S 1561Baal IrANTTn FII 1. IN INFORMATION WITHIN REO LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICA.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDEM 'uric I'TON
ITEIT NO.
S15 61
SANITARY NO.
APPLICATION SUBMITTAL. DAN
/IL�DINGADDRESS:
IJ
C7V
�_� U
AME: PIONS:
C 'RACFOR'g NAME: LIC NO:
L
NIC
❑
CONTR(1LM
ARCHITEC (ENGINEER: LIC NO:
DRESS:
85C T
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
LICENSED CON TRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions w Chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE
wish Scnion]I31pmf DivisionJnf@c BusirtessanJ PmfessionsCoJe, and mylicense is
in full farce and effect.
RFSIDENTIAI•
CSFDWL C KITCHEN REMODEL
APPLIANCES-RISIUIiNT1AL
License Class I.ie.M
Date—�Cnnlrecmr
PLUMBING
[]ADDITION DSTRUCTUR L PIPE
CMULTIANIT ❑STRUCTURAL.
DIFICATION
CINTERIOR HIMNEY REPAIR
MPROVEMENT f7 SWIMMING POOU
ARCHITECTS DECLARATION
I understand my plans shall he used as public records
PANELS
UP TO 200 AMPS
ensed Professional
201-1000ANIPS
OWNER -BUILDER DECLARATION
I hereby offirnt tont I am exempt from the Coulmesors License Law for the
following reason,Sect ipar]W1.5. Business and Professions CWe: Any city.1 roomy
❑BATH RFMODEI/REPAIR GDEMOLITION
❑OTHER
OVER IIXp AMPS
SIGNS ELECTRICAI.
which requires a permit m crmurum oder, improve, demolish, or repair any uncture
SPECIAL CIRC UI'1'IMISC.
pdmm in ...... we. udsonsmires the appl earn for such pvrniuo fide aligned statement
that be is licensed pursuant to the provisions of the Contractors License law (Chapter 9
(commencing with Section ](Np)of Di vision J of the Business and Professions Code) or
TIN P. M E DER OR POLE INST.
COMMERCIAL:
that he is exempt Ihereli oto and the basis for the alleged exemption. Any violation of
❑NEW BLDGIADDITION C DEMOLITION
Section 7031.5 by any applicant for it permit subjects the applicant a a civil penalty of
POWER DEVICES
[]TENANT ❑FOODSERVICE
t more (him live hundred dollar. (85131.IMPROVEMENT
C Las owner of the prnpeny. or my employees with wages as their sole compensation,
will do the work, and the slclure isnot intended p uffien l for sale (Sec.]IW. Business
and Professions Code the Contractor's License Law does not apply to an owner of
[]OTHER
SWIMMING POOL ELECTRIC or
OU'TLE'FS-SWITCHES -FIXTURES
NEW RESIDENTIAL. ELBE: R SQ IT.
property who builds or improves thereon, and who Jots such work himself orthmugh
his own employees, pmebed that such improvements are not intended or offered for
sale. If. however. the Wilding or improvement is sold within one yen ofconpletion.the
SO FT FLOOR ARBA
SISQ. FT.
owner -builder will have the burden of proving that he did not build pr improve for parr-
01psimm. um exclusivelynd cantmcdng with licensed contractors m
❑ a cheer or the
APR 27 WD
TOTAL:
�Zi/
u Site 704,
minute the pmjceUSec. o.. Business and Professions crude:) 91tu improve, do mr'. Li-
whoa Low doesnotapplyloan ownaamorem,Pwho thereon and
QTY PLUMBING PERMIT
/s
CITY Ui IaUYCnIIIYV
cersi porimprothe
who commas nutrient projects with a nommcmr(s) IiccnsW punuam no the ContrunOh
PERMIT ISSUANCE
License Low.
I to. exempt under Sec. . If & P C for this reason
ACTER -DRAIN & VENT - WATER ILA)
Owner Date
VALUATION
WORKERS COMPENSATION DECLARATION
BACK FLOW PROTF.CI'. DEVICE
under:SCtlyof the following evaluations:
under pemhy of one
I hand
SI'pRIES
TYI'L CONSTRUCI'101
❑IM1ave and will maintain eCenl37M ofConsents t) Worker's Comp
willli ai
DRAINS - Fl.00R, ROOF AREA, COND.
Code. for Cher
the
•ming as provide) for mi Section d. of the labor Code, for the perfnmmnce .I the
Labor
work for which this permit is issued,
FIXTURES - PER'IRAP
❑ I have and will ode,maintain Workers Compensation Insurance, h this Teri by Section
I]IMl of the laMor Code, fortbe Performance ofthe work for which this permit is issued.
GAS - FA. SYSTEM-] INC. 4OUTLETS
OCC.GROUP
AI'N
M Wnrke qt vin In so ice carrier and PolicyMtq
Carries 0.4T 'AZ Policy No.: rl 779 {—
GAS - FA. SYSTEM -OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRCASHINDUSTRI, WAS'T'E IM'ERCFFIOR
BUILDING DIVISION ISIS _
GREASETRAI'
PLANCHECK PEG
(This section need not he completed tithe permit is Forane Warcddollors(SIUII
or less.)
SEWER -SANITARY -STORM IA. 200 W.
ENERGY FEL
I certify that In the peloarroceofthe wok for which thispermit is issued.lshuld
not employ any person in any manner sou as m become svhyce, it) the Workers' Compen-
WATER HEATER WIVENTIELECR
GItoDI HERBS
' smion lows of C.1ifomiu. Dam
Applicant
NOTICE TO APPLICANT. IL after making this Cenificme of Exemption, you should
hec.oneh,pot to the Worker's Compensmion jammers of the Luther Grace. you must
WATER SYSTEMITREATING
SOILS ITE
fonhwithcomp.y with such pmviiumor this permit nhall W deemed revoked.
WATER SERVICE
NEW RF_SIDEN'1'IAL 111,MB. SQ. FT.
CONSTRUCTION LENDING AGENCY
I herebyaffum boat there is. twounalima lending agency four the performance of
Rec' M
-
TOTAL:
' the work for which this permit is issued (Sec. 3(97, Civ. C.)
Lenders Name
TOTAL:
Lembes Address
1
E
IELE&RIC
I certify thin 1 have read this application and late that Ilio ahove intnnrmom is
i cored, I agree m comply with all city and county ordinances and state dawsrdatingm
building construction, and hereby reunion nPrescr ive. of this citym enter upon the
QTY. MECHANICAL PERMIT FF,E
PERMIT ISSUANCE
above-mentioned property for inspection purpnsea.
Wit) agree to save, indemnify and keep harmless the City of Capetian against
PLUMBIN PLL?
lixbiditice,judgments, costs and expenses which may in any way aceton, against said City
in consequence tithe graming of this permit.
ATHR OR ADD TO MECIL
AIR HANDLING UNIT DO 10.000 CFM)
MCCHANICAL 'E
APPLICANT UNDERSTAND AND L COMPLY WITH ALI. NON -POINT
E REGUI.ATION)[�
-7-1
AIR HANDLING UNIT iB,((CFM)
CONS 'TRUC'ION 'TA
Signature ofAppl.cantlContrdcor Date
EXHAUST HOOD(WTUCf)
HOUS LNG MITIGATION FL
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO I UO,M) BTU)
Will the applicant or fnmm building occupant store or handle musualus material
as defined by the Cameroon Municipal Cale, Chapter 9.12, and the Health and Safety
Code. Section 25532(a)'t
HHATI NO UNIT (OVER 100,000 IITU)
VA
VI3NTILATION FAN (SINGLE RESID)
E] Yes CNn
PAID '
Date Receipt
Will the applicant or future building accupanl use equipment our devices which
m�Jnus as defined by the Be, Arca Air Quality ManagementTOTAL:
mil haearJom air comm
BOILER-GDMP(JHP OR 100.0001111H '
BOILER -COMP (OVER 100.000 B'TU)
Diuma I
E) Yes El No
AIRCONDITIONER
ISSUANCE DATE
I have nitride Want moteriels mquirements under Chamer695 of the Calm
NEW RESIDENTIAL MECH. SQ. Fr.
form. Health & Safety Code. Seetions 25505, 25533 ad 25534. 1 undcrwmJ that if the
Wilding dos nut currem0y hoe a tenant. mm it ix my resrynniNJity est nrnify the acupanl
of the requiremrns which must M met Inform issuance of a Certificate of Occupancy.
^ 0
ISSUED BY.��`
'ICTAL
Owncrse umhonmdagent Date
OFFICE