S 2947 (2) APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMB ING:MECHANICAL.
BUILDING PROJECTIDENTIPICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI AL DATE
n,*v e IF/ S�- 3 6 I L/ ',/
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
k_/
N/C CONTROL
❑
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ,
CONTACT': PHONE: BUILDING PERMIT INFO
�<5-1 ❑ Consultant Pees Paid by Applicant(Initial) µO RIOT PLUMMO I
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby ammo mat 1 air haeaee der pa.isn,n.ar curl her
9 ma�omeaa^g LOB DESCRIPTION
�Jaz ah Section 9000)af D'nlelon Son .and Padesstona eta dmYliceraa is
�O in PERMIT ISSUANCE RESIDENTIAL:
�y�., nfull force and eBec
6VZU Licence Cl ass "4 ❑SFDWL E2 KITCHEN REMODEL
yG1 Datc Convector - APPLIANCES—RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
z Oon CHITECT'S DE A AFTON PANELS ❑MULTI-UNIT El STRUCTURAL
y z 1 underst ad m plans shall he a avoids MODIFICATION
O z^ UP TO 200 AMPS
<F 4 k9�y,'.W�.l Licensed Prefe:ioned 201-1000AMPS ❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
N OWNER-B UR DECLARATION ❑SWIMMING POOLS
I hereby affirm that 1 am exempt form the Commmor',c Limne,Law far the OVER IOW AMPS [I BATH REMODEUREPAIR El DEMOLITION
?4y� Com.U following reason.(Sermon 9031.5,Business and Pmm.,,mm Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
W y which requires a permit to construct,ahet improve,demolish,or repair any structure Arc . G�5-
.......iissa
uln thepplicanforsuchpermine filensignedaaement SPECIAL CIRCUIT/MISC.
ta hneois alie,ns,d
panacea to the previsions of the Contractor s License Law(Chnpter9 .4.
ly CCO (commencing with Seen...0000)of Division 3 of the Businessand Professions Coda)m TIME METER OR POLE INST. COMMERCIAL:
IL rya o y that Ire is exempt therefrom and The Nei,forme alleged exemption.Any vinterim of ❑NEW BLDG/ADDITION ❑DEMOLITION
�..m Search 9031,5 by any applicant far a permitmbere,the applicure too civil penallyof POWER DEVICES
pq.�} not more than five formed dollars;($500) ❑'TENANT QPOOD SERVICE
AxaO I,as owner of,he pmperly,onnyemDlayees with wages as Meir mlewmpensmien, SWIMMING POOL ELECTRIC IMPROVEMENT
yt,1",o
0]1 do the work,malmrstrunureisact m
iunde (S
dm,afthedforsaleea.J(144,Biomass ❑OTHER
dam and Professions Code:The Contractor's License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
properly who huilds or improves thereon,and who does such work himself or Through
his own employees,provided that such improvements as not intended or offered for NEW RESIDENTIAL ELECT SQ FT.
sale,If,howriver,the huilding or improvement is sold within one ycanofcumpletionme SQ.FT FLOOR AREA $/SQ-Pf.
her-builder will have the burden of proving that he did not build or improve for pur-
pose of sole.).
] 1,as.,,,at of the properly,run exclusively commding with licensed v ntace.to TOTAL:
cause Law d project(Sec.]1144,Business and Pliay who builds
bui ds or i The Character's I,-
cause Lawdoarsach apply risovn its er actf ocauddy deemed
es dirld urreeon,and QTY. PLUMBING PERMIT PEE
who wnmaw.for such pmjeds with oconvacmr(.c)Ilcensed pursuantmthe Cnnimdor'x
F
License Law. PERMIT ISSUANCE S'S'
❑ 1 am exempt u ,B&P C far t is reason
ALTER-DRAIN&VENT-WATER(EA)
Owner Dam VALUATION
WORKER'S COMPENSA'1'10 C RATION BACK PLOW PROTECT DEVICE �U
Iberehy affirm under penally of perjury an following declarations: �Q�(J
❑ I have and will maintain a Cenificate of Consent to self-imine for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES 'TYPE CONSTRUCTION
.sation,as provided for by Section 37W of the Labor Cole,for the perfommnce of the
work for which this permit is issued. FIXTURES-PER TRAP
i] )
1 have and will maintain Worker's Confirmation Insurance,as reI
required by Section
3900 oftbe Labor Code,for the p,derannee odds,weak for which this permit is issued GAS-EA.SYSTEM-I INC,4 OUTLETS d OCC GROUP APN
My Worker's Compensation Insnranc,carrier and Policy number are:
Carrier Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION PROM WORKERS' , GRNASGINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FF.BS _ _
(This scctlon need not be completed if the a.,,is I hundred dollars($FBI
or less.) GREASE TRAP
PLANCHECK FEE
I certify that in the pelf turner
the work for subjethi,marmil is to the Workers
ompell SPWER-SANITARY-STORM EA 200 Pf.
not employ any person in any manner su as m become subject to the Workers'Compen- ENERGY PGE
OZ ppnLawsnf CnGfornia.Ome
AWATER HEATER W/VENT/ELECTR - �
z Applicant - GRADING FEE
NOTICE TO APPLICANT:If,after making this Certilicam of Exemption,you should WATER SYSTEMlI'REA'I'INC
[~
become subject to the Worker Compensation provision,of the Labor Coda,you thus, SOILS PEE
Wnn. andwith comply with such p,actions or this permit shall be dccmedre,t4ed. WATERSERVICE
CONSTRUCTION LENDING AGENCY NEW RE9IUENTIAI.PLMB. SQ.FT PAID
UO Ir%hich rte that therei snww
nsction len ding agency rnrthe perfonnm
anud Dam Receip,N
{lr H Nfowhich
the for this permit is issued(Sec.3097.Civ.CJ t
Lenders Name TOTAL:
O a Lender's Address 'TOTAL: 90
1 cerlify tMn 1 have read this application and scam dsm the above information is BUILDING PEE
dr V1 correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT PEE
UZf building construction,and hereby authorize represented vee of this city to enter upon the SEISMIC FEE
shave-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnity had keep harmless the Cry,of Cupertino against ELECTRIC FEE
liabililmi,judgments,costs and expenses which may in any way aceme against said City ALTER OR ADD TO MECH.
na
asequence ofdhe granting of this permit. PLUMBING FEE _Ciro
APPLICANT 'RS'1'ANDS D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 170 10.000 CPM)
SOURCE .'lIL 'IONS. MECHANICAL FEE
;/ r AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signatu a of Applicant/Comamor 't;',
Urate EXHAUST TO HOUSING MITIGATION FEE
IIAZARDOUS MATER LS In LOSURE
Will theaddieant or future building ca, store or bundle hecanlous material HEATING UNI00.(IIN) T
as defined by the Clara.M,mmipal Code,Chapar 9,12,:red rhe Health cad Safely
Code,Se„ion 25532(x)? HHATING UNIJ I&ITIR 100,000 BTU) (.�
❑yes nn �U PAID I /6-99 Z
VENTILATION (SIt Igb�P.$Ill76 -- Date Reacqu#
Will the applicant iu rr furore building carport A e.Air chat orQrdb devices which BOILER—CO (31 OR 104000 BTU)emitntzvrd,uc air epmnminanL as definedb Bay Area Air Quality Management TOTAL'
District? BOILER—CO Ek If10,Of1(1 BTU)
❑Vex
I have roc munloux mate uiremenm under Chamr6.95oflhe Cnli- AIR CONDITIONE
P ISSUANCE DATE.
Ibruia Heal Safety Ma Semi .c 25505, J3 an 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.FT. jd
building snot to by laved nand,that itis, yhas embiliI t of the
arup m Vl/JS
of the mama .which fabe normis Is ofv Cenifyrle/d ypune n
Owner or authorized agent T Date ISSUEU BY:
TOTAL: ue-
OFFICE