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CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT ' PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PE ITN°
- � 2275-
BUILDINGADDRUSS; -
SANITARY NO.
APPLICATION SUBMI'PI'AL DATE
I
OW NAME: PHONE:
�� L - -i
TRACT Ij NAME: LIC NO:
1 A
N/C
❑
CONTROL#
CHHHCT/ENGINEER: LI
AD SS $`V
o
CONTACT: PHONE:
BUILDING PERMITINFO
BLDG LECT PLUMB MECH
'
❑ CDnsDitant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION
1 motto affirm that I am licensed under provisions of Chapter 9 (commencing
wlm Section 7000) of Divlslon infirm Blemessand Pmconnone Cade, red mY license is
full force and effect,
QTY
ELECTRIC PERMIT
FEF
JOB DESCRIPTION
RESIDENTIAL'
[_1 SFDWL [I KITCHEN REMODEL
PERMIT ISSUANCE
APPLIANCES- RESIDENTIAL
r�
7�
iij
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Hwhich
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License Class Lia.#
Date Contractor
[]ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIRi
IMPROVEMENT - E] SWIMMING POOLS
❑ BATH REMQj7FL/R%R El DE OLITION
❑OTHER - T/- w i -n
ARCHITECTS DECLARATION
1 undersmed my trustful Fz used as public accords
Licensed Profcesional
OWNER - BUILDER DECLARATION
I berehy vffimt unit I me exempt from the Contractor's License Law far the
following reason. (Section 7031,5, Business and Professions Coda'. Any city or county
requires a permit b construct, alter, improve, demolish, or repair any smucture
pfimm its issuance, also reluires the applieran mrsuch permiuo Glad signed smtement
'hat he is Formed pursuant the provisions ofthe Common, License Law(Chupmr9
(commencing with Section 7000) of Division 3ef the Iysmass anA Prnfesslods COde)nr
that he is exempt therefrom and the basis for the alleged exnnphon. Any vioimion of
Section 7031.5 by mryvpplicant Porapenmusnbjec, the upPlicam toacivil pmnahy of
not moro than five handfed dollars ($500).
❑ ],as owneofthctualny, Or my employees with wages innuir sole compensation.
will do the work, and the smdurein not mended omffered for sole (Sec.7M4, Bmsineac
and Professions Cade: The Contractors License Law does not apply m an Owner Of
PANELS
UPTO 2f1(IAMPS
201- IOMAMPS
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT /NUSC.
'
TF.MP� METER OR POLE INST.
-
COMMERCIAL'
❑ NEW BLDC/ADDITION ❑ DEMOLITION I
❑TENANT OFOOD SERVICE
IMPROVEMPNT
POWER DEVICES
SWIMMING POOL ELECTRIC
ER
OUTLETS - SWITCHES- FIXTURES
NEW RESIDENTIAL HLECTR SQ FT.
r
property who builds or improves thereon, and who does xuch work himrelf or through
his own empluyaea, provided that xuch fmpro,onsm, arc not intended or offered for
sale. If, however. the building or improvement is sold within one you ofcompletion ,IM1e
er- huilder, will have IM1e burden of proving In .1 he did not build fir improve liar put-
Q f)�QORAREA ���
V I�! II 11
Q ET
TOTAL
p... of talc.).
1, its owner of the properly, am exclusively contracting with licensed convectors or
O..muet file posed (Sec. 7044, laciness and Paafessinm Code:) The Crmtractor'.v 1.,
close Law does not apply to an owner of properly who builds or improves therein , land
By
QTY PLUMBING PERMIT
FEE
who ematmcm far such projects on a convaamf(s) licensed pursmam m the Commdmr's
License Law.
PERMIT ISSUANCE
❑ I um exempt under See . B & P C for this reason
AL'1'Ek - DRAIN & VENT -WATER (EA)
�3�J
VALUATION
Dee
Q D
Owner
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT DEVICE.
LEEL
J V
Ieland allimnundea penally of at the Worker's Cc:
Ihvveand will mainminv Certificate at Consent xlf- insure for Worker's COmpen-
DRAINS - FLOOR, ROOF, AREA, COND.
STORIES
-TYPE CONSTRUCTIOI
anion, us provided for by Section 37W Of me Latwr Code, fill tiro performance Of the
work far which this permit is issued.
'`
5�
FIXTUkF.S -PER TRAP
❑ 1 have and will mmation Worker's Compwemion Insurance, vs acquired by Section
Sam tppeLahpu�r Code, for oftho work far whicM1 this permit isissued.
GAS -EA. SYSTEM- IVER4(EA) S
OCC.GROUP
APN
Gq5 -[M. SYSTEM OVER 4 (EA)
)!tyormanw
arzi (�¢�J',pID Lion yuwrah' Lamer and Policy n Q �
e- /'V !J Policy NO.. �
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
El
GREASFJINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PEES_
GRP.ASETRAP
- PLANCHECK FEE
(This reshot.led not be completed irma pefmif is fmaushandred mllam($10)
or IessJ
SEWER - SANITARY -STORM EA. 200 FT.
ENERGY PBH
I certify that in the performance at work for whieb this permit it issued, l shall
not employ any person in any manner no as to become subject to the Workers' Compcn-
WATER HEATER W /VENT/ELECfR
GRADING FEE
Z
aunion Laws of California Data
Applicant
NOTICE TO APPLICANT.' If, after cooking this Ceriifiwm of Exemption, you should
become h cosubject m the Worker's Compensation r tis provisions O e de Labor evoke you maxi
fonhwith comply with such provisions or this Admit shall he drained revoked
WATER SYS'TEMGREATI NO
SOILS FF.F.
V1
H^'
WATER SERVICE
Q
%r
U
{✓a
fy
hy
CONSTRUCTION LENDING AGENCY
I hereby aRlnn that hem is a contraction lending agency for the performance of
the work for which this permit is issued (Sea.3097, Cie C.)
Lender's Name
PAID
NEW RF_SIDENTIAL PLMR. SQ, IT
Data Receipt#
TOTATOTAL
' TOTAL:
u
/�s
Lenders Addm.,,
BUILDING F EE
q
I ;;1.Q
1 cerify than I hove read this npPlicelion and stem the the above Infonnmion is
contact, I agree to comply with all city and county ordinances and sate laws relatingm
building concoction, and hcfcby anthoaize rep ,naft fives Of this city to enter upon the
QTY. MECHANICAL PERMIT
FEE
SEISMIC NFB
Er
PERMIT ISSUANCE
ELECTRIC FEE
above - mentioned pmpeny for inspection purposes
(Wc) agree to sava, indemnify and keep harmless the City of Cupertino against
PLUMBING FEE
IiahOities,jnd mwq cos sand asperse, which may in any way arnmeagmimtsaid City
ALTER OR ADD TO MECH.
nteque eoffle,anlin punt.
n on APPLIC UNDI*R DS AND WILL CO PLY TIi ALL NON -P I 'f
AIR HANDLING UNIT (TO III,lN1U CFM)
MECHANICAL FEE
SO EGULATI S. / ^
O ! 1
AIR HANDLING UNIT (OVER 10,000 CFME
CONSTRUCTION'I'AX .
San m of Applicamf/Cn ra r I at
EXHAUST 1{000 (W /DUCT)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO IW.000 BTU)
Will the applicant or future building Occupant smm or handle hazardous material
a s toed by The Cuperino Municipal Code, Chuger 9.12, and the Health and Safely
Code, Section 25532(x)7
HEATING UNIT (OV HR 100,00) B'TO)
_
VENTILATION FAN (SINGLE RESIDE
❑Yes - El No
PAID Date Receipt#
Will mo upplicanl or human building occupant use equipnmm or devices which
it hazadous air contaminants as defined by the Bay Area Air Quality Manages em
tsI °eP
❑Yes ❑No
BOILER -COMP pHP OR 100,0 0 BTU)
TOTAL
BOILER - COMP (OVER 100.000 BTU)
AIR CONDITIONER
ISSUANCE DATE
I have read the hazardous materials requirement under Chapter 6,95 of the Cali-
NEW RESIDENTIAL MECH. SQ. IT.
fomia Health Safety COdP. Secdo . 0511 593 and 25534 1 understand that if the
baldingdo narrout yh��akTven n_. into his myre a tyro notify the w vm
e loons whiced be cmeo� pen
�jj/
+ /�t+� ..-x
ISSUED BY: IDS *—
TOTAL:
Own authorized agent Yffi
/V J OFFICE
111!11.
a
A%
w1*04 mill, 1 8
rthur J. Oellegher— Plessenten
Ha•iend• Drive. *000
CONFER$ NO RIGHT$ NO THE CERTIFICATE HOLDER THI$ CER
0050 NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES 9"OW.
r4301
l e et en t a n
alif.Licent• 4 0726295,CA
COWANIES AFFORDING COVERAGE
26- 460 -9900
Litter A
i .Stet• Ins.Fund Oak
LETTER B
90face Insurance componles
HomsQuerd Inc
610 Mtder■ Avenue
tten"Y C
The Connecticut Indemnity Ca,
Sen Jose
LE1IPEERAW D
American Ini'l Companies
CA 95112
CC UP&W E
THIS IS TO CERTIFY THAT THE POUC@S OF INSURANCE LISTED BEL�OO W HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
MDICA TED, NOTWITHST ANIDINC ANY REQUIREMENT, TEAM OR CONDITIONOfF ANY CONTRACTOR OTHER DOCLAAENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISMACI OR MAY PEATAIN. THE WSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND COW ITIONS OF SUCH POLICIES. IMTS SHOWNMAY HAVE BEEN REDUCED BY PAID CLAMS,
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9/01/90
9/01/99
PROgxr -Cool A
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PERSONµ A AOJ. INJURY
a 0000
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FACH OCCUNSWU
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9/01/99
CA 1111140 SINK[
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t 100000
e0011v INJURY
(TV oeneU
t
ALL Danko AUT03
7CIMIC AUTOS
BONN INJURE
i
ONO AUTOS
NOa•OeXEO AUTOS
(To vendee
PROPERTY OAIAAYE
OARAM UAEIUIY
e LUM LIMY
rAal WCURRENU
s 5000000
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BE3671315
9/01/90
9/01/99
AU9116A 1 1
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OTHER TIAN IMeNUA FOIM
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X STATUTORT LWITS
EAU AcasiNT
1000000
A
NO
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ORP713LNIT2014
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10/01197
10/01/90
11131AX-POLKY
1000000
DSEAN -EACH OAPLOYEE
1000000
emn
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REt Work perfermod by or on behalf of
the Named Insured
WORM�yq
:Wk
A SHOULDANYOFT14E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL 50 DAYSWRITTENNOTICETOTHECEPTIFICATEHOLDERN "OTOTWE
ty of Cupert i n•
dg. Intpoetian Deportment
0C
LEFT. UU M FAILURE TO MAL SUCH NOTICE SHALL POSE NOO UGATDNOR
! LIABLITYOF ANY KIND UPON T HE COMPANY. ITS AGENTS OR REPRESENT ATIVES.
0. Box 690
Cupertino, CA !15016
au" Arms
— «J `1 602505000
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