28572114
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
MRMITNO.
Q C �i
8 J L
BUILDINGADDRESS: V
cRa 1a os
aA�G�yTOR'SN
SANITARY NO.
APLICCAATIO1N\SUBMITTAL DATE
f ' `
DW PHONE.:
L'I S
E:eel LI
�/ /1 D
C
NIC
❑
CONTROLp,
CM LCT/ENGINEEK: LIC NO'.
ADDRESS:
CONTACT.PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED COMRACnderpORS oECLARpnON
1 hereby affirm Nal l oro licensed under provisions of shaper 9 (commencing
With Section ndaffecDivisinn3nl the Business and Professions Gds, and my license is
in full fou and effect.
License Class Lick
7 Dom
QTY. ELECTRIC PERMIT IEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ,❑ KITCHEN
❑ADDITION El PLUMBING RE -PIPE
11 MULTI -UNIT El STRUCTURAL
MODIFICATION
El INTERIOR [:I CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑DEMOLITION
❑OTHER
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
TS DEContra....
j ARCHITECT'S DECLARATION
1 1 understand my plans shell be used as public records
PANELS
_
UPT'02W nMP5
Licensed Professionall2014000AMPS
OWNER -BUILDER exempt
OE Ce Corrosion's
1 hereby affirm mat I am exempt from the Contracmr's Licrnse law (or me
1 folic ing....(Section 9031.5, Business and Professions Cats: Any city or county
Which requires n permit m ci nsmucL oItcp improve, dernmod, or repair any stratums
I prior to its issuance, also requires the applicant for such permit o file a signed statement
that he is licensed pursuant o the Pm6lsions of the Contractor's license Law (Chapter 9
(commencing with Section A#gll of Division 3 of the Business and Pralswi.m Code).,
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
' Section 1031.5 by any applicant fore pariah ubjects theappliand to. civil penaay of
. .1 mom Nan five hundred dollars (S5 W).
iI,ea.wnee of the pmpcny. ser my empioyces with wages as their tufa compensation,
will date work, and the structure is not intended oroffereJ formic (Sec. 9614, Business
end Pomfiamimr Codc: To, Contractor's License tow does not apply m nn owner of
• property who builds or impmves Ncman, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale. If. however, the building or i mprovemrnt is sold within one year ofermpletioq the
owner -builder will have the burden of proving that he did not build or Improve fur par.
po aidtatle.).
❑ I, as owner of Be property, am exclusively amorseting with licensed contractors to
construct the project (Sm. 70voL Business and Profession, Code:) The Contractors Li -
came Law does not apply manowner of jmpeny who builds or improves theater, and
who contacts for such pmims with a contractions) licensed pursuant m Ntra
e Conctors
Lia.. low.
❑ I am exempt under See ,B&PCfor this mama
OVER lOOOAMPS
SIGNS ELECTRICAL
SPECIAL. CIRCUDUM ISC,
TEMP. METER OR POLE INST.
COMMERCIAL
❑ NEW BLDG/ADDITION ❑ DEMOLITION
TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
POWBR DEVICES
SWIMMINGPOOLELELTRIC
OUTLFTS -SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR SQ FT.
SQ. FT. FLOOR AREA
S/SQ. FT.
TOTAL:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - GRAIN @ VENT- WATER (EA)
Owner Dae
VALUATION
1 hereby affirm under pcnnhy of perjury one of the ml lowing declmaumr:
OTYWORKER'S COMPENSATION DECLARATION
JImeatnd will maintain n Cenificam of Consen to self-iname for Worker's Camper-
mtion, as provided for by Section 37a) of the Labor Code, for me performance of Ne
work far which this permit is issued.FIXTURES-P
Fl have and will maintain Workers Compensation Insurance, m requited by Section
37M of the Labor Code, for the performance of the work for which this permit is issued.
My Work C nmtoJn and PolicynWtl�t� p
Cartier. lacy No.: �✓�CJ3d
FRT1 CATE OF EXEMPTION FROM WOR KERS'
COMPE.NSAT'ION INSURANCE,
(This section need not he completed ifthe permit is forme hundreddolla. 00)
m leas)
(certify matin the performance as 1.he ork ca,mor which this Perutheta, . Carrier-
an employ any person in any manner>n as m become svbjut m the Wor et%Compen-
sarion Lows of California. Data
Applicant
BACK I7LOW PROTECT. DEVIC
DRAINS -FLOOR, RO ,ARBA, COND.
-
STORIES
PE CONSTRUCfION
TRAP
GAS -.SYSTEM -1 INC.40I1TLETS
OCC. GROUP
APN
AS -EA. SYSTEM -OVER 4 HIA)
GRF.ASF%INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASETRAP
PLANCHECK FEE
REWER-SANITAR STORM EA. 200 FT.
F
I
WATEREA W NTXLECTR
ING FE' .7 �n
NODCETO APPLICANT.(. a0et making this Cenificafe of F.xe don, you s old
battens subject m the Workers Cnmpenmtion pmvisions of Ne La r Cede, yo ust
forthwith comply with such provisions cr Nis permit shall be deem revoked
CONSTRUCTION LENDING AGENCYI
I hertby aRummm there is. conswction lending agencyf rtheperformw f
the .,it for which this pemdt is Issued (Sec. 3097. Civ. C.)
lender's Name
EATING
wjTER SE
PAA
Date Receipt#
iBIDE PLMB. .FT.
.
TOTAL:
Landes, Address
TOTAL:
1 certify that 1 have reel this application and state that N about inftumation is
correct. i agree to comply with all city and county ordinances m state laws relating to
building construction. it ction. hcmbyouNoriu repreventativesofmi city m enter upon Ne
above-mentioned Propany far inspection purp.ms.
(We).gra in save, indemnify and keep harmless the Cit of Cupertino again
liabilities,judgments, costs and expenses which may in any way m eagainst ityALTER
in consequence of Ih<granting of this permit.
APP( .. T UNDERSTANDS AND WILL COMP.WITH ALL NON -POINT
SO CE iGULATID
BUILDING FEE
QIN.CHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE I /
ELECTRIC FEE
OR ADD TO MECH. '
PLUMBING FEE
AIR HANDLING UNIT DO 10.000 CFM)
MECHANICAL IEE.
CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,0(B CFM)
gnome of ApphcemVCmduart Data
HAZARDOUS MATERIALS DISCLOSURE
Will Neapplicam attar.. building occupant store or handle haaarchasma.rial
as defined by the Coplanar. Municipal Code, Chapter 9.12 and the Health and Safety
Code. Section 25532(x)?
[0Yes %;kVo
Will the applicant or nts a defused occupant use ea Air a at devices which
onet?rduux air contaminants as Defined by the Ray Area Air Quality Management
trict9
❑Yes o
.,25533^ P
I have read me hampal materialsm under Chapter 6.95 of me Cali-
home Realm ri Safety Code. Sections 25505. 25533 and 25534. I undemwed mat if me
notify meoccupant
building doenot ,which have ae ant,mat. ismym, da Certificate
of be requirements which man be rtet prior to issuarra.f n Certificate of Occupancy.
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,000 BTU
HEATING UNIT (OVER IMiWO BTU)
'
PAID
Date Receipt#
VENTILATION FAN (SINGER HFSID)
BOILER - COME (3NP OR IfM],WII BTU)
ITO
HOLLER -COMP (OVER 100,00X)IITU)
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. EL
1. Owner or.umonmd agent Data
OFFICE