99100088APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 17 GJ , 00Q j° 9
I / OFFICE
CITY OF CUPERTINO BUILDING - ELECTRICALERMIT
NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT,IDENTIFICATION
50001
11UILDINp ADDRRSS'.
SANITARY NO.
APPLICATION SUBMITTAL DAIS
•
3 1
OWpIBP.'.S NAPM, .:PI{ONE:
C0 138 O��SOI � C �,QAyIpI� LIC NO: �
• N/C
CON OL#
RCHITECT/ENGINEER: LIC NQ.
ADDRESS: /SL Slii ,S .r
CONTACT. PHONE:
-
tEUILDING PERMIT INFO
^ � /_
a (D
❑ Consultant des Paid by Applicant (Initial)
BLDG EL—ECT/ PLUMB/ MECH
LICENSED CONTRACTORS DECLARATION
1 n by f m that 1 licensed under previsions of chapter 9 (commencing
w) the f 4000) fD... 3 fm Business and Professions Coda and lice i
) i,.,a full d effect.' 3 C +�
Wee se Clan. Lich
Dam00
Conlmcmr
ARCHITECTS DECLARATION
1underhand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following roason. (Seaton 9831.5, Business and Professions Code: Any city or county
w .. n.',a... . permit m tlrns rest, alter, improve, demolish, or repair any sounnre
ns lssuence, alto reyuires the nppliwmfor such Permit to NeosigneJ statement
QTY,ELECTRIC PERMIT FEE
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JOB DESCRIPTION
RESIDENTIAL,
❑ SFDWL TCHEN REMODEL
❑AUDITION El PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT E]SWIMMING POOLS
H REMODFUREPNR ❑ DEMOLITION
❑ OTHER
PERMIT ISSUANCE -
APPLIANCES -RESIDENTIAL
-
PANELS .. '
up'T02W AMPS
201-1000AMPS
OVER IOW AMPS
SIGNS ELECTRICAL
-
SPECIAL CIRCUIT/MISC.
iprion.
3>
(00
4 M [t
that be is licensed pursuant the provisions acted Contractor's License Law (Chapter 9
(commencing with Section ]W0)of Division 3 ofthe Busieessand Professions Code)or
that he is exempt therefrom and the basis for Ino alleged exemption, Any vintremo of
TEMP. METER OR POLE INST
COMMERCIAL:
El NEW BLDG/ADDITION ❑DEMOLITION
c
.xq
p..
W5_
Section 9031,5 by any applicant for a area, ludaeets the applicant it o civil p'naltyof
not mora man five hundred collars ($500).
I] L.snwncrofthe property.(army employees with wages as their sole compensation,
will In the work, and the stmemm is notintended or oOBred forsale(Sec. 90aq Business
and Professions Code: The Contractors License Law does ant apply m an owner of
property who hoods or improves thereon, and who does such work himself or through
POWERDFVICES
❑TENANT El FOOD SERVICR
IMPROVEMENT
❑OTHER
SWIMMING POOL ELECTRIC
_
OUTLETS/' SWITCHES -FIXTURES
his own employeesbuilding that such improvements are not Inteodod or ofiercd for
NEW RESIDENTIAL ELBCTR0474
sale. If, however,me building or improvement is sell within ane year uf.,Pbmeti(an.1he
SQ. PI'. FLOOR ARRA
$/SQ. Ff.
u -builder will area the burden of proving that he did riot F.He or improve for Dur-
- -
❑ 1, as owner of the property, am exclusively contracting will) licensed contmemra
construct the pmc 7044,jeal (Se44, Business and Professions Court) The Cornier,
ce n.e Law Anes not avply m.n owner of pmpeny who milds or improves thereon, and
QTY. t t * PLUMBING PERMIT �.
¢to
whoforgoer projocwithaeonweKs)licensedpursConnector,,Ira Connector,
PERMIT ISSUANCE
Licensense Low. Law..
❑tem exempt under Sec. ,B&P C for dais reason
.
ALTER - DRAIN & VENT -WATER (EA)
BACK PLOW PROICCT. DEVICE
weer Date
VALUATION
WORKER'S COMPENSATION DECLARATION
I hereby office under Penalty of perjury one of the following declarations:
DRAINS: FLOOR. ROOEAREA, COND.
Iheve.nd will maintains Certificaleof Consent toself-inmrefor Worker's Crmpen-
ation, as provided for by Section 37110 of the Labor Cade, for the performance of the
STORIES(
TYPE CONSTRUCTION
-
FIXTURES --PER TRAP
work for which this pem)it is issued
1 have and will maintain Worker's Grmponsalirn Insurance, as required by Section
3900of the ladmir pCooast, for
War orr the performance of the work for which. this permit is issued.
sKI.Varm rand Policy n
GAS -EA. SYSTEM -I INC. 4 OUTLETS
OCC. GROUP
APN ^J
03
i) GAS
I & 1GI t� MPDONy N., W L���.
turner A&M
CATE
-EA. SYSTEM -OVER 4 (EA)
Z
O
V1
Z y�
COMPENSATION INSURANCE
(This section need not ba completed ifthe permit is forme hundred dollars($IW)
or lase.)
I certify that In mo permornmeo ofthe work forwhich this permit is issued, [ shall
mol en In an
p y y Deman in any manner sn ae m become eun]mt tetra Wntkere' Comp'n-
sation Laws of California, Data
Applicant l
GREASF✓INDUSTRL WASTF.INTF,RCEPTOR
° �» ;'BUI1.DINO DIVISRJN PEt.+S`_
s GRHASETRAP
P HECK IT _....
47 ^n
SEWER -SANITARY -STORM F.A. 200 F1'.
E .li iY PP.. 1
WATER HEATER WIVF.NT/F.LF,CTR
DINCrU
T P
S ICE V t
NOT ICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become object m the Workers Compensation provisions of the Labor Code, you most
WATER SYSTEMOTEATINGn
G
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forthwith comply with such pmvmo is or permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
WATER SERVICE
ny�
Ary '
�
NEW RESIDENTIAL PLMB. SQ. FT.
J
�
Iheby nficm that there is a construction lending agency for the rothawn.f
the work for which this permit is issued (Sec, 3097, Civ. C.)
Lenders Name
R
ecc l#O
TOTAL:
Ass
TOTAL:
U
WLendersddre
y fy
ti m
7
1 certify mat 1 have read dais appllca [tor end state that the abrvo urimmttien cs
cored. I agree m comply with all ordinances and state lawsremting to
building construction, and hereby authorize representatives ofthis city to enter upon the
- - .-.
QTY. MECHANICAL PERMIT ' ' ',,
FEE
BUILDING FEE
SEISMIC FEE '
F
above-mentioned property for, inspection purposes.
(We) agree to save, indemnify and keep hornless the City of Cupertino against
PERMIT ISSUANCE
ELECTRIC PEE
liabilities,judgments, costs and expenses which may in any way accme against said City
in consequence of the gmbling of this permit -
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT (TO I0,000CFM)
MECHANICAL DEE
APPLICANT DERSTANDS AND WILL COMPL W ALL NON -POINT
SOURPE/gE LITIONS. (I
AIR HANDLING UNIT (OVER 10,000 CFM)
IA' - V
lln
CONSTRUCTION TAX
Signary%-o dApi)cwVCouccct//rrar )a
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD (W/DUCT
HOUSING MITIGATION FEE
HEATING UNI I(TO 100,000 BTU)
Will the applicant or future bidding occupant stare or handle hazardous material
av defined by the Cupenin(a Municipal Code, Chapter 9.12, sod the Health .net Safely
Cade, Section 25532(.)^
HEATING UNIT (OVER 100,008 BTU)
❑Yes No
Will the applicant or taminants a building by the ay At use rea
roty Manes agement
e hazardous air contaminants as defined by the Bay Alice Alr Qualify Management
Air
p?
PAID _
Dore Receipt#
VENTILATION FAN (SINGLE RESID)
BOILER-COMP(3HPOR 100,0001110)
'TOTAL'
❑Vas E]No
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
fomin Health & Safely Code, Sections 25505, 25533 and 25534. I understand that if,he
Idocs not currently have a tenant, that it is my responsibility to lify th occupant
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of ere rswh h xt tet tpri n inuanc ene sbfOc P cy.
VV sb�
yot
ISSUED BY:
Owner or amounted .,in Date
TOTAL:
I / OFFICE