S 2661 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L'S 2 6 6 .$
11UIIDING PROJECT LIF\TIFICA'I'ION J L FV111
PUILDING ADDR[SS:
SANITARY NO. APPLICATION SUBMITTAL DATE
Cc q v boo k Tt r�. r Sb
O 'R:S NAhf/S I ONIi: C TRA OR'S NAME' LI NO 3
r/ CON I'ROL4
A CHTTECT/ENGINEER: C NO: AD PSS: LJ
Oile
AMVKVrd
CONTACT: PHONE:
BUILDING PERMIT INFO '
❑ Consultant Feces Paid by Applicant(Initial) BLDG ELECT . PLUMB MECH
�/ oI ❑ ❑ X ❑
LICENSEDCOcensed TOR'SDF.CLARA ON QTY ELECTRIC PERMIT
1 hereby affirm Nm 1 am licensed unser provisoes of Chapter 9(commencing FEE JOB DESCRIPTION
��2 with Semion]IX)O)nl Divisiun3ofthe 9ucinaxund Prnl'essinto Cnde.andnry license lx
in fullforee acts cR d PERMITISSUANCE R - IDFNTIA
GZU Lcense Cl z C� Le. 3a5 ❑SFDWI. ❑KITCHEN REMODEL
W Data Contractor APPLIANCES-RESIDENTIAL
❑ADDITION ❑PLUMBING RE-PIPIT
66 ARCHLTECPB DEC. ATION
O
Z y I nndemomd my Pons shall be used ss public records PANELS ElMULTI-UNIT ❑STRUCTURAL
A UP TO 2M AMPS MODIFICATION
FFQ[�'.,1'] 1W I oacsuond ❑INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-100OAMPS IMPROVEMENT EjSWIMMING POOLS
O W Q I hereby rafinn that I am exempt from the C^ntraaor's License Law for the OVER IIXX)AMPS ❑BATH REMOeDEUREPAIR ❑DEMOLITION
3 LL F following Tres..(Section 7031.5.Rosiness and Professions Cade:Any city ler county SIGNS ELECTRICAL El QTHER"3�CTFQ
44-11LL Om which rcy permits era titer P tlmlisry pa anystmctoe
Pe, r L also y tm-th applicant ura ie, i. signedrmtement SPECIAL CIRCUIT/MISC.
} thmM1 I' with
se, tr l p w Iol C t t T'cL I 'IChaprer4 / aI L nj
U�00 (e°m 'ng )ry Sect 7oX)) fD' is 3 IN Business' nsP f.. nx Cadc TEMP.METBE OR POLE INS . COMMERCIAL
d a
�^ Scay that he is cxempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/AUDITION ❑DEMOLITION
ectionN Sion 7031.5 by any applicant for a promitsuhjects the applicant to a civil peachy of POWER DEVICES
Z y not marc than five handled dollar.($500).
❑TENANT ❑FOODSERVICE
�=O []I,as nwnernfrhe propcny,nrmyemployecs with wagesuNeirsolerompcnsariun. SWIMMING POOL ELECTRIC IMPROVEMENT
SFq will do the workvtd thesbucture is not itne^doloroRered far sale)Sec.ODM,Business ❑OTHER
6 g and Professions Code:The Contractor's License Law docs not apply loan owner or OUTLETS-SWITCHES-19XTU
popemy who builds or improves thereon,and who does such work himself or through
his own employees,provided that such imprncoments am not intended or offered for NEW RESIDENTIAL ELECIR
sale.IL howeverthe buildin,mimprnvmnentis.sold within one your ofatmpletlan,the SQ.IT.FLOOR AREA $ISQ.ET.
owner-builder will have the human of proving that he did not build or improve For Pur-
pose of sale.).
❑I,as owner of the propery.am exclusively contracting withic'@oed ocnanutrcLmi 'OTAL
occasional the pobst(Sec.91,14,Burinoss and Pruenuons Codee ) rs .
-
carewl.awdaes not apply loan Owner ofpropeny who builds ler improves theme.,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a commands)licensed puna tto be Comocto s
License Low.
❑I am exempt under Sec ,B&1'C for this reason PERM["I'ISSUANCE
Owner Date ALTER-DRAIN&VENT-WATER(EA)
WORKER S COMPENSATION DECLARATION VALUATION
l hereby affirm under Penalty ofperjuty one of the following dealamtions: BACK FLOW PROI'ECL DEVICE
❑I have and will maintain aCcrtifOmofConsentto self-insum for Workels Cooper. DRAINS-FLOOR.ROOF.AREA,COND. SOOt 0�
satin provided lit by Section 371X)of the Labor Code,for the performance of the STORIES TYPE CONS"TRUCTION
for which his penult is issued FIXTURES-PER TRAP
orj I have and will maintain Worker's Compensation Insurance,as required by Section
37W of the labor Code.for the Perfo ce of the work for which this parmi t is issued. GAS-EA.SYSTHM-I INC.4 OUTLETS
My Wok•'s ti n err Tomos P.Iaymu b .r^ OCC.GROUT'
`(1��� ten u amm�ec `s
Camer._yyla Policy No. QI GAS-HA.SYSTEM-OVER 4(EA) �ZO
CERTIRCANN61e EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEWNDus DO.WASTE INTERCEPTOR
(Thisseaionmeetlnal becaoPletedifNcp mitisforonchundreddollam($IMIJE
BUILDING DIVISION FEGS _
err lass ASE TRAP PIANCHECK FEE
1 cmify thw in the perfarmvnec of the work Carwhich Nis permit is i"faid.I shall
0,� not amplify any Person in any manner ser us to become subject to he Workers Cooper. ER-SANITARY-S T ORM EA.21X1 FT. IiNERGY PIiE
.rano lows of Cullfomia.Dam
z O Applicant ER HEATER WNEING/ELEC IO
y NOTICF TO APPLICANT:IL after staking this Certificate of Exam tion,you shellGRADING FEE
a ; become s.bjeo o the Walker's Compesadnn provision of Ne Lobar Code,you mastR SYSTEA1?REATINC SOILS FEE
4 Q forthwith comply with such provisions or this Permit shall he deemed revoked. R SERVICE
1) z CONS'1'kUCT10N LENDINGAGI3NCY RESIDEN'GALPLMB. SQ.IT. jPA
L) O lhereby a rm that isac^nntuction lending agency far the performance ofP
W P rho work for which this permit is issucd(Sec.31X)],Civ.C.)
0 U Lender's Name Undoes Address
� W TOTAL:
s pr 1 certify that 1 have read this application and.Hole that the above information is4 corect.I^gree u.comply with all cityand army ombamcu and sora laws miming ntMECHANICAL PERMIT FEEzbuilding conduction.and hereby alliance representatives of this city to enter upon the.Dove-amounted pmPcrty for aspect purposes. IT ISSUANCC(We)agree to save,indemnify and keep harmless Ilia City of"Cuperti^n againstliabilities,Ptdgmeoe, sta and exenses whithn.yinany wayacaveagainst saidCityR OR ADDT(I MECH.in con sequence of gtani of chis Formol.APPLICANT ' )P A SAND ' MPI WITH ALL NO -POINTANDLING UNIT(TO 10,0X0 CPM)11. DMECHAANDLINGUNIT(OV13RIg00UCEM) CONSTRUCTION TAX
5 arca Appl J anal' int UST HOOD(W/DUC)HA )OUS MATERIALS DISCLOSUREHOUSING MITIGATION FEE
Will theappliant err fuore building..Paul sore err handle haumou.mann) ING UNIT(TO 100,000 BTU)
as defined by the Cnpertiu Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'? HEATING UNIT(OVER I0dIXX)BTU)
p Yea Dior
VENTILATION PAN(SINGLE RF.SID) PAID _
Will theappllcamor from building occupant use equipment or devices which Date Recefptp
crit hauudous air contaminants co,defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
Dnu d? TOTAL:
❑Yes Na BOILER-COMP(OVER 100,000 BTU)
I have read the hazamn.s materials requiremcos under Chapter 6.95 of Ne Cali" AIR CONDITIONER
fomia Both&Safety Codi Sodium,25505.25533 lend 25534 1 anAemons that if the ISSUANCE DATE
building Nes nI It an6 Nat it ix my responsibility m nmifyt aecmpam N HW RIiS1 DENT IAL MEC)1. SQ.ET.
of the requirenem hich rot r et pnormissuanm'if.Cervi
1
OwnenunohomxN.,lotrole TOTAL: ISSUED BY: Q
OFFICE