29783APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL I PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL Q 7 Q K
RIHIM NG 29783
i 3
PRO IFs-T InEWIFICATION G J I V
Io -t -L- 60(56 "ro
L+
It 000) "1 l.2- `i$°i5
I hereby tantrums, I ora licensed under provision. of Chapter 9 (commencing
with Section 9000) of Division 3 of the Rosiness and Professions Cade, and my license is
in full force and effect
License Class Lic. X
Data Contractor
rs ARCHITECTS DECLARATION
❑ Consultant Fces Paid by Applicant (Initial)
Y W U 1 hereby a that am exempt from the Convector's License Law for Ne
; 0, following rciomi I non 7 1 S, Business end Professions Code: Any city or cnumy
=O which expires a pe ...steal. eller, improve, demolish, or repair any swnurc
y prior to its issuance, also requires the applicant for such permit to Ne a signed statement
} that he is licensed pursuantto Me provisions ofthe Convectors License Law (Chapter 9
.00 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y m pf that he is exempt therefrom and the basis for the alleged exemption. Any violation of
tlS IL
Section 7(131,5 by any applicant for a permit subjects the applicant to u civil penally of
22 N not more than five hundred dollars ($500).
-qC ❑ L as owner of the property, or my employees with wages as their sole compensation.
gay will on the work, and the structure is not intended or offered for sale(See TOME Business
4 � �_ and Professi.ns Code: The Contractor's License Law does not opply to an owner of
13 property who builds or imptwes thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
sule. If, however the building or improvement h sold within one year n[compinion, tM1.
owner -builder will have the burden of proving Nat he did not build or improve for pur-
pose of sada).
❑1,u rofNeproperty,amexclusively cxmtranlns withlicensedontrannmsi-
construct does mutt(Sec.n an Business and Professions Code:)Thew thereon, nd
cense Law does not apply to an owner of property who builds or improves thereon, and QTY.
who contracts for such projects with a wntrectogs) licensed pursuant the Contractor's
License Law.
❑lam exempt undcrSec. ,p&PCfor this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby amred under penalty of perjury one of the following declandions:
I have and will maintain a Cer ificute of Consent to self -insure for Worker's Comped-
emion, a provided for by Section 37M of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, m required by Section
37M of Ne Lubar Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance currier and Policy Mother.re:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section needme be completed Ifthe permit is for one hundred dollars (SIM)
or less.)
I cenify that in the performance of the work for which this permit is issued. )shall
not employ any person in any manner so as to become subject to the Workers Compen-
OZ cation Laws of California. Date
z Applicant
h NOTICE TO APPLICANT. If, after staking this Comfien¢ of Exemption. you should
abecome subject to the Worker's Compensarion provisions of the Labor Cole, you must
{ilforthwith comply with such provisions or this pn an shall be deemed revoked.
�z CONSTRUCTION LENDING AGENCY
V 0 l hereby offmmthauhereis ac.nsvacdon lending agency fonhe perfonnoace of
fes+ the work for which this permit is issued (See. 31107, Civ. C.)
0 Li Landers Name
Lender's AUdreas
01 I certify that 1 have read this epfiiemom and state thin the shove information is
(A mrect. I agree m comply with all city and county cadmances and state laws relating to QTY.
V 4 building construction, and hereby authoom mpressmatives of Nis city to enter upon the
above-mentioned progeny for inspection purposes.
(We) close to save, indemnify it keep hmmless the City "Cogent.. agairmt
liabilities, judgments, costs and expenses which may in any way.cerue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Signature of Applicans Contactor Data
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or future building occupant sem or handle hamrduus tnatedal
m defined by the Capetian Municipal Cod, Chapter 9. 12. tend the Health and Safety
Coda See.. 25532nd?
E] Yes ❑No
Will the applicant or future building occupant use equipment or devices which
2mallons air contaminants as defined by the Bay Area Air Quality Management
o
❑Yes F1 No
1 have read the hu ndd.ux mutcdaB requirements under Chapter 6.95 of the Cull.
fomia Health & Safety Cade, Sections 25505. M533 and 25534.1 undersand that if the
building does not currently have a tenant that it is my responsibility to notify the rccupuat
of the requirements which must be met pont to issuance of Cer ificate of Occupancy.
Owner or authorised agent Date
ELECTRIC PERMIT
PERMIT ISSUANCE.
APPLIANCES — RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
TEMEMITERO POLEINST. COMMERCIAL:
C1 NEW BLDG/ADDITION ❑DEMOLITION
POWER DEV S []TENANT ❑FOODSERVICE
SWIMMINGI'O TRIC IMPROVEh]f(J7'
❑OTHER
OUTLE =SWITCHES ES
NEW R D I ELECT' . Q Pf.
SQ. FT MOOR AREA ESQ. FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER —DRAIN & VENT— WATER (EA)
BACK FLOW PROT'ECT. DEVICE
DRAINS— FLOOR, ROOF, AREA, COND.
FIXTURES — PER TRAP
GAS — EA. 'SYSTEM- I INC. 4 OUTLETS
GAS—EA. SYSTEM -OVER 4 (EA)
GREASFIINDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER —SANITARY — STORM EA. 200 FT.
WATER HEATER WNENT/BLECIR
WATER SYSTEM/UtEATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT
P E
VALUATION
16
S'ORIIES / TYPE C(
OCC. GROUP
BUILDING DIVISION PEES
PLANCRECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date Receipt is
TOTAL:
BUILDING FEB
NIC
❑
CONTROL#(/,'J�(%��{�
� V
PERMITISSUANCE
AUER OR ADDTO MECH.
BUILDING PERMIT INFO
AIR HANDLING UNIT (TO 10.000CFM)
BLDG PLUMB MECH
AIR HANDLING UNIT (OVER H%001CFM)
FEE
JOB DESCRIPTION
RESIDENTIAL,
❑$FOWL ❑ KITCHEN REMODEL.
❑ADDITION ❑ PLUMBING RE -PIPE
13 MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR OCHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR (]DEMOLITION
❑OTHER
It� 1 ION FEE
HEATING UNIT (TO I00,000 BTU) /'I,
'
HEATING UNIT�OVER I00,0011 BTU)
cf r afYLJ
PAID ,
Data Receipt#
TEMEMITERO POLEINST. COMMERCIAL:
C1 NEW BLDG/ADDITION ❑DEMOLITION
POWER DEV S []TENANT ❑FOODSERVICE
SWIMMINGI'O TRIC IMPROVEh]f(J7'
❑OTHER
OUTLE =SWITCHES ES
NEW R D I ELECT' . Q Pf.
SQ. FT MOOR AREA ESQ. FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER —DRAIN & VENT— WATER (EA)
BACK FLOW PROT'ECT. DEVICE
DRAINS— FLOOR, ROOF, AREA, COND.
FIXTURES — PER TRAP
GAS — EA. 'SYSTEM- I INC. 4 OUTLETS
GAS—EA. SYSTEM -OVER 4 (EA)
GREASFIINDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER —SANITARY — STORM EA. 200 FT.
WATER HEATER WNENT/BLECIR
WATER SYSTEM/UtEATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT
P E
VALUATION
16
S'ORIIES / TYPE C(
OCC. GROUP
BUILDING DIVISION PEES
PLANCRECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date Receipt is
OFFICE
TOTAL:
BUILDING FEB
MECHANICAL PERMIT FEE
SEISMIC FEE
ELECTRIC FEE
PERMITISSUANCE
AUER OR ADDTO MECH.
PLUMBING FEE - -
AIR HANDLING UNIT (TO 10.000CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER H%001CFM)
CONSTRUCTI(5NTAX
EXHAUST 11001)(W/DUCT)
It� 1 ION FEE
HEATING UNIT (TO I00,000 BTU) /'I,
'V
HEATING UNIT�OVER I00,0011 BTU)
cf r afYLJ
PAID ,
Data Receipt#
VENTILATION FAN (SINGER RFSID)
BOILER —COMP (3HP OR 000.000 BTU)
TOTAL:
BOILER—COMP(OVER I00,0001ITU)
-
AIR CONDITIONER
ISSUANCE DATE
NEW RESIDENTIAL MUCH. SQ, FT.
OFFICE