S 2863 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. VERMI"r NO.
BURRING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUIL IN A D 5 SANT rARY NO, APPLICATION SUBMITTAL DATE
q*44 C&rtuj 3c,L PL,, el-8-51
OWNERS NAME: PDONE CONTRACTOR. NAME: LIC NO: SIC CONTROL#
IARC 11ECT/ENGINE : EJC NO' AU ISS: 57 ^ a /v ❑
IV,Ll 24
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BL❑Dc FL PLUMB Mn.r
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby of no mat 1 am licensed under pmvislons of Chapter 9(commencing JOB DESCRIPTION
�FaZ fail oimn70 N0)of Dlvisioa 3 of the Businesaund Professions Codeondmy license ix RESIDENTIAL
WOO to PERMIT ISSUANCE
LLl f, t OSFDWL ❑KITCHEN REMODEL
�UU License Class Lic.N APPLIANCES—RF.SIDEN'I'Ad. []ADDITION 492LUMBING RE-PIPE
F Z W Date Contractor
le,<0. ARCIII'I ECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
I_7R4 PANELS MODIFICATION
ZO co,Z 1 understand try planreco
s shall he used as public rd,
OZ-�0 UPT0200AMPS ❑INTERIOR ❑CIIIMNEY REPAIR
ra4LW Licensed Professional 701-l"AMPS IMPROVEMENT []SWIMMING POOLS
Ck F,; OWNER-BUILUIIR DF,CLARAI ION OVER IIN101AMPS ❑BATH REMODEL/REPAIR C1 DEMOLITION
yy C W Q I hereby aTm m
rthat 1 am exempt from the Cmactors License Law for the
h(0 L U following reason.(Section 7031.5,.Insulation and Pndosionn Code:Any city normally SIGNS ELECTRICAL [I OTHER
Y—�O{_ which requites a permit m construct,alter.imm
pw;,demolish,or repair any sfa m e
."71 prior to its issuance.also requires the applicant for such permit o file a sigammmemem SPECIAL CIRCUITIMISC.
north,is licensed pursuanuo the provisions ofthe Contractors License Law(Chapter 9
Wa�pO (enmteencing will,Section 70W)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR FOLD INS. COMMERCIAL,
0.q K that he is exempt therefrom and the basis for the alleged exemption.Any violation of El BLDG/ADDITION ElDEMOLITION
it 4. Section 7031.5 by any applicant for a proof subjects the applicant)a civil penalty of POWER DEVICES fix ❑TENANT ❑FOOD SERVICE
LLl H urn more than five hundred dollars($5010). IMPROVEMENT
�Z6 I,as owner of the norm mlu eeswithwu wsastheirsole atm ensaion, SWIMMING POOL ELECTRIC
�_� ❑ ProPe Y Ye p Y 6 P
F+ will Jo the work,and thesommre isnot immidodmoffered forsale(Scc.7044.Business El OTHER
aim and Professions Code:The Contractors License law cities oat apply m an owner of OUTLETS—SWITCHES—MIXTURES
property who builds or improves thereon,and who does such work himself or nuough
his own employees,provided thatsuch improvements arc not intended or aflered for NEW RESIDENTIAL ELECfR SQ 1R.
sold.If,however,the building or improvement is sold within nine ycarofeampletion.the .Fr.FLOOR ARBA S/SQ.Fr.
owner-(wilder will have the burden of proving that he did not build or improve for pur-
ptne ar sate).
C]1,a,owner of the property,am exclusively contractingwitM1 licensed contract..la TOTAL:
construct the mo,icet(Sec 7044,Ilunineea and PmNssions Cole:)The Contrectnrs LI- C
save Law due,not apply 10 our owner of property who builJ,or improves thereon,and QTY. PLUM BUNG PERM IT FF.F.
who contracts for such projects with a contraetorc)licensed pursuant rot he Cammcmrs.
License Law. PERMIT ISSUANCE Q
❑Inmexcmptund"Sm, .B&PC(armisaumon
ALTER—DRAIN&VENT—WAITR IEA) VALUATION
Owner Date
WORKER'S COMPHNSA'1'ION DECLARATION BACK FLAW PROTECT.DEVICE
1 hereby afrtmt under penahy of perjury arta of the following declarations:
I have and will maintain a Certificate of Consenmo self-insure for Workers Compen- DRAINS—FLOOR,ROOF,AREA,GOND. 'STORIES 'I'YPF.CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Code,for the perfortnanm of the O
work for which this permit is issued. FIXTURES—PER TRAP
❑1 have and will maintain Workers Compensation Insurance,or,requited by Section
3700afthe Lamm Cale,fords,performarceofthe work forwhichthis perman,issued. GAS—EA.SYSTEM-1 INC.4 OUTLEIS OCC.GROUP �]�/AJI'�
My Wor sCo ns rat a ' icy NolArTi � Q O� '
Carver s rt Policy Nn��� GAS—EA.SYSTEM-OVER4(EA) 8
CERT + AITOFE .MI'fION PR( WORKERS' GREASE%INOUSTRL WASTli 1NTERCIiPI'OI
COMPEN. TIONINSURANCE BUILOINGDIVISIONFEES
(This acedno need not be cnmplvtN ills,permit isfmone hundred dollar,(S 100) OR
or less) I'LANCHL'CK NIiE
I comity that in the performance ofthe work mrwhich this permit is issued,I shall Slzw?A,�kNI14KY—�STORMIzA. oFT.
not employ any person in any manner so as m become subject m the Workers Compton- EN
PEE
0Z saition Laws of Colitnmia.Dam WATE 1 '1'FRW/VId,U d. I' IGRADING FEL' '
z Applicant
NOTICE TO APPLICANT:If,tater making this Cer ificute of Exemption,you should WATES'I'E TI s
(~ hecoom.subject to the Worker's Compensation provisions of the Labor Code,you most SOILS FF.Ii
forthwith m
comply with such provisions or this permit shall he deeed rcvokeJ. WA'TF: RVIGE
Q
CONSTRUCTION LENDING AGENCY NEW S ' IAL('LMB 4BUILDINGFE
UC I hereby utfinl that there is aamswction lending agency for the perfmmanee of Receipt#
f, me work for which this permit is issued(Sec.3097,Civ.CJ
U Lenders Name pTOTAL:
f1a Lenders Address 'TOTAL:101-90 O
a 1 certify that I have read this application and state that the above information is concert agree to mmply with all city and county ordinances ani.11-11 laws refining do Q'Ty. MECHANICAL PERMIT FEEUZ building covwction,and hereby amhoive representatives as this city m enter upon the
above-mentioned property for inspection purports. PERMIT ISSUANCE ELECTRIC FF.Ii
(We)agree tat save,indemnify and keep Imenless the City of Cupenino against
liabilities,judgmetda,costs and expenms hich mayin any way tomme,against said City ALTER OR ADD'TO MECH. PLUMBING FEE
m
I consequence of the granting of nit.
PLICA NT UNDP STAN W ILL COMPLY WITH ALL NONPOINTAIR HANDLING UNITGO 10,000CFM) MECHANICAL 17EE
S IRCIi R ION,
AIR HANDLING UNIT(OVER 11.0011 CFM) CONSTRUCTION TAX
Signal li t/Cnnt c O
Date EXHAUST DODO(W/DUCT) HOUSING MITIGATION 17EE
HAZARDOUS MA'1'IiRIAI 9 DISCLOSURE
Will the applicant or future building exampantsmreor handle hmmidaus material HEAT]NO UNIT TO 100000 BTU) ,
a,defined by the Cupenino Municipal Cole,Chapter 9.12,and the Hersh and Safety
Cole,Section 25532m)7 IIEATING UNIT IOVI?R 100.000 BTU)
AN VENq'ILAq'IOIS PAN(SINGLE RISIO) PAID Date Rattlpt# -
. Will the applicant or future building oecupmn use equipment or devices which BOII.I?R—DDMP(311P OR If niIfTU)
coal hvammous air commfitments as defined by the flay Area Air Quality Management O T TAC:
District/ BOILER—COME(OVER I0fBm)BTU)
C)Yea 71No
1 have mad the hvardous materials requirements under Chapter fi.95 of the Cali. AIR CONDITIONER ISSUANCE DATE.
amnia Health&Safety Code,Seeders 5505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.1T.
huilding dtws urn cute that it is my responsibility m notify the wcupmt
oftherryut isnen must (pilar m' ate ofo papcy.
0. <d m Uam 'TOTAL: ISSUED BY:
OFFICE