30776APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL-POINT PEN ONLY -
OFFICE
CITY OF CUPERTINO 'BUILDING -ELECTRICAL
PERMIT NO, ^O^1/�^•
BUILDING DIVISION APPLICATION/PERMIT - PLUMBING - MECHANICAL.
BUILDING PROJECT IDENTIFICATION
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BUILDINGADDRESS:-
'SANITARY NO.
APPLICATION SUBMITTAL DATE
W
+1fS NAME,:
SSI'=-`�-O�!L- GnRr.
CfaNTRACfOR'SN E.-" LIC NO:
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'RCHIT4CVENGINEER. LIC NO:
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corvrncr - PHorve:
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BUILDING PERMIT INFO
725- o i 55.
❑ ,Consultant Pees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
El El El
LICENSED CON'TRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section ]000)o(Divi,idn3oflhe Brodessand Prefeaners, Code, and my license is
.n
t fuBfooe and effect.
Llcenre Clens Coir -
Date Contractor
QTY. ELECTRIC PERMIT FEE
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mand
JOB DESCRIPTION
RESIDENTIAL:
DSFDWL' ❑KITCHEN REMODEL.
❑ADDITION gVLUMBING RE -PIPE
❑MULTI -UNIT 0STRUCTURAL
m r I MODIFICATION
❑ INTERIOR El CHIMNEY REPAIR "
'IMPROVEMENT
D BATH REMODEL/REPAIR 0 DEMOLITION
DOTTER
'
PERMIT ISSUANCE _
APPLIANCES,- RESIDENTIAL -
ARCHITECTS DECLARATION
ImMere,and my plunahull he used as public recoFds
PANELS - •d
UP TO 200 AMPS
Licensee Professional
OWNER -BUILDER DECLARATION
I Caron affirm that 1 am exempt from the Commis Co :Any, Law for the
Coda', Any city or county
following reason Permit
t 7031.5, Business and vet de id demolish,
require, a permit ov aoovx he phe9 improve, demolish, fi repair any tnec een
prior bile censecormeneyuiree,frovi, rsofcant for wchpmmil to Bense [.ne(Chaptem
License sw (Chapter 9
,bol he menti ng with
to rhe of
Disldns of the a Business
Section
wnh Secf ]000) fD''sld 3 flhe0 ,'mess IProfessions Cdde)or
Thar he is exempt therefrom d the basis is f r the alleged exemption. Any violation of
Section 7031.5 by any applicant f subjects the applicant a civil of
elm than f hundredd Ilam ($500) r
fthe prop ny y ply ,h' g'. a. Ih„clecom,seralion,
will do the k and the structure not intended orofficandf (Sec. 7044 Business
Professimus Code The Contractors License Law docc'not apply to an owner at
_
201 -IOW AMPS
OVER 1000 AMPS - t �
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC.
_
T'P.MP MEN ER OR POLE INST.
COMM R [A '
Ll NEW BLDG/ADDITION El DEMOLITION
❑TENANT DFOOD SERVICE
_
IMPROVEMENT
_
DOTHER
POWER DEVICES
-
.� -
SWIMMING POOL ELECTRIC•
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 iia, intended or offered for
NEW RESIDENTIAL ELECTR sGIT.,0
sale. If, however the building orimprovement is sold within onoyeerofwmpl'etien,the
SQ. FT. FLOOR AREA
$/SQ. FT.
owneolmilder will have the burden of moving that he did not build or improve for put-
pose df sale.),
❑ 1, as owner of the property, am exclusively contracting with licensed contractors m
PM A II
ff- A 9
TOTAL 11PIF-
onswm he Project (Sea 7044, Business and Pmfessidns Code:) The Cantmmals Li -
Come Lawdoesfnorchp lots owner ofpmpeny who builds drupoves thereat and
QTY. PLUMBING PERMIT - PEE
i, RLCU
r
who contracts for such projects with o conlrucror(s) licensed pursuanvo the Contractors
PERMIT ISSUANCE
-
License law.
O l am exempt under Sec. ,B& P C for dimovased
/x pp
Cili Or VvrcRIlIVL
ALTER - DRAIN & VENT - WATER (CIA)
-
Owner Date
-' - '
WORKERSCOMPENSADONDECLARATION
Ihereby affirm under penally of perjury one of the following declarations
�D
BACK FLOW PROTECT, DEVICE'
DRAINS- FLOOR, ROOF AREA,COND.
I Invented will maintain nCeroficam dfC n. esu If -insure fm Workers Compen-
,.lion, as Provided for by Seared 3700of the Labor Code, for the perfnrmanw of the
STORIES
TYPE CONSTRUCTION
.
FIXTURES -PERTRAP
VAX'
work for which this permit is iesued.' . -
❑ I have and will mainmiu Werkar's Compensation insumnee, as required by Section
3703 of the Labor Code, for the performance of the work for which this permit is issued.
My W., Co pen,ndr�Ic,amncc corder and Policy
GAS - EA. SYSTEM -I INC. 4 OUT LETS
OCC GROUP
APN
Carrie, 'D 1$,,;Ti_ Policy No.:1 GA/dJ
L$i Gf�3y i3961
GAS-EASYSTEM-OVHR4(EA)
CE TIFlCATP.OF EXEMPTION FROM WORKERS' ”
-
-
"
,
,Z
1 O
ci
i O
l
t_W
.. COMPENSATION INSURANCE
or I(Tlns'section need not be completed lfthopermilinfornnehundreddollws($I(H))
-
Lthat theprnthe work for which t Permit shall
not employ ad,pmon to anyIaCne,,d smearmesjecr tohe morkersCcoopto-
sand. lawsof California. Date
Applicant
GREASFANDUSTRL WASTE INTERCEPTOR t',
Y' „ v BUILDING DIVISION FEES
GREASE TRAP
'
PLANCHF.CK FEE
SEWER -SANITARY- STORM EA. 200 FT`
ENERGY ME _
WATER HEATER W/VENT/PA.ELTR
GRADING FEE
NOTICE TO APPLICANTS IL after making this Certificate of Exemption, you should
become subject to Worker', Cnmpensntidn provisions of the Labor Cold ynumu,t
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Thereby affirm that is a construction lending agency for the performance of
the work for which Ihie permit is issued (Sec. 3097, Civ. C.) I
Lender's Name
Lender's Address
1 certify I have read This application and state that the above information b.
WATER SVS'1TiM?BEATING
SOILS PEE -
WATER SERVICE
,
PAID "
Dare Receipt#
NEW RESIDENTIALPLMB. SQ. FL
i I. I.'
- - TOTAL:
'
TOTAL:
UILDING ME
QTY MECHANICAL PERMIT `EEE
JELECTRTC
IZ)
correct. l agree 0 comply with all city and county ordineuces andstme l.somining In
building construction, and hereby authorize representatives ofthis city to enter upon the
EISMIC ME
abovFmemtioned property for im,ecti m puryoses.
(We)agree toxmm, indemnify and keep harmless the City of Cupertino egcamil
PERMIT ISSUANCE
FEEbernEties,judgments,
casts andexpenseswhich may in any way ancon, against suit[ City
consequence of the gmming of this permit. -
ALTER OR ADDTO MECH:in
LUMBING FEE
AIR HANDLING UNIT (TO IO,O0f1 CPM)
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS..
ECHANICAL FEE -
AIR HANDLING UNIT (OVER 10,000 CFM)
`
CONSTRUCTIONTAX-
,.
Signatureof Applicant/Conuacmr „ Dam.
_ HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
-
HOUSING MITIGATION FEE
HEATING UNIT DO 100,000 BTU)
' Will the applicant or future building occupantetore or handle hazardous material
a, defined by the Cupertino Muoicipel Code, Chapter 932, and No Heahh anis Safely
,
Cale, Seeded 25532(x)?
HEATING UNIT (OVER 100,000 BTU)
❑Yes ' ❑No "
Will thea licant or future building
Pp d by the Bay A ea Air Quality Management
mi, act? us air con,dminanl, as defined by the Bay Area Air Quality Managenem
lrid? ,
PAID
Dole Receipt p
VBNTILArIONFAN(SINGLE RESID)
BOILER - COME QHP OR 100,000 BTU )
- n
TOTAL:
BOILER - COMP (OVER 100,000 BTU)
.I
'
❑Yes r ;, ❑No
It
Ihave road the hazardous tectal. mqui -coments tinder Chapter 695 cifthe Cali-
forms Health & Safety Cord. sectican, 25505 25533 Card 25534 I understood bad rithe
building does tcurrently tenant, 0dt y 'ryl lfYthe dec
oftherq t 'which �Ib met prior ofa Certificate o
er'f at r'0 cupancy.
AIR CONDITIONER
ISSUANCEDA
-
NEW RESIDENTIAL MECHSQ. FT
tt
.
ISSUED BY:
Oame oramhr vocal •e,
6 - Date
TOTAL: �
OFFICE