S 3134APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
,';BUILDING'PROJF.CTIVENB'IFICA'CION,,i Yi f,
PHIti'I'NO.
3134
BUIIDINC ADDRESS:
0 88S -
SANITARY NO.
APPLICATION SUBMH'I'AL DATE
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OWNER 'SNAMG PHONE:
yT
✓V
CONT 'RAC IOWN NAME: LIC NO,
NIC
❑
CON 'I'RI11.M
ARCHITECT/FNG[NEER: IC NO:
M/ 470
ADDRESS:
CON 'IAC '0 PHONE:
''. `fo "BU IC DING PERMIT INFO'' '
❑ Consultant Fees Paid By Applicant (Initial)
BLDG ELECT PLUMB MF.CH
LICENSED CONI ItACTOR$DECLARATION
I hereby share the( Iia, eet,odmdcrpmvisimry of Chapter 9 (commencing
QTY 'r 7 t 'EI ECPRIC PERMUF:" -'FEE' t t
•i- -aa #r
,� . i. .:. :..: .. .:. .. ..
JOB DESCRIPTION
�-�
FERMI' I' ISSUANCE .J
with Seen l 7000blafDa,inse3ofine Businessland P ,fulsome, Crdrno,dey liev,eisr'T
in full force and effect.
RESIDENTIAL: -
❑SFDWL El KITCHEN REMODEL.
APPLIANCES - RESIDENTIAL
-
License Class Lien
❑ADDITION El PLUMBING BEPIPEDale
❑MUI:1-UNIT ❑STRUCTURAL.
MODIFICATION
❑INTERIOR - El CHIMNEY REPAIR
IMPROVEMENT DSWIMMINGPOOLS
ARCHITECTSCramarioDECLARATION
I understand my plans shall he used as public records
llbeusdaspucrecor
YANF.hS, '
UP 10200AMPS
Licensed Professional -
201-1000AMPS
DE Ce ConteRAI ON
OWNER -BUILDER exempt
I hereby affiant( (hat 1 um exempt Imm the Contrncmks License Law I'or the
following reason. (Section 7031.5. Business and Professions Code: Any city or manly
❑ BATH REMODHIAREPAIR DEMOLITION
11 OTHER
OVER 1000 AMPS
SIGNS ELEC'I'RICA],
which requires a permit to construct, nher, improve, dunullsh, or repair any elvclurn
SPECIAL CIRCUIT/MISC.
-
prlono is examinee, also requires the applicantforsudi,cond to Glc asincedstaterecnt
-V
,hat he is litensalpnrsusn telneprovaion, of the Contractor's Liter,. Line (Chapter 9
(columnar ng with Section 7000) of Divi lion 3 of the Businessand Prof essima Code)or
'CBM R M FTER OR POLE I NST.
COMMERCIAL, '
that he is exempt knurl Ho and the basis for the alleged vacr ion. Any violation of
❑ NEW HLDG/ADDITION ❑ DEMOLITION
IK)WER DEVICES
Section 7031.5 byany applicant fore permit -subjects the applicant w n civil penalty of
[I TENANT ❑ FOOD SERVICE
mm r ..nre her five hundred dollars ($500).
C] 1, as owner of [lie property, or any employees with wages as their sole compmmenal,
will do the work, and the structure is not intended of off mod far sale (See. 7044. Business
IMPROVfiMHN'f
0 OCHER
SWIMM ING POOL ELECT RIC
and Pmfesaions Code: The Contractor's License Lew does not apply to an owner of
OU'I'LEIS- SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR SQ Pr.
"
property who holds or improves thereon, and who docs such work In oneff or through
his Own employers, provided that such elp loalsonts arc nal inrandod or offcral for
sale. If, however, lhebuilding or improvement is sold within, ycarefcumpl It ,the
SQ. FT. FLOOR AREA $/SQ.UP
o lie,,h alder will have [lie burden cef,losing that redid nal huild Or improve for pus
paxc of sale).
I, f Owner of the property, nm exclusivelywnlrucling with licensed contractors0oc, to
-
1 IAL'
constructt protect (S70a,L Busini andP f Cde) The Contramo: L
on d
t I lapplyt fp p ty 1 n n.ormprove,mrc
si.
QTY ;PLUMBING PERMIT;' FEE'
,d Pursuant Pursuano the Couting,1
sts far such with ac nel r(c) Icma
who lalm
t. L
PE001 Ii ISSUANCE -
Liam. Law.
❑ I am exempt under Sec. R h P C for the reasan
VALUATION
ALTER =DRAIN de VENT' -WA'T'ER LA)
Owner Dam
WORKER'S COMPENSATION DECLARATION
RACK FLOW PROTECT. DEVICE
under penalty of perjury ens of the following declarations
1 nand
Worker
❑INrve and will mniomin uCerliEcom ofCnnsem msclf-insure for Workers Cnn,pm,-
will
sutler, as provided for by Section 37(sm
of the Lima, Code fora Isomam urec of the
DRAINS -FLOOR. ROOF, AREA,`I'AND.
GJ_S'TORIES
ZZ.Ql/
TYPE CONSTRUC'T'ION
work for which this permit a issued.
F
1 have and will maintain Worker's Compensation Inwrunca, us rcyulrcd
39W of me LuborGWe, fnrthc perfom,vnw ofthc work far which this pent sued
%'` S-HA.S STEM .401JTLET$
OCC. CROUP
APN
MyWorker 's Compensation]nwmnce carrier and Policy numbsrare;
Cartier. Policy, No:
s r
SYSTFM�jj
4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
, E RL
"
17INTERCEPFOR
Nl11LD1NO•DNI51ON EP.ES-
(fhis-swlinn neat nod bemmplemd lRhepem,it is for one hundred Anil '($IfM))
nr less.)
GREASE TRAP
PLANCHECK FEE '
SEWER -SANITARY -ST RMHA.2WFT.
Icorny (hill in the performance ofthe work for which Bev permit is issu Ishnll
not employ my person many manner so as to become subjeol In the Workers 'a
ENERGY FEE "
cation Lucas of California. Date
Applicant -
GRADING PEE
NOTICE IT, APPLICANT: It, aftern,ake, this Ceeifiuleof Exemption, you should
subject la Ire Worker's Compensation provisions of the L.alafr Code, you must
WATER SYS'I ENVI BEAT INC
SOILS FIE.become
WATER SERVICE
form%itheomply with such previsions or this permit shall hedeemedrevoked.
_
CONSI'kUC'1'ION ].ENDING AGENCY
I nerenyaflinffer ere is a construction Dfuling agency farepr,hrourecof
NEW RESIDENTIAL FUME. SQ. I%',
PAID.
late Rcccipl#
,he work for which this permit Is island (Sec:. 3099, Cie C.)
Lenders Name
TOTAL:
TOTAL:
L,nden,Address
BUILD] ,1?
1 certify that 1 M1ovo rend mil application and state that the above inhnnmtlon is
QTY stncHANICAL.PERMIT -'f; - FEE S.• .
f. ( t
eto comply with all city and ty u - t d t t m I g
Correct. I fgreo
build'ng co,neuci on soli herhrarmor veapr-emaf c. oro -s eiymemernptmme
-
Se1SMICIT
PERMIT ISSUANCE
ELEC'CRIC sCE
above-mentioned property for impmtion purposes.
(We) agree to save, indemnify ad hornless Wo City of Cupertino a stw
mkart{,
ALTER OR ADD TO MCI].-
PLUMPIN, F.E
liatuhnies,Judgerents, coca and expenses which may in any way aecme against seat City
inconsegaeeccofthograntingofthi,permit.
AIR HANDLING UNIT (TO Igaw GPM)
MECIIANICAI. ,
APPLICAN'TUNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER I TWO CPM)
CONSTRUCTION TAX
Signaereof ApplicsnpCmdevemr Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD (WIDUC'I)
HOUSING MITIGA'T]ON FEE '
HEAll INC. UNLI_TO 100,000 RTU)
Wllideapplicanua fair, build'mgocmipan. ....color lie Ineordousmatcrisl
it, defined by the Coat inn Municipal Cade, Carrier 9.12, and life llcalth Imd Safety
Code, Section 255320[)?
I IHA'TING UNIT (OVER 100,000 BTU)
E] Y" ❑No
Will the applicant or Cetus building cArmam use equipmevn or device, cal icM1
emit hazardous air contumimears as defined by the Bay Arca Air Quality Management
PAID
pent RceelptK
VENTILATION FAN (SINGLE RES ID)
BOILER- COME 0HPOR]00,00i) RTU)
f0'I' L:
BOILER - COME(OVER 100,000 BLU
District'
71Yes EINo
AII4 CONDITIONER
I have read the hazardous oilmodsrc is under Chapter 6.95 of the Call-
ui p
ISSUANCE DATE
- NEW RESIDENTIAL MECII. SQ. PI'.
fomiu Health ti Seely Cute Sactions25505, is my and 25534.1 understand tnat if me
building lust ismyceofasCertyicate(ifymcoaire, l
/�
7 / -
`�/�y/�)
aflhertgnircmnnswnichmustbemttpriortoissnvneeofnCenilieumaf Ocatpnncy.
uire eats which be met prior to
ISSUED BY: �
TOTAL:
O,wrorauthonledagent - Date
OFFICE