S 1268APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDINGELECTRICAL
L.
BUILDING DIVISION APPLICATIONIPERMIT PLUBNG. MECHANICAL
BUILDING PROJECT IDF:MI'IF'ICA'rll)N
LNG.
PEBtdITNO 12 6 8
ILDINC. ADURESS:
� erE;Yw
SANITARY N0.
APPLICAI'I ON SUBMl"FAI. DATE
2 qi
Lvrar.
PHO2069.
O NE :SNA is C . NC. 343
al 4 O
CONTRACTOR'S NAME: LIC NO:
NIC
❑
CO l'ROLa
ARCHITECI'MNGINEER: LIC NO:
ADDRESS
CONTACT: PHONE
I
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDGT:LF PLUMB MECH
E:1 El
LICENSED COM'RACTORS DECLARATION
I hereby alli m that 1 out lieenoal under ptvishm. ar chapter 9 (countercoup
QTY. ELECTRIC PERMIT PEE
_
JOB DESCRIPTION
PERMIT ISSUANCE
with Section700(h or Divisiaa3ot the Business and P..m,wions Code,andnry licence is
in full force and effect
RESIDENTIAL:
❑SFDWL O KITCHEN REMODEL.
- RESIDENTIAL.
- License Class —Lay. Or
CoalAPPLIANCES
J Dam r
❑ADDITION O PLUMBING RE -PIPE
❑MULTI -UNIT [I STRUCTURAL
TION
CHIMNEY REPAIR
[I INTERIOR OCIIIMNEV REPAIR
IMPROVEMENT SWIMMING POOLS
ORATH R' PAI MOLITION
❑OTHER
TSDEC
ARCHITECTS DECLARATIONPANELS
i 1 understand my plans shall M used as public records
j Licensed Professional
j OWNIiR-BUILDER DECLARATION
C 1 hereby affirm that 1 am exempt from the Comrucmr's License Law fur the
Jfollowing reason. (Section 7031.5, Business and Professions Code: Any city at county
UP To 200 AMPS
201-100RAMPS
OVER ]Bob AMPS
SIGNS ELECTRICAL
which requires a permit to conamct, alter, improve, demolish, or repair any structure
Fannie itsvee, alsorequiresth ppll t fa,uchpcmht file a signed statement
SPECIAL CIRCUTUMISC
Y
that he is licensed Firearin (o0a, (o0prirviooro, of11 Cournaren, Luenno, Lies (Chapter 9
J(commereng with Seaton7(0X8 of Division3ol he Business and Pr l e,on: Coda) or
L that he is exempt thenchman and the basis for the alleged exemption. Any violation of
TEMP. MET Lit OR POLE 0.5
COMMERCIAL:
0 NEW BLDGIADDITION 0 DEMOLITION
o Section 7031.5 by any applicant for a Estero subjects the applicant to a civil Penalty of
t Ones flem f ve hundred dollars 05(0).
0 Las owner of the progeny, nr my employees with wages as theirsole compensation,
will do the work, and the structure is not intended or offercl for sale (Sec. 7814, [1[]OTHER
and Pmfcsvianv Code: The Cnntramads License ],nw does nal apply m an owner of
property who builds or improves thereon, and who does such work drawl I or through
his own employees, provided that such improvements an not intended or offered far
llf,however, the building or improvement is said within one year ofcompletion, the
me.
POWER DEVICES
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
SWIMMING POOL ELECTRIC
OUTLETS- SWI TCHES-FIX 'I URES
NEW RESIDENTIAL ELECfR SQ IT.
SQ. FI'. FLOOR AREA
LSQ.IT.
uwnef-builder will have the burden of proving that he did not Wild or improve for pur-
pose of sale.).
❑ 1, as owner of the property, sun exclusively contracting with licensed conte.,,, to
P Y'Y p I D
TOTAL:
mamau tfheOn
he,mao (Sec. 7044, lheincss and 11 le,ron, Cnde:)'C(mclars Li-
cense law does an funny to an owner of progeny who huilds or improves thereon. and
whocontmcOfersuch projecnwuh a chmracmrts) licensed pureeanna nm Conhwrt`s
QTY PLUMBING PERMIT FEE
1'a�Fa®
� Affil
PERMIT ISSUANCE
License law.
[am exempt under Sec. . B & P C for this mason
FEB �
;jIALTER-DRAIN&VENT-WNI'EREA)
D
ITY Uta uurri-MIY@PD"
WORKER'S COMPENSATION DI!CLARATI ON
HACK FLOW PROTECT. DEVICE
1 1 hcrchy affirm under pmtafy nI perjti, one of the following declar.Jons:
STORIES
TYYF. CONSTRUCTION
O l haveand will maintain eCcnificmeof Consennn w1f insure for Workers Compen-
moon, as provided for by Smian 3710 of the Labor Cele, for the perfommarm of the
DRAINS- FLUOR, ROOF. AREA, COND.
work for which this permit is issued.
FIXTURES - PER TRAP
0 1 have and will maintain Workers Compensation Insurance, as required by Section
3708 of the Labor Code, fur the perlimnunee of the work for which this Per miI,,issued.
OCC. GROUP
APN
GAS -EA. SYSTEM -1 INC. 4 OUTLETS
GAS - EA. SYSTEM OVER 4 (PA)
My Workers Compensation Insurance carrier and Policy number am:
Career: Policy No.:
GREASF/1NDUSTRL WASTE INTERCEPTOR
CERTIFICAT[i OP I:%F.MITION FROM WORKERS'
COMPENSAFiN INSURANCE
BUILDING DIVISION FEES
(This wanton need not he cnmPletN true, Permit is for.. hundred dollars T$ IW)
or less.)f`LANCHECK
GREASETRAP
FEE
SEWER -SANITARY -STORM EA. 2W FT.
ENERGY FEE
I certify that in the perliureanw ofthe work for Much this pmmii is issued. )shall
nm employ any person in mry nnmrer m fa to became nvhject to the Warkan' Cooper-
WATER HEATER WNENTIF.LECTR
GRADING FCC
moon Laws of Cali ern— Dare
Applicant
ie of Exemption, you should
i NOTICE *10 APPLICANT: If, he, making this Cenfcm
became subject to the Workeex Compensation provisions of the Labor Caste, you must
WAILR SYS'ITMO`REATIN0
Eq
SOILS FEE
WATER SERVICE
PAID
Dao n
'f fAL:
y forthwith comply with such provisions or this permit shall he deemed revoked
CONSTRUCTION LENDING AGENCY
I herebyaffimnthal them isaconstmmian lende,minncy for the perfumtance of
the work for which this Kenn is issued (See 30)7, Civ. CJ
Lender's Name
NEW RESIDIiN'I'IAL PLMII. SQ Fr.
TOTAL:
Lender's Address
BUILDING FEE
SEISMIC FEE
4 I certify that 1 have read this application and state than the above information is
❑ carrot. agree to comply w'nh all city end county mhnamccs and state laws muting to
bugildinOnamm tine, and herohy vulhorize representalivc.x of chis city center upon the
Q'IY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
above-nmtninned progeny It,, inspection purposes.
(We) agree as save, indemnify and keep lameness the City of Cupcninn against
ELECTRIC FEL
PLUMBING PCE
liabilities,jalumanns,Ofoernd expenri which may many way accmeratim"said City
in consequence atthe granting of this Exceed.
AI.TERORADDI'OMECH.
AIR HANDLING UNIT (TO III,IX)(I CPM)
MECHANICAL PIiE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT'
SOURCE REGl11.AT10NS.
AIR HANDLING UNIT (OVER 0,0h)CFM)
CONSTRUCTION' TAX
Signamrenf ApplicarmlConnow, Datea
EXHAUST HUOD(W/DUCD
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT ITO 100,0(01t'I'll)
Will the applicant or future building occupant stere or handle filtrations material
as defined by the Cupenino Municipal Cady Chapter 9,12, and the Ilealth and Safety
Cade, Se,liou 5532(o)7
HEATING UNI "T (OVER 100,010 RTI))
VENTILATION FAN (SINGLE RESID)
Yes 7 No
PAID
Date ReceiptM
IWill the applicant or future building occupant use equipment or devices which
emit aras air containments as defrost by the Bay Area Air Quality Management
hNoumin
BOILER - COMP (JIiPOR 110.g0BN)
TOTAL:
District?
[:1Ym ANO
BOILER-COMP(OVER Too,IXXIlvau)
AIRCONOI'1'IONER
ISSUANCE DATE
L have mad the hvanlaua materials requarcummx under Chapter 695 of the Cal l-
NEW RESIDENTIAL MECH. SQ. FT.
forma Health & Safety Code. Sections 25585, 25573 and 25574. I understand that if the
building doestnotnmcurrentlyhave a¢rantthat it ismym
offito
af.0 ernotifytheoccupant
of the rcyuirertmnts which meet he nret poor m iksuanec nIa Cenificme of (Xcury' ncy.
ISSUED BY:
TOTAL:
Ownerorandoun ed agent Dam
OFFICE