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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OP CUPERTINO BUILDING- ELECIRICAL " ,.
BUILDING DIVISION APPLICA'1'IONI'ERMIT o- PLUMBING - MECHANICAL
PERMITNU./-
BUILDING PROJECT IDENTIFICATION
V1139
BUILDINGADDRFSS: -
SANITARY NO.
APPLICATION SUBMI V'I'AL DALE,
Z el GTE /NE T���V
2�
OWNER'S NAME PHONE:
CONTRACTOR'S NAME: LIC NO:
❑
, Ts'
\RCHRHLT /ENGINEER: TIC NO
ADDRESS: -, - + -
CONTACT PHONE:
- _
BUILDING PERMIT INFO
o/M' _ fpG E-Y A4p (9 G 2
❑Consultant Fees Paid by Applicant (Initial)
BLDG ELEC ° PLUMB MIiCH
❑ ❑' ❑
LICENSED CONTRACTORS DECLARATION
I rarely affirm that 1 ntn Emenrm anger provisions of Chapter 9 anntmmcmg
QTY
ELECTRIC PERMIT
PEE
JOB DESCRIPTION .
wish Sectibn 7(g0).f Divisinn3.f the Bosiners and l'mfessinns Cade; ana mylicense is
infullforcewideffe.:t. ,.
DateClass Lic.H
Date Contrvcmr
RESIDENTIAL:
El SUDWI, D KITCHEN REMODEi.
[]ADDITION ❑PLUMBING RE-PIPE
❑MULTI -UNIT C1 STRUCTURAL
MODIFICATION
PERMIT ISSUANCE
APPLIANCES — RESIDENTIAL
ARCHITECTS DECLARATION
I make and my plan shall he used as public records
PANELS
UPTO2 AMPS
El INTERIOR DCHIMNEY REPAIR
IMPROVEMENT' "
D BATH REMOD 1aRFPAIR D DEMOLITION
D OTHER 1505 O ti il_
�f'�"'�I�
Licensed Par[ axslannl
OWNER - BUILDER DECLARATION
1 hereby affirm @m 1 am exempt from the Comractnrs License law for nc�
fnllowing newer. (Suaion 90315, himina.+untl PToI'eesions Code: Any city of county
which requires a permit a ednswcl, ulna improve , demolish, or rep.ir,any nmeurc
201- II11)OAMPS
'OVIiR IORAMPS
SIGNS BLEC'I'RICA).
pd., to its its ... re, also daRimr the tmtsmem hnsmh permitto file.signedaatemenr
SPF;CIAL CIRCVITIMISC.
,bar he is I"creed jtursn.m to the pravislore of the Comn ceir s I icense Law (Chapter 9
TEMP. METER OR POLE INST
COMMERCIAL: "
(commencing with Section 7(X10) of Uivislan 3 ofthe Business and Professions Corelor
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
See a 70315 by any mppliuvo to, it permit - Ifieel, the applicant in it civil penalty of
m
nor ate Nan five hundred dollars Bison).
O Las owner ofthe property, or my employees with wages as their side compensation.
will Jn the work, and the swctnre is nm InenJeJ omffered for sale(Sa.7UYd, 13uslness
D NEW BLDG /ADDITION D DEMOLITION
0TENAN'1' DFOOU SSERVICE
IMPROVEMENT
O OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
and 1'ofessioms Code: The Co..,. ex License Law does not apply t. an owner of
OUTLETS— SWITCHES — FIXTURES
property who build or i im theater, and who does such work himself or through
his own m
employees, provided that such improvements are not Imaided or offered for
NEW REST DETI
NAI.ULEC'LR SOFT
sale. If howevee the building or improvement is sold within one year nfrompderi.n ,the
-
.FLOOR AREA
LSQ. FT.
owner-builder will have the harden ofproving that hedid not build or improve for put-
Awn of rata
owner as of the property, contacting with licensed mmmson.o
-
♦
PA I .
r
A
, B ,i.c,, said
onstmm the pmjem(Sa.7(Idd, Business nnJ Pmfesxintts Cale) The Cnntrucmrt Li
D
ono nor apply to an owt�f- g)peny who bonds or improves thereon , tend
,
o commcls 1prsuch ro' ms wiNac m ed pursuant lobe Contractors
QTY
PLUMBING PERMIT-
PEE
g(f1/ryf
-
PERMIT ISSUANCE?
License Law. (J
O I ate exet aide Se , B & 1' C for thds reason
'••�R 27�cq
ALTER - DRAIN &VENT- WATER (EA)
wncr 1. tkd
yr uur��f¢j��j
WORKER'S COMPENS '1'1 LARADON.
rl I befchy affirm under penahy of perI f Ne fallowing Jecdartnirns:
I have and will maintain. Cenifiente of Cooscol o'clgim'ure for Waker's_Cnmpen-
ration, as provided for by Scene. 3700 of the tabor Code, for the perfomurmc, of the
BACK PLOW PROTECT. DEVICE
UNAINS— hLOOR, ItOOP,AI2PA,COND,
STORIES
TYPIi CONS'i'RUC'IION
VENTURES — PER TRAP
work for which Nis .it is issued
D I have and will maintain Worker's Compensation Insurance, as required ny Seaton
,
3700.fthe Labor Cede. for the perfomtance.frhe work fo,which Nis permit is issued.
My Worker' s Compensation Insurance carrier and Policy number are:
Carrier 's Policy No.:
GAS — EA. SYSTEM -I INC. 4 OUTLETS
OCC. GROUP
'
-
APN
GAS —EA. SYSTEM -OVEN 4(EA)
cwri CA7EOFEXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE,
(This section need not hewmpletcd if the Irish is f..one hundred dollars ($11X))
m less)
GREASFAND_USTRL WASTE INTERCEPTOR
BUILDING DIVISION FI ?135
GREASE TRAP
PLANCHECK FEE
SEWER — 'SANITARY — STORM P.A. 200 Pf.
I ceni fy that in performance of the work for which this permit is issued, l shell
set employ any Berson in any manner so as m hec.me subject m he WorkeM Cnmpem
ENIR16Y PEE
WATER HEATER WIVENTtiLECI'R
sation laws of Cafifamia. Date
Appl'sam
GRADING PEE
NOTICE TO APPLICANT: If, titter making this Cenificme of Exemption, you should
became,.dea m the Worker's Compensation provisions or the Labor Code, you rum
WATER SYSITwrREATING
SOILS FEE
forthwith comply with such provisroax or llle permit shall he deemed revoked. _
WATER SERVICE, o
CONSTRUCTION LENDING AGENCY
I herchy affirm that hem is a correction lmdingagency for the performance of
PAID
,
NEW RESIDENTIAL PLMB. SQ, FL.
Date, Receipt#
the work (., which this permit is is ... I Sce. 3097, Civ. C.)
TOTAL:
,
Lender's Nunn
Lenders Address
TOTAL:
BUILDING FEE
1 certify that 1 have mad this application and state that the above information is
correct. I agree In comply with all city and county ordinances and sate laws raising to
building convection. and hereby tra n it representatives of this city to enter upon the,
QTY. MECHANICAL PERMIT
FEE
SEISMIC FEE,
above- mentioned prepeny for inspecdon pur,swes.
(We) .grce m save, iudcmnify and keep hartnless the City of Cupeninn aga inm
PERMIT ISSUANCE
ELECTRIC PEE '
Bunt e,jud'drums,c.s¢ and experts ichma in any way rectum against said City
' n1cqu ofthega in ofthis Perot /
APPLICANT INDERS' A. 1) 'ANDWI .IC MPLYW ALL NON-POINT
SOURCE RE ILATIO S. \\
ALTER OR ADD TO MECH.
PLUMBING FEE .
AIR IIANDLING UNITOO 10,1X10 CUM))
MI[CHANICALFIif3
AIR HANDLING UNIT(OVER MAIL) CFMI
CONSTRUCTION TAX
Signewr fApplicanJComactor . Dsc
HAZARDOUS MATERIAL DI .OSURE
EXHAUST HOOD IV/DUCT)
HOUSING MITIGATION IEF.
HEATING UNIT (TO 111q(XXt BIRL
NIIINeapplleantor l'umrehuilding weal .sere orhmne he ... dounntaerial
t
as defioea by the Cupeninn Municipal Castle. Chapter 9.12, and the Health and Safety
COAL, Section 255321x)^ /
' Dyes I.
} ,and the opplicam nr it muldia,mectipant
tit Imzard.us air conwminenrs es Jefinea by the Bay A. Air Quality Management
By AcyuipmenuvdManaement
��stdm"
DYES, _o--� +
HEATING UNIT (OVER 100,000 FIT
,
PAID
sReceid
-
VENTILATION FAN (SINGLE RESIDE
Date
BOILER — CONE3HP OR 1110,000 B' I' U)
- TOTAL:
BOILER —COMP (OVER 100.1X10 B'TU)
„
AIR CONDITIONER
Bread the hazardous material q' men der Chapm,695 of the Cali
ISSUANCE DATE ,
NEW RESIDIiNTIAI. MECII. SQ. Fr.
Rod. Halt Safety Ia, Sad s 2550 + 5. 3 and 5:14. 1 unde,usad the if the
istradngdces air. nl a tenant. N' it s yrcspnn ibiditytomaifytheceeupam
.00he mqui car, w is nst im cc of Certificate of Occupancy.
L
ISSUED BY:
Owner authorized gem Doe
TOTAL:
OFFICE