S 2173APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY-
CITY OF CUPERTINO BUILDING - ELE (T OCAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PEIy1IT N °. 217 3
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BUO.DWGADDRESS:
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SANITARY No.
APPLICATION SURMITTAI. DATE
9 � q
.
OWN'`.�A ^ / q PHONE:
C I'RACIOR'SNAME LIC NO:
N/C
❑
CONTROL N
!JORCDITECI'A NGINIlH LIC NO:
ADDRESS /' v' VGA �- ��
CONTACT: PHONE:
BUI INGpERMITINFO
a Xi ELECT' PLUM" MOCll
I❑ ❑ ❑
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7
❑ ConSUDant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION
,1 herby affirm that lam licensed miler provisions of Chapicr 9 (e)mmencing
with Sedinn]01(0)ofDivision Ldthe Business unJ ProfeasinnsCuJe , and mylicemet,
i
in full laves and affect. -7 9 / _ Z,y
QTY.
ELECTRIC PERMIT
PEE
JOB DESCRIPTION
RR -IDS
[1 SFDWI. 11 KITCHEN REMODEL
PERMITISSUANCE
APPLIANCES — RESIDENTIAL
License Class Lic.# �4'
Da¢ Contractor
❑ADDITION El PLUMBING RH -PIPE
❑MULTI -UNIT' ❑ MODCNRAL
MODIFICATION
E3 INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
ARCHITEC'T'S DECLARATION
I understand my plans shall lx used as Public records
PAN17LS
UPT0200 AMPS
Licensed Professional
201- 1000AMPS
OWNHR- BUILDER DECLARATION
1 hereby affirm that Iran exempt from the Commcmrs License 1'. for the
following reason. (Sect Ion 7031.5, Business and Professions Coda: Any city m county
which requires a permit to amamct, alter, improve, demolish, or repair any structure
�I.
❑BATH RF.MODEUREPAIR DEMOLITION
ED MITER
OVER IOW AMPS
SIGNS ELP.CI'RICAL
SPECIAL CIRCU IT/MISC.
prior to its issuance, also requires the applicant for such Permit o file a signed statement
that he is licensed .. rvuun h m the pmvisitun, of the Cant... ,it x license Los (Chapter 9
i
(commencing with Section]IX(I) of Division 3 of the Business and Professions Coda) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 90315 by any applicant for a permit subjects the upplic"a in aoivil penalty at
not more thin five hundred auditors (S5IX).
E] 1, as owner of the Foolery, or my employees with wage, as theirsole compensation.
l will Jo the work. and (lie strucnnc is nm Intended or offead(or sale (Sec. Business
and Profcsamws Code: The Contractor's License Law doss not apply to an owner of
TF.M II METER OR NILE INST.
❑NEW BLDG /ADDITION ❑ DEMOLITION
❑TENANT El 1700D SERVICE
IMPROVEMENT
[I OTHER
POWER D17VICFS
SWI MMING POOL ELECTRIC
OUTLETS — SWITCHES — F ES
NEW RESIDENTIAL ELE SQ FT.
property who build, or impmves thermal, and who does such work himself or through
his own employers, Provided that tech Impmvemems arc not intended or offered for
sale. IL however. the building or improvement is sold within one year of complctina. the
$Q. PT. FLOOR AREA
$/SQL FT.
owner - builder will have the burden of proving that he did not build or improve for pur-
pnsu of sole.).
❑ 1, as e r of the property, um exclu,waly counseling with licensed continuous m
compact he project (Ste. 7044, Business and Pmfessinrta Code:) Tbc Count Li-
,c Law dues not sPplytnmo,vocrof properly who build, or lntptoves thereon , and
QT'Y. PLUMBIN E
E
who contracts for such projects with a contractor(%) licensed pursue?), to the Comracmr's
PERMIT ISSUANCE
License Ire,
❑ I ran exempt under Sec. , B & P C for this reason
ALTER — DRAIN & VENT — WATER (:
VALUATION
Owner Date
2 p o
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT DEVICE
I hereby affirm under penalty in one of the following dad
ST IFS
TYPO CONSTRUCTION
mfCoo i-tm e's Cro.
❑Ihavc and will mvinmina Ccnifcam of Comenuoseide, Wremar COmpcn-
DRAINS — PIAOR. ROOF,AREA, COND.
ribs,
%,bons as 4vvch r k , mi Section 3]IXI of the hahor Ctde, for the performance of the
work Inv which th'n permit is issued.
-
FIXI'URCS — PER TRAP
I have and will maintain Worker, Compensation Imsumnce, as required by Section
37N) of the Labor Calc, for the performance of the work for which this permit is issued.
GAS —EA .SYSTEM -I TNC.400TLITS
OCC. GROUP
APN
GAS — GA. SYSTEM OVER dTA)
My Ca er:rkv/ ComtJKysatxwln.vuJnpcc carte Policy Ne:
KK / /NN OO,
ORIiASF/INDUS'fRI. WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSA'T'ION INSURANCE
BUILDING DIVISION FEES
(This xectinnncedma be completed ifthe permit is fortune, humlred dollars ($100)
act less)
GRHASETRAP
YfANC11ECK FTai
STOVER— SANITARY —STORM EA.20(I IF
ENERGY FEE.
I sanity that in the Fed'nrmanoval WC work for Much this permit is ismed, lxhnll
not employ any person in any manner so as in become subject to the Worker' Courted-
WATER HEATER WNENT/F.LECT
GRADING FEE
/
cation Laws of Califomia. Dam
1 Applicant
S
j NOTICE TO APPLICANT. If, after making this Cerlticute of Exemption, you should
' become subject m the Workei s Compensation provisions of the Labor Cale, you must
WAFER SYSTENUT
WATER SLi 1
forthwith comply with tech pruvkim,o, this Frican shall be deanedrevoked.
NEW RESIDE PLMB. S
1
CONSTRUCTION LENDING AGENCY
I hereby o nto thatthere lsn emsmmction lending agency for the performance of
the work for which this permit is isaed (See 300, Clv. C.1
Lander', Name
ReceiptM
J
TOTAL:
'1'OTAI:
Lenders AJdress
BUILDING FE
1 cami, Nov I have read this application rand stmt that the move information is
cancel I agree m comply with all city and rounty oNinances and state laws rdming m
huilding cnnstmctlnn, and hereby amkniec represemativc, of this city m cntcr uqm the
QTY. MECH. N I. P
FEE
SEISMIC FEE
PERMIT ' ISSUANCE
ELECTRIC PF.E
,hies - mentioned pra,vc, for inspection purposes'
(We) agree to save, indemnify and keep hmmlesr the City of Collection against
PLUMBINGFT.0
Iianhours,jt gments. costs and expenses whichmay in anyway recent against said City
ALTER OR ADD TO MECH.
oneey ceofthegramin• emit.
APPLIC,TUNDERS DS AN WILL COMPI.Y TTH ALL N -POINT
AIR HANDLING UNIT (TO IO.WOCFM)
MECHANICALF-E
SOt iREGULATI
/,
l
Antra
Alit HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION OAK
Sig cram of AppIicecVC er D e
EXHAUSTHOOD(W/DUCT)
HOUSING MITIGATION FEE
HA' )OUS MATERIALS DISCLOS URI!
Will the applicant or fawn building occupant stare or handle Woudoos milmd
HEATING UNIT GG I00,0d0 B' IT)
_
as defined by the Cupeninu Municipal Cale. Chapter 9.12, and the Health and Safety
Cade, Section 25532(a)?
HEATING UNIT (OVER IINtand B'I'IT
VENTILATION FAN (SINGLE REMO)
❑Yes ❑No
PAID
Data Receipt g
'Will the applicant pr future building occupant use equipment (it devices which
emit hiumdous air contaminants as defined by the Bay Area Air Quality Management
BOILER — COMP CHP OR Iph,M) xTU)
IYTf
It
MOILER — COMP (OVER 100,00 BTU)
District?
❑Yes [:1 No
AIR CONDITIONER
ISSUANCE DATE
I have mad the hazardous mammals tequirentent maker Chapter 6.95 of the Cali-
NEW RESIMNIT1AL MECH. SQ. ET
forma Heath & Surety Cale, Sabo.., 25505, 25533 and 25534. 1 mndcmmnd that if the
/�
building does amt currently have a tenant, that it is my responsibility to notify the occurred
(// _ Y
of the mquirement, which mast he met Prior to issuance of a Cenificam of Ocetwmy.
TOTAL:
ISSUED BY:
Owner r unfurled agent Data
OFFICE