30748APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY, OF CUPERTINO BUILDING - ELECTRICAL PERMIT NO. 30 / /1 O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL I (�o
BUILDING PROJECT IDENTIFICATION
BUILDINCADDRESS: - SANITARY NO. APPLICATION
2 SUBMITTAL DATE
Z-V7—V1,
OWNER'S NPIdE; _ .PHONE: C R CfOR'S NAME: LIC NO:
V r��, 1� �LI CONTROL p
ARCHITT(.'I/E GANEF•\ r— 4) O. A\ RES [a
CONTACT PHONE: PHONE: FV_ • `BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
1 hereby offrm that I am licensed under provisions of Chapter 9 Bemmencinp
{OOZO with Secsion]Uq))of Division3of me Rosiness end Pmressiom Codeindnaylicencir
Fin full forte end attar.
�U License Class Lic.N
� Z Dom Contractor
Fly
ARCHITECTS DECLARATION
ZO {aA'Zi 1 uridersmnd in, plans shall be used ea public records
OWNER -BUILDER DECLARATION
1 herehy affirm that I am exempt form the Contmmors License Law porous
following reason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit to construct, alien improve, demolish, or, repair any structure
prior to its issuance, also requires the applicant for such Permit to file a signed statement
that he is licensed puna.. to the proskimrs of the Cootramora License Law (Chapter 9
(commencing with Section 7") of Division 3 afore Business and Protamines Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of
not room than Eve hundred dollars ($50%
0'1, as owner of the property, or my employers with wages as their win compensation,
will do the work, and the cmtaum is not intendedoroffere l for sale (Ser. ]OW, Business
and Professions Code: The Contractors License Law does nm apply to an owner of
property he builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements art not intended or offered for
sale. If, however, the building or improvement is sold within one year of completion, the
owner -builder will have dm burden of proving that he did not build or improve for pur-
pow of soled.
E] 1, es owner of me pmpmy, um exclusively contracting with licensed contractors to
construct the pmjerm (Sec. 7044, Business and Professions Cade:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such prejecu with a conuactons) licensed pursuantto the Communes
License Law.
El 1 am exempt under Sec. , R & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
i❑ I have and will maintain a Caniot of Common in arlf-inaure for Workers ComPen-
.tio.,
o moninself-insureforWorkersCompen-
ation, as provided for by Section 39W of the Lahm Ccala for the performame of me
work for which mis permit a issued. -
I hove and will maintain Workers Compemoram Insumame, ax required by S—non
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Came,. Policy No.:
A'I R OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thies edonn not o plered if1hapennit is forone hundred dollars Stop)
or less.'certif that' the
in nee nectarine work forwhich this permit is issued,Ishan
not employ an an ins arms)tis @sler�y'ogm subject to the Worked Co npen-
q y NOTICE TO APPLICANT: If, after mdkilrg this Ce tificme of Exturnium, you should
a became subject to me Workers Com pam�lss�ltion provisionsof the Inbor Code, you ..It
madevitb comply with such provisions or this permit shallbo deemed revoked. _
Q
z
CONSTRUCTION LENDING AGENCY
L) Q 'l herebywhich
thi thermere ismad(San. 3 97,Cis. agency for the perfortnancc of
0 � the work far which this pcmait is issued (Sec. 309], Civ. C.)
t) Lenders theme
l.endera Address
1 mify mat I have mad this application and state that the above information is
A.1 agree m comply withall city and county ordinances and state laws relating m QTY.
U � ng conswcuon. and hereby authorize repeascnutives ofthis city to enter upon the
I al�iove-memlonc , y h r nspecIum purposes.
(We) ra m a e. indemnify trod keep harmless mhc City of Cupertino against
liabilitickjVL;N
sss nn x set whish may in any way accrue against said City
in ecosequ truthmnri g of w permit.
APPLICAST ND. AND WILL COMPLY WITH ALL NON -POINT
SOURCEN.
t 20 H
Signamreof ApplicanBCommrmr - Dam
HAZARDOUS Is E AIS DISCLOSURE
Will me uppli<am or finure hail mgr eupunt xtore errhandle hazardous mumdnl
as defined by me Cupetaivo Municipal . Chapter 9.12, and the Health and Safety
Code, Seaton 25532(x)4
❑Yes ❑Not
Will the applicant or future building occupant use equipment or devices which
Nall., hazardous ear noncom nants as delated by the Bay Area Air Quality Management
I h e read h o x mots mis requirerwncn under Chapter 6.95 of the Celi-
fumia Heal' & Saf ry C 'utio 25505. 25533 end 25534.1 understand tent if the
building not tly ho ea mr,masitismymsponsiidi". mify m�occupant
name rano phsn max etrkimmiasuanre orn cenir�nr+Kar<{,pyasy.
ELECTRIC PERMIT
PERMIT ISSUANCE �}
APPLIANCES -RESIDENTIAL '1
PANELS`
UPTO 200AMPS
201-1000AMPS
OVER IOW AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST. Ile
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECfR SQ FT.
FEE 1JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
�❑ADDTf10N ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
�Q MODIFICATION
❑INTERIOR' B ® MODIFICATION
REPAIR
CIROVF.MENT
"SR E EPAIR (]DEMOLITION
/ -❑ OTHER
S
�Y! 1:
urtH7)�1
COMMERCIAL:
EWBLDG/ADDITION .❑DEMOLITION
ANT - ❑FOODSERVICE
IMPROVEMENT
❑ OTHER
SQ. FT. FLOOR AREA $/SQ. FT.
PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER -DRAT VENT• WATER (EA) VALUATION
BACK FLOW PRO VIC`s--
DRAINS - FLO
-DRAINS-FLO ,ROOF,A C la D. .-......ems +vnv—It—I
FIXTURESEIXTURES-PE:TR -
GAS- E. SYSTEM-iINC4GAS-EA. SYSTEM INC. O�S
GAS- EA. SYSTEM -OVER 4 (EA)
GRE,ASFANDUSTRI. WASTE INTERCEPTOR
GREASETRAP
SEWER -SANITARY -STORM EA. 200 FT.
WATER HEATER WNENT/ELECTR
WATER SYS] FAGREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
MECHANICALITRMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD OVIDUCT) '
HEATING UNIT (TO 100.00) BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RFSID)
BOILER - COMP (311P OR 1 W,000 BTU)
BOILER -COMP (OVER 1 00,000 BTU)
AIR CONDITIONER
OFFICE
SQ. Fr.
ISSUANCE DATE
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ENERGY FEL
GRADING
SOILS
PAID
Date
Receipt#
TOTAL:
s
BUILDING
FEE
SEISMIC
ELECTRIC FE
W
PLUMBING FE
MECHANICAL 'E
CONSTRUCTION AX
HOUSINGMITIGA ONFEE
PAID
- Dam
t"I Ist
W
Receipt#
TOTAL:
ISSUANCE DATE
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