S 0024TO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING • ELECTRICAL, rcnm„
BUILDING DIVISION APPIACATION/PERMIT r PLUMBING • MECHANICAL
OFFICE
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OWNS S AMC./ C t WE WE: �� ��
CONTRACfOR:S NAME: LIC NO:
NIC
El
CONTROL#
ARCHITECT/.NGINEER: I,IC NO:
ADDRESS:
CONTACT: PHONE:
BUILDING PERMIT INFO
BLDxaSk 13LEI PLUNIH MHCB
,❑ Consultant Fees Paid by Applicant (Initial)
O�Z
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SDECons of CON
Lm dee IDCONTRd under
I hereby a10rtn that 1 am licensed unJer provisions of Chapter 9 (commencing
with Seninn ](NIH)of Divinion3 of Ne Business ana Professions Cafe. ana mylianu is
in fall force and effect.
License Class Lie.#
Dam Contractor
QTY ELECTRIC PERMIT FEE
JOB DESCRI7fION
RESIDENTIAL:
❑S•DWL �KITGHEN kIiMODFiL
TION ❑ PLUMBING BE PIPE
I- MULTI -UNIT ❑STRUCfURAI.
MODIFICATION
INTERIOR C1 CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
PERh11T ISSUANCE.
APPLIANCES - BESIDES 'DAL
In6a
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ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
PANELS
UPT02MAMPS
` W Licensed Profesein el
201-1000AMI'S
pKg OWNER -BUILDER DECLARATION
1 frothy .from that I am exempt from the Conaactnr's License Law for the
O L U following reason. (Section ](131.5, Business and Professions Code: Any city or county
IL which requires a Permit est consumer, aper, improve, demolish, or repair any sormame
V3. st prionuils issuance, also rcyuires the applicant for such permitmEleasigncJ statement
0
thancckllcamecip... III no the porco..as ofthe G�mrucmr'x Liceme Luw [Chupter9
y�.c, (commencing with Section 7000)ofDivisinn 3ofthe Business and Professions Code)or
y o Y that he is exempt therefrom and the boas for rhe illegal exemption. Any sad. ion of
Section by any applicant suM1jurs the applicant to .civil pemlry of
4X1
Z py. nm more than five hundred dollars(5500).
G❑ L usownernfthu properly, or my employees with wages us their sole compensation,
7I44, Business
❑BATH RE EPAIk (]DEMOLITION
❑ OTHER
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIALCIRCU1T/MISC.
'I EMP. MILER OR POLE INST.
COMMERCIAL:
❑ NEW BLDGIADDITION ❑ DEMOLITION
❑TENANT FOOD SERVICE
IMPROVEMENT
OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-SWITCHIS-FIXTURE
will dothe work, and the evumurc is nm intended modeledlin sole (Sec.
kal3 m and Professions Code: The Contractor's License Law does not apply m an owner of
builds improves thereon, and who does such work himself in through
Frupeny who an
his own employees, provided that such impassioning an not intended an offcmd for
vent is sold within one year ofeempletion.me
sale. IL however, the building or improme
NEW RESIDENTIAL ELECIR110
NO Ff. FLOOR AREA
5/SQ. FT
nwner•hm1d,r will have the burden of proving that he did not hand or improve for par-
poseofmle.l.
F)1, m+wn<r of t e prnpeny, am exclusively convecting with licensed contractors to
consvua rhe proje (Sec. ]1144. Nosiness and Professions Cale:) The Contractor's Li-
OarraLuwdown upplymanownerofpropenywho buildsorlmproves thereon,and
LI B
WY
00TAL.
QTY. PLUMBING PERMIT FEE
who Co.masfu chprojecrs the colaals) licensed pursuumm the Cnntmcto's
License Lnw.
❑Iumexe rider Sec. .B&P C Aho naso
•✓!
�I
PERMIT ISSUANCE
ALTER -DRAIN & VENT- WATER (FA)
pVrA•LU�A1TION
~F'ri /�j�JV
15
`vxnet ORKI3R' COMPENSATIONDECLARATION
BACK FLOW PROTECT. DEVICE
hcreh aRrm unJer peasilyof perjury one of the fol lowing declarations:
❑ Ihnve mW will maimvin aCenificnm of Consenunnelf-Insure (or Worker's G+mpen-
DRAINS- FLOOR. ROOF, AREA, GOND.
STORIES
'I'YPECONS'I'RUC'HON
sation, as provided for by Section 37M of the Labor Code, for the perf ermace of the
work fur which this panni. is issued.
--
FIXTURES - PER TRAP
❑ 1 have end will maintain Workers Camp rsommn Its... a, as required by Section
37W ofihe"WrCwle,for flue performance ofthe work for which this pliant is issued.
GAS -EA. SYSTEM-] INC.0l1TLF7S
OCC. GROUP
APN
GAS - EA. SYSTEM -OVER 4 WA)
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTI FKATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE:
GREASEANDUSTRL WASTE INTERCEPTOR
HUILDING DIV ISI(]N hEFS
(Un, sectionaeWna becompleted tithe permit is forone bundmldo1lars(SI08)
GREASETRAP
PIANCHECK FEE
SEWER - SANITARY - STORM EA. 200 IT.
ENERGY FEE
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I lenity that in lbs perfnrmanceol he work for whkh this permit is issued, [,bull
not employ any person m any manner ro as to hecome object to the Wnrkers' Comae.-
satin. Laws of California. Dare
Applicant
WATER HEATER WNFNTIELIE.0 It
GRADING MEO
NOTICE TO APPLICANT. If, robs, making this Cer ifierm of Exemption, you should
become subject m the Workers Compensation provisions of the Labor Cale, you must
fnrNwith comply with such provisions nr thin lxtrma shall adeemed mvnked.
CONSTRUCTION LENDING AGENCY
Iherchy affirm thauhere isaconstruction lensing agency for the perforr.mnu of
the work far which this permit is issued (Sec. 3097, Civ, C.)
Leaded Name
WATER SYSTE:MO'REATING
SOILS FEE
WATER SERVICE
PAID
Data ReceiprX
NEW RESIDENTIAL PLMB. SQ, FC
TO
BUILDING FEE
TOTAL:
Lenders Address
1 certify that 1 have mad this application and site that the above information is
contort. l agree to comply with all city and county ordinsnces and Sum laws relating to
building construction, and hereby a ilsore mpmaratiives of this city to enter upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
ELECTRIC FEE
above -menti ed pmPar for inspection purposes.
(We) tea msam, indemnity and keep harmless the City of Cupertino against
liabiliries,jud meats, avuma expenses which may in anyway seems against said City
in consequen cof the greni of his permit.
APPLE UNDERST D NO WILL COMPLY WITH ALL NON -POINT
PLUMBING FEE
AIR HANDLING UNIT(TO IMOOCPM)
MECHANICAL FEE
SOUR( ± :GULATIO
AIR HANDLING UNIT(OVER 10,000CFM)
CONSTRUCTIONTAX
sI
ign coe; pelican Co.acrar Date
Signifies, ;
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building rccupam store or handle haeradou.s mamost
as defined by the Capeninn Municipal Cole, Chapter 9.12, end the health and Safety
Code, Section 25532(.)'1
EXHAUST HOOD(W/DUCf)
HOUSING MITIGATION HE
HEATING UNIT (TO 101000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILANON CAN (SINGLE RESID)
❑Yes El No
PAID-
Datc Receipt#
BOILER - COMP (3HP OR 1(10,000 BTU)
Will the applicant or futuresbuilding by the Bt use allotment.AQuor devices which
emit hvuNuus air cuntnminams as aefincd by the Bay Aree Air Quality Muwgetrmm
TOTAL:
Df,vill?
❑Yes No
BOILER -COMP (OVER 1011.IX1) BTU)
AIR CONDITIONER
I have read the Encomiums tmamrick requirements unJer Chapter ti 95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. fT.
fomia I1ea0h As Safety Cale, Sections 25505, 25533 and 25514. I uMemand that if the
building dens not currently have a m...1. Nm it is my rawmaibiliry, to oudfy the occupant
of the requimmeres which imp he met prier to isevance of. Camp wifte of Occupancy.
\'1�' (�//J/'
ISSUED BY: v — ' ,
TOTAL:
Owner nr umhariud ngenr [)ate
OFFICE