31167APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION . APPLICATIONIPERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDF.N'1'IFICATION'
PERMITNO. w
.IL
BUILDING ADDRF_SS: -
V I ORI
SANITARY NO.
APPLICATION SUBMI' 11' AL DATE
OWljb TNA PHONE;.
R:SN l 11C N0:
tRCONTHOI.
G/
❑
'ARCHTECI]EN NEER: LIC NO:
ADDRIlSS.
CONTACT. PHONE_'
❑ Consultant Fm Paid by APPHUnt (Initial)
BUILDING PERMIT INFO
B 1 ELECT PLUMB MECB
❑. ❑ ❑
LICENSED CONTRALTORSOECLARAIION
1he70by arm,,,WNl 3 fthe Buinm ciP inns of. Code, 9(cnmmcncmg
iwith llforc dff Divisiun3nf We Rueimsx and Pofeuionr Crdc, oris myliccnm is
in full fmcannticffr
Licemc Licg
'
Dmc or
� Cant ti
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
R .SID NTIp
❑SfUWL 0KITCHEN REMODEL
❑ADDITION ❑ PLUMBING HIiPIPE
❑MULTI -UNIT ❑S'MUCURAL
M)D117CAT10N
❑ INTERIOR HIMNEY REPAIR
MPROVFMEN'1'
[I BATH REMODEIJRR EPAI❑ 1, MOLG'ION
C1 OTHER
PERMIT ISSUANCE
APPLIANCES-RISIDhIAL
ARCURTCTSDECLAIy{/ K
Iurdemnrd my pl... hall be uvlwpubhiremNx
•
PANELS
UPTO n10 AMPS
Licensed Pmfeviunal OWNER BUILDER DECLARATION
1 hereby alirtm that 1 am exempt from the Convectors License Uw for the
following reawn. (Srction 7031.5, Business this Pmfeuionv Code: Any city or county
which re9uiro a permit no conwrvct, alter, improve, demolish, or repair any sv snare
Pdmto its hsuance.also rt,at— the a,In,rm fmsucb permit or filc,vigretsmcmem
that he is licensed pursuant male pmvisionhofrM Con uMs Litems, Lew(ChapterY
(corNnencingwith Section ](100)of Dvision3ofthe Bminesxand Ptofessum,Core)w
the, M is exempt themfmm and the hams for We alleged e.xemptioo. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil pewlty m
not moa Wm five hondred dollars ($500f
❑I,vownaofthe pmpeny, or my emphryees with wages ea tM:ir Rrle compenwaion,
Mil do the wank, and the wucmre is m imend lorofferM for .rsle(See. 704L Busineix
and P fir, . Code: The, Cnntrxwr, L rl law tines m apply to an owner of
Property w1n Isoids or improv,, thereon, and wM docs such work Inumelf or through
his own employees, povidd that such impovereents arc not imenced or offeml for
sele.IL hoxsvcr. the Mildingmimpovement is sold b�Win ore yearofcomplaimL We
vertu -builder will have the huNen of prming that he did out huild or improve f« psm-
pose of sale.). -
❑ I, as owner of the pmpeny, em exclurivdy contmning with licensal conorse ms to
emunre, the pojm (Sec. 70W, Bu,m. and Pmfcvums Ccre:) The Caeurtors Li-
triseLto, o un, apply to an oxner afpapcny veno buil, or improve. Wcrenn, W
win conhans for nr_h projects witb a lool.mrs) licensed pursuant to the CmmmsctN,
U. Lass. I
I am exempt wider See ,B& P C for this rcaxon
201-INX)AMPS
OVER IOg1AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUURMISC.
TEMP. M=R OR POLE INST.
COMM RCIAl
❑ NEW BLDG/ADDITION ❑ DEMOLITION
�TFNANT FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES -
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FlXTURES
NEW RESIDENTIAL ELECTR Q
SQ. FT FLOOR AREA
SISQ. FT.
'
AL:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAW & VENT - WATER (EA)
Oaw DLc
VALUATION
STORIES
CIiY ur Ludt
OCC GROUP
TYPE CONSTRUCTION
fINO
APN
1 WORKERS COMPENSATION DECLARATION
I hereby emrm unM penalty of perjury acre of the following dcclarwicm:
❑ I hove and will maintain it Ccnif roof Conserv towlf-insure, fa WMc's C.,n-
.1f av provided f« by Seem 3]00 of de Ixlrr Code. for We pMumuvcc of rile
work for which this mountain
isavm`
El 1 Mve era bill nulntair Wml:els Contpenwian stuckfor eIn h his Perm 6Y Section
myW WclabmCadc.far ere perfe ccowrfthc wank farwbichrhis permit is issued.
My Wmkc(s Cnmpeosetioo lesunocc carrier eM Policy dumber are
lr�
Carrier: L' ATE OF
T Policy FROM
CE FlC OMPE SATIONIINN FROM WORKCRS'
COMPENSATION INSURANCE
(This simian recd na be conrpMN ifrM Perrot is for omhwdrNdal Wx (Sim)
ex las.)
Ioysayave in be anfmrmrrcc of thewW for subject fbt Wt 1issuW,lshall
tris employ hey person in any, ea ra b"
qq Icer m We Workers' Cnmprn
ado,, laws of Calif9R�/ pqato y2 z ��orrcw
ApplicaN / /./iY�a��
BACK PLOW PROTGC. DEVICE
DRAINS- FLOOR, ROOH AREA. COND.
FIA"lURES-PER TRAP
GAS - PS. SYSTEM-] INCA OUTLETS
_
GAS - EA.SYSTFM-OVPRdIPA)
GREASF/INDU.STRL WASTE INTERCEPTOR
BUILDING DIVISION hT'FS
GREASE TRAP
CK FEE
SEWER -SANITARY -STORM F.A. 100 PT.
ENERGY FFE
ENERGY PER
WATER HEATER WNFM/ELECIR
GRADING FEE
NOTICE TO A o f : I�e(rcr making this Ce lifiote of Exemption, you should
become the Wake, Compcnhaim posisianv of tk Calve Code, you row
fmbwith comply with such rovision, or Nis pemdt shell he deemN rewkah.
CONSTRUCTIONLENDINGAGFNCY
Ihueby,iRnn Ww Were isaconetrunianlending aleocy fm the performaree of
Be work fe, which tMh permit n ievucd (Sec. 3097. Cv. C)
ImLer'v Name
WATER SYSTFM/IRPATING
SOUS ITE
WATER SERVICE
PAID
NEW RESIDENTIAL PLDIB. SQ. IT.
DNc R.ia0
TOTAL:
Lenhr'I Ad try
1 �ae, Wert I Mve read Wis y tons] our y o hate Wnt We above.l rvaarmauon or
cmreng eertemeanPly wret,y cityand county adimttof this.ms,lawsr upingm
baldingcrosvucti m,era hereby auction ,,u,.nutiva of this city to carer upon do
ebo.e- (Weianea papery for inspection iso pupas,,.
(we)agreem save, mac xpenera keep mamas. tle City of Cupnirrsnd City
Iiabiliriczjudgmrnv,ave and cxpen.sen which nuywany waY accrue egninu bid City
in cons,quenre of We grmurrg of Wis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WTIH ALLNON-POINT
SOURCE RE ILATIONS.
-3/-97
TOTAL
BUILDING FEE
QTY_ MECHANICAL PERMIT FEE
SEISMIC EEE
PERMG'IssunncE
ELECI1tIC PPE
,
ALTERORADDTOMECIL
PLUMBING FEB
AIR HANDLING UNIT GPO 10,UD0 CFM)
MECHANICAL FEB r
AIR HANDLING UNITIOVER I0J(BBCEN) ,
CONSTRUCIIONTAX
Sigoa ofnpple onlrYlm 0.e
HAlARDO��)) AMIALS DISCLOSURE
Wdl Oreeppivantmfwuk6uiWiog rcsvpntuaa«Mrdle he:nrdprs mmvid
as lefurd by We Cupentiee Munwnipel Code, Chaps, 9.13, end the Health this Safcry
Cade, Secdon 35532(,)?
❑Yn F1 No
Will the air cora err fwwe building by lhp B us, aqui it Qum devices which
I emit haaardous air cantnndnmua as defirtd by de Bay Aro Air tTuliry M1lawgaoem,
DisVrel?
Ll Yea❑No
1 have erad the hwrdnu muerids rcquim. under Chapter 6.95 of de Cali-
f rmins Rall & Way Cade Smiorm 2PKp. 25533 end 2 5Yt. 1 urdastnd Wet a de
bursting does tot cmrtMY Mve a taunL Wer it is my re pwtibility an mdfy the ocenpa t
of We rtquiremens which ms be met pier to hsuaec of a Ccnifcerc of Oc'r+rPa^cY.
EXHAUST HOOD IWTGCf)
HOUSING MITIGATION FEE
HEATING UNG' TO IWLM10 BTU)
HEATING UNIT (OVER 100." BTU)
PAID
VENTILATION FAN (SINGLE RESID)
D. Rceci r
pt
BOILER - COMP OHP OR I00,01D) BTU)
TOTAL -
OTAL❑To
BOILER - COMP (OVER 100.000 BTU)
AIR CONDITIONER
ISSUANC
ISSUED BY:
NEW RESIDENTIAL ME". SQ. IT.
Oweerm auWmv 1egeN Detc
TOTAL
OFFICE