S 0294 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PE7 411`NO. 0294
BUILDING DIVISION APPLICATION/PERMIT PLUMBING TIDENTIFIC 1`�
BUILDING PROJECT IDENTIFICATION
4 :7E:-;_7
UILDING wUURESS: SANITARY NO. APPLICATION SUBMITTAL DATE.OWN RSNAMIE PHONE: CO ACTOR'S NAME: LIC NO:
NIC CONIROLM
9�3- o sss9 3
ARCHITECiENGINEER: LIC NO: AD S: ❑
CA
CONTACT: ONE: 3 �� S�' BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT , PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE00
1 hereby affirm that I atm licensed under pmvisions of Chapter 9(commencing PERMIT ISSUANCE JOB DESCRIPTION
O0Z with Section7")ofoivision 3ofthe Business and Professions Cade.and my license is RESIDENTIAL,
in full farce and effect.
�U� License Clam Lic.p ❑SFDWL [I KITCHEN REMODEL
QV APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE;
F Date Contractor
DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Zpto'�, lead my plums shall he N
used as mblto rceos PANELS MODIFICATION
Oz O UP1'0200AMPS
F��u] Licensed Professional 11 INTERIOR ❑S CHIMNEY POOL
�a •] OWNER-BUILDER DECLARATION 201-10f11AMPS IMPROVEMENT ❑DEMOLITION POOLS
X'aJ OVER["AMPS [I BATH REMODEURF.PAIR ❑DEMOLITION
yy PC 6 1 hereby.(Sant that 11. exempt immune Cssions rs License Law traffic
'aaOLV following mason.Permit t ]onstr Business and ver,demolish,
Code:Any city or county SIGNS ELECTRICAL ❑OTHER
4417 a Y, which requires a permit u min,snvct,aafter,pplicant
improve,demolish ore a sig any,Immure
�0 do,heslcensepuraged1.he theapplicam tarsuch Contractors
LiceeLow(statement SPECIALCIRCUIT/MISC.
yy that M1eislicen�licensed 1.he pmvisions of the Comre rot's License Low(Chapter
V 3a�pO (eommencing with Section llp0l of Division 3 ofthe Businmsand Professions Code)m TEMP.METER OR POLE INST. COMMERCIAL:
0.q K that he is esempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
YXI Ic
Section 9031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
y not more than live hundred dollars($500). IMPROVEMENT
Q ❑1,us owner of the pmpcny,or myempinyeea with wages us thcinole rnmpenxmimn; SWIMMING POOL ELECTRIC
O will doth,work,nndthesoucwreisnot imendedoroRercd for sale(Sec.2D94,Business [I OTHER
-' and Professions Code:The Convector's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES /
a 3 propmy who builds or improves thereon,and who does such work himself or tNaugh
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however the building or improvement is sold within one year ofcomp[etiontheSQ,FT.FLOOR AREA $/SQ.FT.
owner builder will have the harden of proving that he did not build or improve for pur �" PAI
1yt1
pose of mleJ. Y
❑ 1,as owner of the property,am exclusively contracting with licensed contrechem m
answer the pmjett(Sec.7094,Business and Professions Code:)The Contractors Li. IfB �a
ectow law does not apply to an owner offampeny who builds or improves thereon,and QTY, PI.UMBING PERM IT FEE F9(Jj� g
who contracts for such projects with a cormis ads)licensed pursuant to Ne Contmttors
License Law. PERMIT ISSUANCE
❑1 um exempt under Sec. ,B&P C builds reason ITY Ur LUPE
ALTER—DRAIN&VENT—WATER(CAI VALUATIO
Owner Dae
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declaration,
I have and will maintain aCenificxte of Consent to self-insure for Workers Conism- DRAINS—FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCT ION
section,as provided for by Section 37M of the Luba Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Si
32Mofthe Labor Code,for the performance of the work for which this permit is issued. GAS—EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Work m nsationlnmmncecamrma Pulicy n�fJber
artier. F�UII ,Policy No.: SL^t(2 GAS—EA.SYSTEM-OVER Y(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASOINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need nm h,completed if the permit is for one hundred dollars(51(1)) GREASETRAP
or less.)(n
FEF.
Icrnify that in the perfmmaaceofthe work for which this permit is issued,l shall SEWI7R—SANITARY—STORM EA.200 IT.
not employ any person in any manner so as to become subject m the Workers'Compen- ENERGY FEE
O Z moon I.uwa of CaGfomia.Dote WATER BEATER WNENTMLECfR
Applicant GRADING FEE
O
z y NOTICE TO APPLICANT:If,after making this Certificate of[ixcmplum.You should WATER SYSTEM/TRHATING
a ; become subject m the Workers Comlxns ition pnrvisions of the Labor Cede,you most SOILS FEE
w .+ foMwith comply with such Provisions or this permit shall be domed revoked. WATER SERVICE
Q
.4�. Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID Date Receiprp
V QI hereby am that them is a construction lending agency for the Ivrformmer of
the work for which this pertnb Is issued(Sea 91199,Civ.C.)
H. i~ Lenders Name TOIAI.'
O lenders Address 'TOTAL:
I certify that 1 have read his application dad state Nat the drove information is BUILDING FEE
cgl correct.l agree to comply withal[city and county ordinances and state laws mining to QTY. MECHANICAL PERMIT FEE
U z building convection,and hereby authorize repreaemativesofthis city menrerupun the SEISMIC FEE
above-mnnioned property lot inspection purpose, PERMIT ISSUANCE
(We)agree m save,indemnify and keep hmmless the City of Calmdn against ELECTRIC FEE
SO
holdlities,judgments.,msanlexpen,s which may in any wayaame againmsaid City ALTER OR ADD TO MECH.
consequencein of the granting of this permit. PLUMBING FEF.
APPLICANT UNDERSTAND §ND WILL COMPLY WITH ALL NON-POINT A IR HANDLING UNIT(TO I Built CFM)
SOURCE TI MECHANICAL PEE
19 AIR HANDLING UNIT(OVER ty"CFM) CONST RUCTION TAX
Signature tippicantlContrudor aDma EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAPARDOUS MATERIALS DISCLOSURE
Will theapplicam or future building occupant more m licndle hazadous material HEATING UNIT(TO 100,011)BTU)
As defined by the Npenino Municipal Cade,Chapter 9.12,and the Health and Safety
Cede,Section 25532(,)'1 HEAPING UNIT(OVER 100,000 BTU)
❑Yes F1 No VENTILATION PAN(SINGLE RESID) PAID
Date Receipt#
Will the applicant or to,..building eacupam low equipment or devices which
.,emit hamNnus air contaminants as defined by the Bay Area Air Quality Management BOILER—COMP(JHPOR IW,IXp BTU) TOTAL:
District? BOILER—COMP(OVER Ind."BTU)
E]Yea ❑No
I have read the handmade,materials requimmems under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Cade,Sections 25505,2P03 and 25539.1 understand that if the NEW RESIDENTIAL.MECH. SQ.In
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the which mum ro met prior to issuance of a Cenificde of Occupmmy.
TOTAL
Owner nr uuorizW,gent Dam : ISSUED BY
th :
OFFICE