S 1791wool Via NTTO ala IN IMFnOUATInM WITHIN mien I INFS - IMP BALL POINT PEN ONLY
CITY OF CDPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PING R OJECTiCIIAITFIC
BUILDING PROJECT IIIEN'1'IFICATION
PEI` 1T NO
v 17 91
BUILDING ADDRESS
SANI'TAHY NO.
APPLICATION T
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/SUBMITTAL
ynDAE
OWNEIi'SN A2�/��IA (/
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CONI 't CIORS-NAM ^ 1.1. (.
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❑
CON '1'ROLp
ARCHITECT/ENGINEER: 0:
l M lei o y N
ADDNE S:
i E5 �E ��cP s 95a
CONTACT: PHONE:
S/ �0W7_ 30`
❑Consultant Fees Pail by Applicant (Initial)
BUILDING PERMIT INFO _
BLDG E-73"En vLU❑Ma h1E❑CH
LICENSED CONTRACTORS DECLARATION
I herehy al lion that 1 am licensed under provision. of Chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE
with S..11oa]ODOOf Division 3oflhe Businessman .�al,.'SOM�ny license is
in full force and cllect. 5 //7�y
RESIDENTIAL
❑ SFDWL El KITCHEN REMODF.I.
APPLIANCES - RESIDENTIAL
License Cl Lich
Due Contractor
OADDLION ❑ PLUMBING RIiPIM
❑MULTI-0Nll' OSTRUCTURAI.
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT OSWIMMING POOLS
{ ARCHITECTS trECL RATIONPANEfS
1 mndemmad my plans shall W used as public records
UPTO 200 AMPS
j Licensed Pmmssional
2111-IWl AMPS
OWNER -BUILDER DECLARATION
I hereby .R..a to.. I mm catnip, from the Cimmator's License Law far the
following reason. (Secli.0 ]031.5, Business mad Pndcssinns Cndc: Any city or county
❑ BATH REMODEIIREPAIR El DEMOLITION
OOGHEH
OVER IIIIOf AMPS
SIGNS HLECI'RICAL
which requires a permit to consumer. alma improve, demolish, or repair any slrucmrc
SPEC1ALCIBCUITIMISC.
'
Prior to it, i.w...0. also reyuimsthe vpplicam tin such pennluo filenslgncdgammem
that he is licensed pursuant to the provisions of the Catharines License Law (Chapter 9
(commencing with Section 7000) of Division 3 nl the lm,incssand Promsoons Code)on'
that he is exempt therefrom and the nasi, for the alleged exemption. Any violation of
'f EMP. M ET17R OR POI.B I NST.
COMMERCIAL,
❑ VEW BLDGIADUITION O DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant hn m civil penalyof
t mom than live hundred dollars (SNYT.
C ❑I.ex-amal-from property, or myemlklees with wages m theirsulecom,sosion,
will do the work, and the structure is not intended uroffered forsale (Sec. 1814, Holiness
i and Professions Cale: The Cnnlmnoes License taw does not apply man owner of
POWER DEVICEq
'TENANT ❑ FOOD SERVICE
1 PREVENIENT
OOTHER
SWIMMING POOL ELECTRIC
OUTLETS-SWI"I CHIiS- uRES
NEW RESIDENTIAL 177LEC. R SQ IT.
progeny who builds or improves thereon, and who dmes,ueh work himself onhrough
his own employees. provided that such impmvcmems art not intended or offered for
sole. If. however, the building or improvement is sold within one year of completion, 'he
SQ. F1'. MOOR AREA
&SQ. FT.
writ -builder will have the burden of proving thin he did not build or improve for pur-
'rEl'A
e
pose ofsmlcJ.
❑ I, as owner of the foolery. am exclusively contracting with licensed contractor, to
QTY PLUMBING PERMIT FEE
rostrum the project (Sec. 7094, Business and Professions Com,)I he Contractors Li-
cense Law does nofapply to an ownerof propeny who builds to improve, thereon, and
whocontmcu for such projects with a cortmetu (s) licensed punned to the Counselor's
License Law.
❑ I am exempt under Sea .B&P(2forthisrea,on
I PERMIT ISSUANCE
AUGER - DRAIN & VENG- WATER IEA)
VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby aRmn under penalty of Perjury one of the following declaration
❑ I have and will maintain a Certificate of Consent (I)salt'-Insure far Worked Comper-
BACK PLOW PROT[CT. DEVICE,
DRAINS- FLOOR, ROOF, AREA, COND.
STORIES
TYPE CONSTRUCTIOI
Orion. as provided for by Section 37X1 of that Labor Cole, for the Performance of the
work for which This permit is issued.
FIXTURES -PER TRAP
GAS-11A.SYS'ITM-I INCAOUTLETS
❑ I have and will nnaintain Warker'v Compensation Insurance, as required by Section
3700 of the LaMrr Code. for of the work for which this Permit is issued,
-OCC GROUP
APN
GAS- EA. SYSTEM.OVHR 4(EA)
My Workers Compensation Insurance carrier and Policy nu Iwnw
Carrier: Oe &0 Policy Na: oi'"h .-A L TG
GREASEIINDUSTRLWASTE INTERCEPTOR
CER TFICATE OF EXEMPT ON TROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION MES
GREASETRAP
PLANCIiECK ME
(This section need not W completed it the permit is for tine hundred dollars lE l W)
or It,,.)
I verify he, in the perllsrmaneenfthe work far both thisp,ohno is issued, Ishal[
mm employ any person in any manner so as to become subject to the Workers'Compen-
SEWER - SANITARY -STORM EA. 200 FT.
ENERGY FEE
WATER HEATER WNENT/ELECTR
GRADING FEE
SOUS ME
scion laws of California. Date
Applicant
NOTICE TO APPLICANT. If, attar making this Certificate of Exemption, you should
become subject to the Worker'. Connpensation provisions of the [.shot Code, you most
forthwith panoply with such provisions or this permit shall be devoted revoked.
WATER SYSTEMn'BEATING
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hereby affirm that is u construction lending agency lin the performance of
the work far which this pe.if is issued (Sec. 1391, Civ, C.)
Lances Name
PAID
Data eceipfN
NEW RESIDENTIAL FILMS. SQ.FT
TOTAL:
TOTAL'
Lenders Address
L. 1 certify that I have read this, application and state that Ne above information is
correct. l agrcem comply with all city and county ordinances and state laws relating III
7 It construction, and herby authorize representatives of this city to enter upon the
above-mentioned property fin inspection purpose,.
(We)agree m save, indemnify and keep Wanda,, the City of Cupertino agaian
[iabililles,judgmems, costs unit expenses which may in any way accme against said City
BUILDING ME
QTY, MECHANICAL PERMIT FEE
SEISMIC FEE
p
PERMIT ISSUANCE F-
AI.TERORADDTOMICL stal
ELECTRIC EEE
PLUMBING FEE
in consequence of the granting of this Permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1. NON POINT
AIR HANDLINGUhl III,
MECHANICAL ME
SOURCE REGULATIONS.
AIR HANDLING UNIT (OV Il) 007) CTO
CONSTRUCTIONTAX
Signature of ApplicanfiContmmor Dale
EXHAUST HOOD OVIDUCT)
HOUSING MI'HGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will thevpplicamia fair. Wildingoecupantsmreor handle hchaviss horrid
HEA'T'ING UNG ('10 IW,000 BTU)
HEATING UNIT (OVER IOQ000 RTU)
as defimW by the Cuperthm Municipal Calc, Chapter 9.12, and the Health trod Safety
Crowle, Section 25532(a)y���
❑Yes Tun
,
PAID Dam Receipt Of
VENTILATION FANS INGLE RPSID)
WHI the applicant or future building taciturn use equipment or devices which
emit hnzmdnm air nml:nminamx as defineA by The Buy Arca Air Quality Mmmgemmtt
BOIL ER -COMP OHP OR 1 W,00O BTU)
BOILER-COMP (OVER 100.000 BTU)
XNo
AIH CONDITIONER
ISSUANCE DATE
/ /� �%�
d me hamNoux mafcUsa rcgnircmems under, Cbupmrfi95 nRM Cali-
Safety Castle, Sectio., 255115, 25533 and 25534. 1 uaJemm�d that if the
"�cd.,vm
NEW RESIDENTIAL MECH, SQ. FT.
murmntly have a tenant, thaf'n is my rcspan.sibility to nobly[lie occupant
/V^/ I/ 7
msw hot st hr met i "Ounce of a Cemficme of
ISSUED BY:
TOTAL:
,riatacdagem t�
OFFICE