAL,
I.. In full baronial effect.
<—U License Class Conor ❑SFDWL ❑PLUMBKITCHEN REMODEL
�Za Dom Contractor APPLIANCES-RFSIDFNI'IAL ❑ADDITIONPLUMNING RBPIPE
G ARCHITECTS DECLARAT(ON ❑MULTI-UNIT ]STROUT ORA[,
,DoPPANELSZ O yyj Z I understand my plans shall he used as public records MODIFICATION
OZ—O UP TO 200 AMPS El INTERIOR ❑CHIMNEY REPAIR
r en„i"41 Licensed Professional 201-IIMAMPS IMPROVEMENT
pd ,
OWNER-BUILDER iRmIon CoATION OVER I000AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
a 6 1 hereby off loco that I R-exempt Item DECLARATION
Liaenac Law fnr the
sL O6 V following reason.(Section'1031.5,Business and Professions Code:Any city or county SIGNS ELECfRICAL ❑OTHER
FO E-' which requites a permit m constmct,alter,improve,demolish,or repair any sbuaurc
piimtoa,issuance,aleorequim,1hv.pplicum fi permirtn lite asigncdatmmmcnt SPECIAL CIRCUIT/MIS,.
U} that he is licensed pumusnuo the provisions of the Contrcon's license Law(Chapter 9
..00 (commencing with Section 7(X00)of 0ivisionJof the Nosiness and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
d m oC that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
-,m Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES LlTENANT ❑FOOD SERVICE
oat mom than Eve hundred dollars(5500). IMPROVEMENT
^ 4 [ I,asnwner of the property,or my employees with wages us their sale compensation, SWIMMING POOL ELECTRIC
_ will do the tarok,and hostmetum isnot intendmo,offered batiste(Sri.7044,Business ❑OTHER
e 3 m and Professions Code:The Contractors License Law docs nm apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided shot such improvements arc not intended in offered for NEW RESIDEM'IAL ELECTR SQ FT
aide
-
aide.If,however the building or improvement is sold within one year of enmpleiian,the SQ.IT.'FLOOR AREA s/SQ,PT.
mer-builder will have the burden of proving that he did nm build or improve for Aur- s jit2T
,an of sale.).
1,as owner of the property,am exclusively contracting with licensed rmarmoms to TOTAL:
construct the project(Sm.9614,Business and Professions Code:)The Conractor'x Li-
mass,
J- t APR '
c se taw does not apply to an owner of property whobuildxro
or improves QTY, PLUMBING PERMIT FE 1996.
who contracts-for such projects with a pantomimist licensed pursuant to the Contractors 4
License Law, PERMIT'ISSUANCE C�!} V� LVr
Iamexemptundm Sec. ,B&PCfor Nis000m N'-f)11fVU
Owner Date ALTER-DRAIN&VENT-WATI7R(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby amp under penalty of perjury one of the following declarations:
I]I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLUOR,ROOF,AREA,COND. STORIES 'TYPE CONSTRUCTION
sued.
sation,its prl
ovided ar by Section 3900 of the Labor Calc,for the perGmnance of the - �
trek far which this permit is isFIXTURES-PER'MAP
El I have and will mutation Worker's Compensation Insurance,as requited by Section
37M of the Labor Care,for the performance of the work for which this permit is issued, GAS-EA.SYSTII-I INC.4 OUTLETS OCC.GROUP APN
My Werke{{{{'s�.�.Com����pensatig,,,,o.Ipsumnce curticra.d Policynr are: p
My Wck]f_,..��✓D�Policy No.: �'. U.>o4T! GAS-GA.SYSTEM-OVER 4(EA)
`"� CERTIFIcCATE OF E%F.MPTIONIROM WORKERS' GREASF/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE
THris semis...it not he completed ifthe permit is for one hundred dollars IS 100) GREASETRAP
BOILUING DIV ISION PERS
or less.) PLANCHECK FEE
I certify that in the performance of the work fit,which this permit is issued,I shall
not employ any person in any manner sn as na become n
suhjeco the Workeri Cnmpem SEWER-SANITARY-STORM EA. Pf. ENENGY FCIi
OZ cation laws of California.Date WATER HEATER W/VENT/ELECTR
7 0 Applicant GRADING FEF.
Cs NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTIiM?REAI'ING
a , hecomesubject to the Worker'.Compensation provisions of the Labor Code,you must SOILS FEE
W ..a foMwuh,comply with suchproviumi aun,permit shall he dumM invoked.
WATER SERVICE
Q
7z CONSI RUC'I]ON LENDING AGENCY NEW RESINIVI'IAL PLMB, SQ,FT. PAID
U0 l herebyaflirmthauhere iso comswetion leadingagevay fonhe perfmmaneeof Dale RmciptN
Hr (~ the work for which this petit,is Toned(Sec.3099.Civ.C.)
O U Lender's Name s TOTAL:
lenders Address TOTAL:
1 I certify that I have mad this application and pate that the ab ve abo and is BUILDING PER
N correm.l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
U � huildiagcourbaction,and hemby amhmiac representatives of this city[reiteration the SEISMIC FEE
aMsveancmioneJ property for inspection purposes.
(We)agreem save,indemnify and keep hapless the City of Cupertino against PERMII'ISSUANCE ELECTRIC IEE
liabilities,judgments,consandexpennes which ma 'n any wuyrccrup against said City ATTER OR ADO TO MECH,
no onacgaence of the greening of his pend /I PLUMBING PILE
APPLICANT UNDF.RSTAN S tD s' L OMB-Y WITH ALI,NON-POINT AIR HANDLING UNIT'(TO HT"CFM) MECHANICAL TEE
S URCE�RETBfI..
AIR HANDLING IINIT'IOVER 1(1,0011 CFM) CONSTRUCT ION TAX
Stgnime ofVCoDate tD EXHAUST HOOD OVTUCTI HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant=or form building occupant smro or handle bamrdous nuncnal HEATING UNIT LTO 00,000 BTI])
ss defined by the Cupertino Municipal Code,Chapter 9.12.and the Het and Safety
Code,Section 25532nd? HEATING UNIT(OVER 100,000 BTU)
[]Yes ONo PAID _
VENTILATION PAN(SINGLE RESID) Date RuciptN
Will the applicant or future building apparentuse equipment or devices which BOILERCOMY(7HPOk 100,000 BTU)
mit hnrutdous air conterminous as refund by the Bay Area Air Quality Managem -COMP TOTAL:
District'!
❑Ye. ❑No BOILER-COM P(OVER 100,000 BTU)
I have read the bazamiss matcriuls requirements under Chapter 6.95of the Cull- AIR CONDITIONER ISSUANCE DATE
I'omia Health&Safety Code,Sections 25505,25577 and 25534.I understand Nut if the NEW RESIDENTIAL MECH. SQ,FT.
building docs not currently have o anent.that it is my reaptmsibility to nmify the onsp ant
of be requirements which must M met prior to issuance of a Certificate of Occupancy.
Owner or euthodzW agent Dme TOTAL: ISSUED BY:
OFFICE