28564 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - — PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT, PLUMBING.MECHANICAL L
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO APPLICATION SUBMITTAL DA":E
a sg o
OWNER'SNAME PHONE, CONTRACTOR'S NAME: TIC NO:
Se--27 yyyy /Ce'YT Q.a Go a?«u, ..a 2s6asA
ARCHITECT/EIJGIBEER LIC NO' ADDRESS
F=7 8./r LT, 4�3 C.gnjoct Cn. 9,T/2
CONTACT: PHONE. ( y - - .' I BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) eBLDp ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby storm drat 1 am[fee...d under provivams of Chapter 9(commencing QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
�Z with Section TRIM)of Division 3 of the Business and Professions Code,andmylicereers 11 RESIDENTIAL:
(y .full force and effect PERMIT ISSUANCE 1
�UU License Class Lic# _ - - - -- CSFDWL. ❑KITCHENREMODIT
Date -- Contmaar APPLIANCES-RESIDENTIAL El ADDITION C PLUMBING RE-PIPE
F,pvi ARCHITECTS DECLARATION' PANELS
❑MULTI-UNIT ❑STRUCTURAL
1 understand m 1 hall be used as public records
y Or'-,, my P
O'L MODIFICATION
� Ca UP TO 200 AMPS
�.�., Licensed Professio out TERIOR 11 CHIMNEY REPAIR
CY4 OWNER-BUILDER DECLARATION 201-1000 AMPS 1 PROVEMFNT
u1 I hereby affirm that I am exempt from the Contractor's Lreense Law for th_ I OVER IWOAMPS_ _ ❑BATH REMODEUREPAIR D DEMOLITION
66 3 C,U following ream..(Section 7031.5,Dismiss and Pmfessmns Code.Any eny ar county I SIGNS ELECTRICAL C OTHER _
tai LL which requtrea a period to construct,alter,improve,demolish,or repair any structure -
l"k7N prior to its......ce.also regmres Ne applicant fm such permnmrileasgned sta.ment SPECIAL CIRCUIUMISC,
r� a.••�]ii
that he
menacensed pursuant the provisions ofthe Contmcmrs Ircem,e Law(Chapter 9 _ _ _
aCl Q�
(commencing with Section]WO).f Dlvrxion 3 ofthe Business and Professions Cole)nit TEMP.METER OR POLE INST. GOMMERC7AL:
d c that he is exempt thereon.and the bases for the alleged exemption Any violation of 1
Section 1011,1 by any applicant for a permit sublects the"natirn to a civil penalty or POWER DEVICES CNE ANT ADDITION DROOLS SERVICE
t more than rive hundred dollars($500)
_ L1 TENANT CFOOD SERVICE
�Q ❑I,amwner of the propeny,tar my em to ees with we es us then sale coo IMPROVEMENT
x P Y 8 pemanor, I SWIMMING POOL ELECTRIC COTHER
F will duthe work,andthe atrucwre is not intended oroffered for sale(See.701 BUsmcs�
3 m end Profitss n
mns Code:The Curnmen its License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Initiatory who bolds or thereon,and who does such work himself or Hough
his own employees,provided that such improvements are not ...tied or mkred for NEW RESIDENTIAL ELECTR SQ FT.
sale If.however,the building or improvement is sold within one year ofcomplehon,th_ SQ FT FLOOR AREA $/SQ.PT.
er-builder will have the burden afpmvmg that he did not build or improve for par-
poseafsalc)
❑I,as owner of the property,am exclusively enmmetmg with licensed evarn adars to TOTAL
mwcuhe protect(Sec 76Y1,Business and Professmns Code:)The Cmuractols It --I
tense Lew does not apply m an owner of property who builds or pursuant nproves thereon,aril QT1'. PL G PERMIT FEE pT
LI<ese law PEVBHT ISSDANCE
❑Ian exempt under Sec ,B&PCfor this reason �L Iyp'j0g1_-
Owner Dat- AITR-DRAIN&VENT-WATE A) //�� VALUATION
WORKER'S COMPENSATION DECLARATION BICK FLOW PROTECT DEVICE f.e�J 1 1995
C� Ihereby affirm under penalty ufperlury one of me falln,amg declaration _ • (II-
I have and will normal.a Certificate of Consent to self-insure tot Workers Cumber-��DRAINS-FLOOR,ROOF,AREA,CONDD\ "tSTOR /1 TYPE CONSTRUCTION
— a tion,as provided for by Section 3]00 of the Labor Code.for the Nffon^ance of IS .ITAVV
work for which this permit's I...ed. - (FIXTURES-PER TRAP
C I have and will mamt.m Worker's Compensation Insurance,as required by Seem
37M ofthe Labor Code,for the performance of the work fir whmh this Permit issued GAS-EA.SYSTEM{INC, IITLE'f� � I OCC.GROUP I APN
My Worker's Compensation Insurance canter and Policy number
Carr• Policy Ni GAS A.SYSTEhf- R (EA) I
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTR. E IN'IE OR / I BUILDING DIVI IUN P rES
(Thisttnm^neel not be completed Rthe Permit is for one humdredmilars l$IWi 'qSE TRAP I
or less) Cr PLANCHECK ME
I certify that in the Performance ofthe work for which this permit is issued,I shall (SEW -SA R�J-ST IIXs 2W PI'.''
t employ any pe,s.n,sn�any manner sy as tp bee; a subecuo the W.,kc.'Campem- ENERGY FEE
APPlment ra11 r/]e.e S..j/N/4 WATER II lER / E R '
' GRADING FEE ()r '
to NOTICE TO APPLICANT If,after making this Ccmficate of Exemption,you should WATER SYSTE REATING 1 t l
l•" ti become sub3ect to the Worker's Compensation provlanas of the Labor Code,you must ¢OILS PEE
LaTa
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q.
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FL I PAID
I hereby affirm that them iI.ed(See 0m lending agency for the performance of to ccipt#
44.O the work Pot which this permit is issued(Sec 3097,Cm C.1 _-
0 Lenders Nam- , TOTAL: '
Ua Lenders Address TOTAL:
C) 1 curdy that I have read Nw application and state that 0e above mfonnnunn is I 1 BUI 1 '
W correct l agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT PER I �l �
V Z. building construction,and hereby authonm representatives of Nis eny to enactment the ISEISMIG
above-mentioned Property for inspection purposes PERMIT ISSUANCE ' s
(We)agree to save,indemnify and keep harmless the City of Cuperma against ELECTRIC PEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH (PLUMBING FEE
in - '
.sequence of Ne granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON- INT AIR HANDLING UNIT fTO I gOfNi CFM) MECHANICAL FEE/
t SOURCE ULATIONS
�! M • - LAIR HANDLING UNIT(OVER 1U.WB CFMI CONSTRUCTION T
S atumcfApp m-ontractor Date EXHAUST HOOD ONMUCT) HOUSING NOUGAT NME
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or furore building ottupantsmre or ha nllehavMmilaterial HEATING UNIT(TO IW(W BTU)
as defined by the Cupertino Municipal Code,Chapter 9 12,and due Health and Safety t/1i
Cade,Seaio^25532(aI] HGTING UNIT(QVER IN,000 BTU)
Ves C No PAID
VENTILATION FAN(SINGLE RMID) pain R e'pt#
Will the applicant or future building occupant use equipment or devices which NOILER-
`t hea.tious air contaminants as defined by the Hay Arc.An Quality Management COST(3HP OR 1 W,00D BTU)
DistnctL]Yes ❑NO BOILER-COMP(OVER Erfogo B'TU) ALL
I have read the harardoms materials mquireme ato-nts under Chapter 695 of me C AIR CONDITIONER i
ISSUANCE
foram Heahh&Safety Code.Sections 25505,25533 and 25534 1 understand that if Due NEW RESIDENTIAL MECH SQ.FT. '
building does not
enDwhich have atenantiorto isuace of a responsibility me occupant
of fire regmrements which must be met Anon.issuance nfaCM'ficate of Occupancy
Owner or auNnnuJ agent ,• Dam TOTAL: (ISSUED BY
OFFICE
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