B 0628Baal Ir.ANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT eINGTROJECT IDHANIFIC
BVILDING'PROJF.GT IDENTINICA'r10N
PFkMH' NO.
,S660t ,60 4 Z 42 �1
v
BUILDINGADDDRESS:
-
SANITARY NO.
APPLICATION SUBMITTAL Pat F
OWNBR2NAME: �/ rjjfJ
V` .,
TRACTOR'S NAME: LIC NO:
N/C
E.
CONTROI.#
n
9390
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GINE.:
kF.55: _
TACT: r
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Consultant Pees Paid by Applicant (initial)
BUILDING PERMIT INFO
BLO / ehBCT, PLUMB MECfI
LICENSED CON FRACFOR S DECL R FION
I hereby affirm that I am licensed under previsions of Chapter 9 Roauaear
with Section'Baboo(Division 3of the Basidesdaud Professions Code,and my licensPERMI9'ISSUANCE
in full force anti effect.
License Class Lilt.#
Date Gmtmetor
I
• •' ELECTRIC PERMIT.
FEE
JOB DESCRIPTION
TIAL
SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑I'LUMRING RE -PIPE
❑ MULTI -UNIT ❑ STRUCTURAL
MODIFICATION
❑INTERIOR CCHIMNEY REPAIR
IMPROVEMENT' SWIMMING POOLS
❑BATH REMOUEIJRIiPAIR ❑ DEMOLITIDN
❑ OTHHR
-
gpPLIANCES— RESIDENTIAL
ARCHHEcrs DECLARATION -
1 understand my plans shall be used as public records
PANELS
- -
UP TO 4W AMPS
Licensed Professional
OWNER - BUILDER DECLARATION
I nereny ammr mat 1 am exempt rrhm mm chtnramors Lmen,e Law rte
following reason, (Section 9031.5, Business and Professions Coda: Any city ornadty
which requires a permit m conduct, ale,, improve, demolish, m mpair any sracture
poortoitsissaaace, als. hopires the applicant for such permit,. file a aiRrednatemenl
that he is licensed pursuant to the provisions of the Character's License Law (Chapter9
(commencing with Section 7000) of Division 3(if the Business and Professions Code) or
that he is exempt Iherefrnm and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a perml dabje,ns the applicant to a civil penalty of
not more than five hundred props dollars y carig.
❑1,,the owner k, the property, or myot intended with wages
rsal their sole 7044, Business
will do coo work, Code: The structure is not intended or Case for., apply to im own,t xs
and licit, hie bu Code: The..a thrown License Low dohs not apply to if owner of
property who bulls, or imp roves thereon, and who does ouch work himself or through
his own employees,
the building that such improvements are ma Intended a offered for
said. If, however, me building orimprovemwtie sold wimin one year h[eormpleti.n, me
h Ider will have Inc burden of proving that he did not build or improve for pur-
R.)
o sae as.wner of me property, am exclusively contracting with licensed contractors to
construct the protect (Sec 7044 Business and P f C de) The Contractor's L'-
come Law does an, apply I. an owner of ficech, he builds nr i mprrves Ihereo add
who raincomis Y suah proietts with a ciannionmed, ltar,wd pursaadl mothe Contractors
Ltwnse Law.
❑ I am exem t under Sec. B & P C for this reason
201- IBm1AMPS
OVER IIHIIIAMPS
-
SIGNS ELECTRICAL
SPECIAL. CIRCUCOMISC. "
TEMP. METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG /ADDITION ❑ DEMOLITION
❑TENANJ' Fl FOOD SERVICE
IMPROVEMENT
El OTHER
POWER DEVICES -
SWIMMING POOL ELECTRIC
OUTLETS — SWITCHES — NI %TUSES -
NEW RESIDENTIAL E EC'IB
� SQ Fr. FLOOR AREA
, ,/ Qi%t
T /7D
$ /SQ Fr.
) 9
/ G 7sJ�
TOTAL:
QT�. ` r `PLUMBI - IT
PERMIT ISSUANCE
Owner Data
ALTER- DRAIN &VENT- WATER(EA
VALUATION
3 a
..
COMPENSATION DECLARATION
1 hereby affrm under penalty of perjury one of tine following dcclamtiom:
,] I have and will maintain a Certificate of Consent to self-imduro for Worker's Compeo-
union, as provided for by Section 37M of the Libor Code. for the performance of the
work for which this permit is issued.
El 1 have and will maintain Workers Compensation Insurance, an required by Section
3700 of the Labor Code, for the performance or the work for which this permit is issued
My Workers Compensatiominsurance carrier and Policy number are:
Crunch: - Policy Nn,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This eemion need norhe complwed if,he permit isf one hundred dollars ($If10)
or less.) -
I certify that in the performance ofthe work for which this Enron, is issued, l shall
not employ uay person in any manner an as m become subject m the Worker' Compen-
.,all,,. Laws of California Date
Applicant
BACK FLOW PROTECT DEVICE
DRAINS — FLOOR, ROOGARBA, CONO
-
STORIES
TYPE C'ONS'fRUCi'ION
FIXTURES - PER TRAP
GAS -1? .SYSTEM -I INC. 4 OUTLETS
- OCC.GROUP
APN
GAS - F.A. SYSTEM - OVER 4(EA)
GRFASFJINDUSTRL WASTE INTERCF,PTOR
3 aa� f CITING DIVISION :F ES
-
GRFASFTRAP
PLANCHEA11 V
SEWER — SANITARY —STORM F.A. 200 FT.
ENERGY F E
WATER HEATER WNENT/ELFCTR -
GRADE
NOTICE TO APPLICANT: If, after making mid Cenificme of Exemption, you should
become eobject o the Worker', Compensation provisions of ae Labor Code, you must
forfloarm comply with such powisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lendidgvgency for performance of
the work for which this Forma is Issued (Sec 3099, Cis, C.)
Lender's Name
WATER SYS'FEMOREATING
-
SOILS FEE
WATER SERVICE
-
PAID
NEW RESIDENTIAL PLMH SQ. FT.
me Roccipr#'
Pe T
Lender's Address
TOTAL^
BUILDING F v
I ramify ,bar l have reel this application and state mat the above information is
ehrert.l vgrco m comply with all sly and county ordinances nm see cows relating m
building construction, and hereby amhodzere predemadves of ml city m curer apom the
In wo mentioned Emparry for inspection proposes.
(We) agree to save, indemnify and keep harmless the City of Cant against
babilitics,judgmenrs. costsand expenses which may in anywayarcme against said City
in onsequenecof the grunling of Ihis permit
APPLICANT U DERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOUR EGI .ATIONS,
el A
1
-
QTY. MECHANICAL IT
- FEE
sets ,
h
PERMIT ISSUANCE
ELL '1' 1 rEE
ALTERORADDTOMECH.
PLUM G
AIR HANDLING UNIT('f0 IQ000CFM)
-
MF.0 . FF,F.
AIRHANDLING UNIT(OVER I0F00CFM)
se
CONSTR IONTAX '
Si mhreof rmoC.mrneter Date
HAZARDOUS MATERIALS DISCLOSURE
Will the ... heamor future building oc,c,aatstere or handle honoring, material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
C .de, Section 25532(e)?
❑Yes ❑Nit
vWill the applicant or future building occupant use equipment or devices which
harardous air contaminants as derided by the Bay Area Air Quality Management
)istrist? I
Year ❑Sm -
I have read the hazardous materials regoirements under Chapter 6.95 of the Cali-
fords Florida & Safety Ede Sections 25505, 25533 and 25534. I understand Ihat If the
hu'ding drys nrn wrrently havealenam, that it is my respsnsihility to notify therccupa_m
or a qu'cm tswhich mhalbemer ptinnnirwance nun CeniGhmc.f Occupancy.
.. I
EXHAUST HOOD (W /DUC'D
_
HOUSING MITIGATION FEE
HEATING UNIT(T0100.01N1 BTU)
_
-
HEATING UNIT (OVER nomfor BTU)
VENTILATION FAN (SINGL E RESID)
Dole Receipt#
BOILER — COMP (311P OR 100.000 BTU)
-
TOTAL:
BOILER —COMP (OVER 100,000 BTU)
-
AIR CONDITIONER -
ISSUANp�DATE _ Q "
/ 2 1(J
ISSUED BY'.
NEW RESIDENTIAL MECH. SQ. FT.
-
err a ndaed gent Date
TY)TAL.
OFFICE "