99100068APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL 4
PERMI'
BUILDING DIVISION APPWCATION/PERMI'1' PLUMPING -MECDANICAI.
BUILDING PROJECT IIIEPTIP'ICATION
BUILDING ADDRESS:
SANITARY NO. LICATION SUBMITTAL DATE
ILE Q
'R'S NAME' PHONE:
_O-LJA
CONTRA OR'S NAME: LIC NO
N/C
❑
C AOL#
CHI RCTIENGINEER'. LIC NO'.
/
ADDRJSS. 17w�- N Tfo A j �a F__
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECTPLUMB MECH
„y Z
UJ00
CSF
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LICENSED CDNTRACI'OR'S DECLARATION
1 hereby affirm that I am licensed ander pmvi.ion, of chapter 9 (commencing
with Section]000)of Division 3ofineairlines, and Prom,tem, Cale, and my license i.
wt
face.ain �,rvC=�tlrell /_ /j /J'
Licens la„SG
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN
❑AUDfI'ION [I PLUMBING RE-PIPE
PERMIT ISSUANCE
AI'PhIANCHS-k1iSIDENTIAh
�Lm
Dom Co
F � y
pyZ
AN,hrill h, use UEPublic ourd,
IunJcmanJ my plant shall be used a, public mt,ords
❑MULTI-UNIT [I STRUCTURAL
MODIFICATION
PANELS
Z—r,
Oil TO 2W AMPS
1 ❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT E3 SWIMMING POOLS
❑ BATH REMODEVRCPAIR ❑ DEMO ITIO
❑ H Riq
—0—ty y
, N
.XLa
C =
0 d O
a
0Q
p
Licensed Pmfessinnal
OWNER-BUILDER DECLARATION
I Imrchy nffimt that I an exempt Gore the Camara, hiccncc Law for the
following rsvwn. (Scuunn )031.5, BUGna„ unJ 1'mlesaon, Cade: nny city or c...mYSIGNS
which requires a permit to constrvn, alter, improve, demolish, or repair any structure:71Q.
prior to its issuance, also requires the applicant for such p ardtto file a signed sentiment
that he is licensed pursuant o the provisions of the Contramnrs Licence Late (Chapter 9
(commci
enng with Section 90XDivision
Xp of Sol the Nasines,mtd Professions Cde)nr
mat he is exempt tberefmnl and the basis fin the alleged exempt..... Any violnl'um of
201-10CAMPS
OVER 1000 AMPS
ELF,CENICAL
SPECIAL CTRCUITIM PSC.
_(
TEMMETER OR POLE INST.
P.
COMMERCIAL:
❑ NEW BLDGIADDITION ❑ DEMOLITION
Way
F?>
Section 93 15 by any applicant hire led rm. t xubjects the applicant ma civil pen.11yof
I more man live hundred dollars S50x0.
wi Las with wagesastheirvotecompensiness
k. thepe%tmct
the Business
will dothesocas
(snot
POWER DEVICES
El TENANT ❑FOOD SERVICE
IMPROVEMENT
El OTHER
SWIh1hINGfYI(11, ELECTRIC
F.
6 3 m
othewowner mmyemntended
and ow do
he Comisnoti License ed
apply town,
and Proper, [I,, h cde: The hors L I ,c Law does not apply to an owner e(
ny who me.mW who does nmb wore ( mnmgb
or oked
OfIlLLTS -SWITCHES-FI%Tl1RES
,et,.udd,
M1ia own enoploycrs. Provide) Ihw sucM1 improvement, are not immndeJ or olY'araJ it,,
m, o t i Ir ., intended b
NHW RESIUEN'TIAI. ELECTR jQ IT.
SQ. NL FLOOR AREA
E/SQ. PT.
sale. IL however, the building or improvement is sold within one yaarefoompletion,the
-
er-builder will have the burden of proving that he did not hold or improve for puren
Q,'ruf.ovecofineImprt,u xdusivcly c,mmcdng with licensed contrucmmo
TO 1
tn,nect the pmjmt (Sec. 9(94, primes amt Prof ,ton, Calc) The Connector, Li-
-
seLaw does not apply et an owner of property who build, or improve thatsmo. and
QTY. PLUMBING PERMIT
who comeans for such projc is with a coatmctor(x) licensed pursuant to the Contractor's
PERMIT ISSUANCE
License La,
C]I am exempt under Sec. , R d P C for this moron
AI:TER - DRAIN & VENT- WAT ER EA)
Uum
VALUATION
'�qq
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of the following declarations
RACK FLOW PROTECT DEVICE
DRAINS- FLOOR, ROOF. AREA. COND.
I have and will maintain a Cenificata of Consent mself-insure for Worked Camper-
ation, as provided for by Section 37W of the Labor Code, for the performance of the
STORIES
CONSTRUCTION
work for which this permit k issued.
FIXI URES - PFR'TRAP
❑ 1 hest, and will moinwin Weakcr's Compensa a Insuaac, av I'cquired by Section
37W (it the Lean Cole, Gm the performmu,rA the work lir which this mat IIs issued.
Worker', Compensation Insurance carrier and Policy nmber areCareer:
GAS-EA.SYS'HIM-1 INC4OUTLEIS
OCC.GROUPN1y
LAPN
Policy No.:
GAS - EA. SYSTEM -OVER 4IEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
�
COMPENSATION INSURANCE
flbis.wninn need not Nicompleted if the Tennis is &none M1unJrctl Jnllam (811X1)
or Ices)
GREASEIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PEGti
GItICASE'TkAI'
PLANCIIIiCK P1i1i
SEWER- SANITARY -STORM EA. 200 FT.
I ociifytha inde, perfannance aOM1i work forwhuhr mispennh is issued, 10.1i
not employ any person in any manner so as as become subject to the Workers Camper-
ENERGY PEE
WATER HEATER WNENf/ELECTR
zZ cation W I Callforma. Dm5
O Applicae�lrl � 'S�
GRADING IEE
h
UZ
UO
t•+
NOTICE'I0 APPLICANT: IL afutr making this Cenifimte of Exemption, you should
become whims ret the W...kuf, Cnmpenmtian.....vision, of dee Lops" Code you nta.I
forthwith comply with such prnnsinns or this Pereit,hall ht, decmalrevoked.
CONSTRUCTION LENDING AGENCY
kforr, hichehilha ono. isaco(Ser.3rl7. Cngagency for the perfonnancmf
he work far when his pt,rn,h is issnca ism. 3o9t, Civ. c.)
WATER SYSTIzmrIRIiATING
SOILS FEE _
WATER SERVICE
PAID
NEW RESID&'.TIAL PLMB, SQ, FT.
Dae RmeiptN
O •`-�
0 V
F y
to
C„) Z
Lener's Name
d
TOTAL:
Lender's Address
TOTAL
BUILDING PRE
tyt that I have ,cad this y and coup and stn a the the above slalinm is
1 a agree gm
correct. .agree men, and withy tithent ropresnrdiwncesarra smte lawsenter
building nmamaion. and hereby amhorize representatives of this city to corer upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
'
abovcmantioned proper{y for inspection ptir,rwes.
1 We) agree to a indomnlfy and keep hamdu, the Cdy of C.penlnn aplllmu
1117RMIT ISSUANCE
ELECTRIC F13H
ALTER OR ADD TO MECH.
PLUMBING FEE
letbiliav,.,dgme .ros and expenses which may in any way accrue against said City
nscqucncc me (this permit.
,UR HANDLING UNIT (TO By"CFM)
MECHANICAL FEE
APLICAN STAN S A ' 1. CO 'LY WITH ALL NON-POINT
S,
O 'P r IONS
AIR HANDLING UNIT (OVER 10,00) CFM)
CONSTRUCTION TAX
Signuwrc nfnpplicaHA t r Jam
DISCLOSURE
HAEAkDOUS Mding
EXHAUST HOOD (W/DUCT)
EXHAUST
HOUSING MITIGATION PEE
HEATING UNIT(TO IW.fx)O BTU)
Will occep
nofumm Wilding acupaptr
as de rte, by the Cupertino9.12. and thh echo and Safety
the Capeninn Municipal Cala Chapter 9.12, and me Health and Sxfery
44ntna'
o
Code Scninn 25532(0)'!
❑Ye,,
v�
Will me applicant or Tatum building occupant use equipment or devices which
at havardou,air conmminre, as defined by the Bay Area Air Quality Management
❑Yea �n
HI?ATING UNIT' (OVtiR 100.0x1 ❑'TU)
PAID
-
VENTILATION PAN (SINGLE RISSID)
Date Rmeiptk
BOILER- COMP OHPOR IW.000BTUI
TOTAL:
BOILER-COMP (OVER 100.000 BTU)
AIR CONDIIIONFIk
I buvere' chavxr material, is once, Chapter h95of the Cali-
mquimmen p
ISSUANCE: DATE
NEW RESIDENT IAL MECH. SQ. FT.
(odic Hesse act e.. do U5. 255 3 and 255&1.1 to hardly de that if me
buildin I c yhav amtmn ha iii nsCof,mI hardly cecapant
afire lc cafe Ccnific:ne of (Xe,
ISSUEDBY:
Ox croraaea. gent Dm
TOTAL:
OFFICE