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CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPI.ICATIONTERMIT PLUMBING -MECHANICAL.
"I BUILDINGPROJF.CTIDE.NTIFICATION'
PF5` NO
0354
0354
-
BUIIAINGADDRESS:
SANITARY NO.
APPLICATION SUBMI'1'I'AL DATE
10 7 AtJsp,J -
OWNER'S NAME: t PHONE:
s 'L5 Z a 910
CONTRACTOR'S NAME:. LIC NO: .(
O 1 Z`F e)
NIC
LiIo0
CONTROL
ARCHITECT/ENGINEER: - LICNO:
ADDRESS:
5 J 0
- PHONE:
CONTACT.
o^ j0
" BUILDING PERMIT INFO
BLDG HLECT PLUMB MECI I
❑ Consultant Fees Paid by Applicant (Initial)
Fulax- Ms ccs 45713321,❑
❑ ❑
LICENSED CONTRACTORS DECLARATION
1 herehy afm thfirI 1 am 1 eenked d p f chapter 9,¢a o n g
QTY ELECTRIC PERMIT '� FEE
- -1 "
JOB DESCRIPTION
license is
with Sachem 70011 Civilian '+ fdwl afire,, rod Profession, Gude and nny fi
in full force and effect. �2_4,6
PERMIT ISSUANCE
—
RESIDENTIAL'
❑SFDWI. ❑KITCHEN REMODEL
APPLIANCHS— RRSIDRNTIAI.
PANELS -
UP T02W AMPS
Liareoclass hic.N /
Dale Gmmator
ARCHITECTS DECLARATION
I understand my,I..a shall he used., Public reefed,
'
❑ADDITION OPLUMH]URAL PE
❑ MULTI -UNI T ❑STRUCTURAL
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT ❑SWIMMING POOLS
Licensed Professional
201-100aAMPS
OWNER -BUILDER DECLARATION
1 thereby sffimt bar 1 am exempt Beatific Gmlmclor'a License Law fm the
following tenser. (Section 90315, Business and Professions Code: Any city br wanly
❑ BATH RF,MODFUREPAIR ❑ DEMOLITION
[_1 OTHER _
OVER 1(XX)AMPS -
_
SIGNS ELECTRICAL
which requires a permit 1. actmmd, alter, improve, demolish, or repair nny mmaute
SPECIAL CIRCO IT/MI SC.
prior to its issuance, also requires the applicant for such permit to file a signedxtutement
that he is licensed pursuant to the provisions of the Contrecmr's License Law (Chaptir9
(commencing with Section 7000) of Division 3 of the Business and Professions Code)or
that he in exempt therefrom and the basis for the alleged exemption, Any violation of
TEMP. METER OR POLE INST.
COMMERCIAL,
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section 7031.5 byany applicant for a permit subjects the applicant o a civil penalty of
POWER DEVICES
[]TENANT ❑ FOOD SERVICE
not more than rise hundred dollars ($50d).
[:]Las owner oftha propeny, or my employees with wages as their sole compensation,
will de the work, and be treetere is not intended oroffered for sole (Sea. 7044, Business
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
3 and Professions Code: The Contractor's License Law does not apply to an owner of
OUTLETS—SWITCHES—FIXTURES
propeny who huilds or improves thereon, and who does such work himself or hrough
his own employees, provided that such improvements are not intended or related for
sale. If, however. the building or Improvement is sold within one yearofcomnliniar,the
NEW RESIDE91'I AL ELECTR
SQ, PP. FLOOR AREA
$ISQ. PI'.
onsurebuilder will have the burden alternating That be did not build m improve for pur-
poseoLsuleJ,
❑ 1, as owner of the propeny, am exclusively contracting with liccnerd contracer, Int
p I1 D
TOT
instruct the ppecat (Sec. 7044, Business and Professions Code) The Comedienne's Li-
rearsa Law does not apply to an owner of property who huilds or improves thereon, and
t
QTY. ', ', PLUMEHNQ PERMIT
who commits for such p Jells with a comracmr(s) licensed pursuant to the Comment's
[I1�
JUL OGEC
PERMIT ISSUANCE •
License Law. - -
Q lam exempt under Sec. .B&PCforthisrenson
/RI
-
ALTER — DRAIN & VENT —WATER RIA )
NLA. T10N
Owner Dam
-. -
1'�.((�C p�
WORKER'S COMPENSATION DECLARATION -
RACK PLOW PROTECT. DEVICE
I hereby ulfitm under Penalty of perjury ane of the following deafen ium:
I JoO�'••r
1 JJJ
❑Ihave entl will maintain aCerifca¢orGmsenlln self -insure lar WmkeCc Camper-
,soon, r provided for by Section 391X1 of the Lrtwr Gsde, for the performance of the71
wark fico which this permit iss issued.
DRAINS— FLOOR. ROOF, AREA, GOND.
TORIES
-
TYPE CONSTRUCT ION
FIXTURES—PER TRAP
ds 1 have and will maintain Workers Compensation Insurance, as required by Section
iI.of the Labor Coda, for the performance of the work for whiGthis permit is issued.
GAS—EA. SYSTEM -1 INC. 4OUTLETS
OCC,GROUP
APN
My Wake 3 Com enation Insumr-a tour r and Policy
Carier,.3T�i'S i ePolicy No.: T' ' li—t%b
_
OAS — EA. SYSTEM-OVER 4(EA)
GREASIIINUDS'TRI. WASTE. INTERC[I'1'OR
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thixseenionneed not hccompletediDhe prormilislbmnebundred dullurnl$IIXq
or less.)
veep -s ". UII,DINO DTVIEG86
GR[A$G'fRAP
PLANCHECK FEB
I certify bat in lhepufonnance of the work farwhich bis Perml, ie iesued,Ishnll
not employ nny Person in any manner so as a become suhjacl m the Workers' Compen-
SEWER—SANITARY—STORM EA. 200 FT.
ENERGY FRE
WATER HEATER W/VENIFELECfR
GRADING FEE
kation Laws of California Date
1 Applicant t
NOTICE TO APPLICANT: If, after making this Certificate or Exemption, you should
become ambit to the Walkers Compensation provisions of the Inbar Code, you most
WATER SYSTEM/TREA'rING
SOILS FBB
WATER SERVICE
forthwith amply with such provisions or this permit shall he deemed revoked.
I
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a commotion lending agency fonhe perfnrmanseaf
NEWRESIDENTIALPLMIL SQ. Ff.
PAID
Dam Receipl4
t the work for which (his permit is issued (Sm. Civ. C.)
t Lenders Name _
TOTAL:
'TOTAL:
Lenders Add
NUILDING Fil
I reality that I Hove read this applia,lon and ,ease ten the ahnve informmlon Is
- -
1 correct.I agree to comply with all city and county ordinances and state laws relating to
building wradmi liam and hereby amhmise repse sheathes of this city to ente c'mar the
'QTY. MECHANICAL PERMIT ( FEP
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC PEG
derve-roci oned property for Inspection purposes,
(We) agree m a.ve, indemnify and keep harmless the City or Calandra ngninsl
ALTER OR ADD' 10 MUCH.'
PLUMBING FEE
fiahiufe,,)udgmems, costsard aspen... whielt may in any wu,,d...eaidktmid City
in asequence of the gaming or this remelt
AIR HANDLING UNIT TO 10,(M CFM)
MECHANICAL THE
APPLICANT UNDERSTANDS AND ILL COMPLY WITH ALL NO POINT
S011RCE REGUL 01.
AIR HANDLING UNIT (OVER d0NTCFM)
CONSTRUCTION TAX
y
-/ -Zp��7
1
tgnatum of Appllcant)Comacbr Dere
HAZARDOUS MAT ,S DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION PEE
HEATING ON IT TIO I natural BTU)
Will the upplicanl nr rauro buil ui�ca pere xfine handle lament ers material
as defined by the Cupertino Municipal Code, Chapter 912, and the Health and Safety
- Code; Section 25532(a)P -
HEATING UNIT (OVER 100,000 BTU)
❑Yat No
VENT] LATION CAN (S INGLE RES ID)
PAID Date Receipt#
e011.ER—COMP (3HP OR 100,F010 BTU)
Will the applies., or future building necnpant use equipment m devices which
mil hazardous air contaminants as defined by the Bay Area Air Quality Management
'TOTAL:
BOILER — COMP (OVER Ina.[NX1BTU)
District?
❑Vev 7 N
AIR CONDITIONER
I have read the hazardous materials requirements, under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
ratio. Health & Safety Cede, Sections 25505, 15533 it 25534, 1 understand that if the
building des no, eumendy have tenant, that it is my responsibility to notify the raCupvnt
of the requirements which must b, ma prior to issuance of a Camfam of Occupancy.
-
ISSUED BY:
TOTAL:
Owner or authorized agent Dole
OFFICE