S 2360H
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING, - ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONA'ERMIT ^'!^uX�xuntoo r.,m�ciAry L Aon r^^ C+ 2360 OCO
yasoo C_F_i sTa Ray M
)WNER'S NAME: / _HDONIi:
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm End 1 for licensed under pmvisions of Chapter 9 (can
with Sectio 7000)ifDivision 3 afore Business and Professi Cade.andmy
in full foaeandeffeco S Q
I.iccnse Clas ].icp
nateV V Cammtoo
A CHITECI SDEC A'IO
I understand my plans vital] be used as public recoals ipA
ViL,L—h #q -s
❑ Caneeltant Fccs Paid by Applicant (Initial)
..I OWNER -BUILDER DECLARATION
6 I hereby oftirm that 1 nor exempt from the Gommctors License Law to be
6 U folhwing reason (Section 701 L5. Business and Professions Code: Any city nr county
WO ywhich re4mm' a penult ea com"uet, ulcer, impmw, demolish or repair any vwcture
prior m it issuance• also memm, the applicant for such permit tootle a.ognedstatement
yy that he s lken.sed pursuant to the pros loons of the Committees License Law(Chapter9
30g0 (citmmeating with Section 7") of Division 3 of the Business and Professions Code) or
y ya that he is exempt therefrom and the basis for the alleged exemption. Any violohnn of
Section 7031.5 by any updt,ma far a permit subjects the npplicanl ran civil penalty of
W of more than five hundred dollars ($500).
Q❑ I, as owner of the property, ur my aeplayees with wages as their solo, compensation,
will Lifie work. and the structure is not intended mufferW forsale (Sec. 7n1<, Badness
and Professions Code:'the Comannes License Law does not apply to an owner tfU
property who huilll.s or improves trereon, and whit does such work himself or Ihmug
his own employcn, provided that such improvements am not intended or offered for
sale. IL however, the building or impmvcmenl is sold within one year of completion, the
owner4milder will have the burden of proving that he did not build or improve for pur-
En eof sole.).
❑ 1, as owner of the prnpeny, am exclusively contracting with licensed contractors m
emwwm the prnjet, (See. 70H4. Busineve and Professions Cade:) The Contractor's Li-
eLew does not apply m an owner of progeny who builds or improves thereon, and QTy.
wont contrac s for such projects with a contrations) licensed pursuant o the Contmemes
License Law.
1 am exempt under Ste . B & P C for this reason
Owner Dam
WOR KF.R'S COMPENSATION IIECLARAq'ION
1 hereby affirm under Penalty of perjury one of the following declarations:
❑ I have mrd will comoude a Cenificam of Comenno self -insure for Workers Compcn-
s tion, as provided for by Section 3700 of the Lahr Coot, far IM1e performance of the
work far which his permit ix issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
370(1 afore Latin, Cale, boccie ped ormance of the work for which this Permit is issued.
My Workers Compenaaoian Iranian. artier and Policy another are:
Camey: Policy No.:
CLIO IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Ibis section cool not hneo npleted if the NMI, is forone hundred dollars ($1001)
or ons.)
1 certify that in the performance of the work fnrwhich this pemtit is issued, l shall
col employ any persnn in any manner so a". e •'i hjec jlpielurkta, Conapen-
(ELECTRIC PERMIT
PERMIT ISSUANCE.
APPLIANCES — REMDEN'I IAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIWMISC.
'TEMP.. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWITCHES — FIXTURES
NEW RESIDENTIAL ELECTR
PLUMPING PERMIT
PERMIT ISSUANCE
ALI ER — DRAIN & VEND — WAI ER EPA)
BACK FLOW PROPECK DEVICE
DRAINS — FLUOR. ROOF AREA, GOND.
FIXTURES — PER TRAP
GAS — EA. SYSTHM-1 INC. 4 OUTLETS
GAS — EA. SYSTHM{OVER 41EA)
GRFASEIINDUSI RL WASTE INTERCEP
SQ FT.
0 z
Q
satian Laws ilio 'n D'
WA4! GYt TATER W '7t�" /[�yCi�
a;
W
Applicant
NOTICE APE AAT fr making Nis Cenificme to emp6on, you should
bcunne suhjecl In (enmpensalinto provisions Labor Coec, you must
forthwith mampl withvisns or this permit shall tented mvokcJ.
LENDING AGENCY
�—b—y—
WAT SYST . I R A LNG
WA'I'T
SfiRVICE
NEW EN'1'IAL I'
L) Q
W
thereby, is a constmctinn lending agency for the performance of
IM1e work lar which Wxpcnnil In inward f5u:. 3097, Civ. CJ
TOTAL:
QU
LU
y
F" to
lender's Name
lenders Address
1 mitify that 1 have retie this application it sunt In.I the above inliumnann is
correct., l agree to comply wim all city and county ordinances and stem laws relating in
QTY. M ECHANICAL PERMIT
U Z
building construction. and hereby aullamice reprewmativex of this city to enter upm the
above-mentioned property far inspection PMvi
(We) agnea to save. Indemnify and keep harmless the City of Copeman against
PERMIT ISSUANCE
liabilities, judgments, costs and expenses which may in any way woman against said City
ALTER OR ADD TO MECH.
in consequence of the granting of this pencil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNIT (TO 10,000 CFM)
SOUrF.GULATI( '
/ ��'y� /0
M�/
AIR HANDLING UNIT(OVER 10.00007M)
E%IIAUS'f HOOU(WIDDC17
ica VComracmr Mile
Signm6M`,by.h
IAZARDOUS MATERIAL SCLOSURE
HE icamor Noun, building« t amnia handle hmurdous material
HEATING UNIT(TO I (X),000 BTU)
HEATING UNIT (OVER 100,00l BTU)
as defCupertino Municipal CNc, pier9.12, and the livers and Safety
32(tp7
VENTILATION PAN (SINGLE RESID)
Will the applicant or future (wilding oceup ad use equipment or devices which
enol lemardoux air conmminams as defined by the Bay Arca Air Quality Management
BOILER—COM(' (JI11' OR 100,001 BTU)
MOILER— COMP (OVER 101,0011 BTU)
Distrito?
C] Yes n
A]R CONDI)TONER
I have readthe homidnos materials requirements under Chapter 6.95 of the Cali-
NEW RESIDENTIAL MECH. SQ.IT'.
l inn a Ilmlth & Safety Cade, Seninns 25505.25533 and 25534. 1 understand that If the
building docs not currently have a tenant. that it is my mopen.sibility no notify the occupant
of tcquinnnemr which must he man prim to Issuance of a Certificate of Occupancy.
OFFICE
❑ 1 o
_ BUILDING PERMIT INFO
BLDG Z ELECT, PLUMB MECH
❑ ❑
FEE JOB DESCRIPTION
—O RESIDENTIAL
❑SIUWL ❑ KITCHEN REMODEL
[]ADDITION ❑ PLUMBING RE -PIPE
El MULTI -UNIT ❑STRUCTURAL
MODIFICATION
JS}INTERIOR El CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH REMODELIREPAIR ❑ DEMOLITION
❑ OTHER
COMMERCIAL,
NEWBI.DG/ADDITION []DEMOLITION
ENANT FOOD SERVICE
IMPROVEMEIT
❑OTHER
SQ . FLOOR AARREA $ISO. FT.
FEE
Z� VALIJATION� VALYIIA'TION--
STOR .S TYPE CONSTRUCT
OCC. GROUP AI'N
BUILDING DIVISION FEES
PL LFT' FEE
ER E 3S
DI G FEE
FEE
P )
Date Receipt M
OTA.:
BUIL NG FEE Q 7 r
FEE SF:ISMI FEE
ELF . RI FEE 8
PL 1 G IBE
EC ANICALFEE
t SIRUCDONTAX
H USING MITIGATION FEE
PAID
Date Receipt it
T
ISSUANCE EhYFE.
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