B 0267 PLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
' CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT No 0267
/ BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL SOoo�
BUILDING PROJECT'BDENTIFBCATION
BUILDINGADDRESS: SANITARY N(1. APPLICATION SURMITTA1.DN
YGW0 , X
S A : PHONE: CO ALIO S NAMIi: A 'A �L{f,Np
(Nee V C(lL-lC NIC COATROLX
Mr
LCTTNG ECR. LIC NO: ADDElIPS i0
CSONITACT: (1�) PHONE: BUILDING PERM11IT INFO
„ � � • g{ .3,. .r y Q, 7C(795- DC....Itant Fees Paid by Applicant(initial) BLDG ELECT PLUMB , MECH
LICENSEDCONT ACTORS DECLARATION QTY ELECTRIC PERMIT FEE,
1 hereby affirm mat I am licensed ander provisions of chapter 9(a,mmamcfag JOB DESCRIPTION
,0Z with Sedinn]001y of Division3 of the Business and Pmfeaions GNc.soil mylicensc is RESIDENTIAL:
X00 in PERMIT ISSUANCE
FK Uy full force and eBr►� Z-/.Z L� ❑SFUWI. 0KITCI{IiN REMODEL
l UJ Liceme Clas Lica 1� APPLIANCES-RESIDENTIAL
yzw Dam Cn manor [_1 ADDITION C3 PLUMBING BETTE
ARCHITECTS DECKAA ON ❑MULTI-UNIT ❑STRUCTURAL
PANELS
O Z�4 I ancentaid my plans shall be used as public recnnl, MODIFICATION
UPT0200AMPS El INTERIOR. ❑CHIMNEY REPAIR
I-4F-{n Licensed Professional 201-I0(M)AMPS IMPROVEMENT C]SWIMMING POOLS
oWNLiR-BUILDER UECLANA'UON OVER KMAMPS ❑BATH REMODEUREPAM ❑DEMOLITION
st I hereby affirm that 1 am exempt from the Contractor's License Law for the
xdxp ILU following reaver.(Section 703 LS,Ruinous,and Professions Curie:Any city or county SIGNS ELECTRICAL �OTHEN Q
W 3 fay which requires a permit tot construct,altar.improve,demolish,m repair any Nameare s
, I prions le issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC.
294 A
f n} that he is boomed pursuant me provie:ons of the Contractor's License Law(Chapter 9ot
1 00 (commencing with Section](R()of Division 3 ofthe Businasand Profusions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
d 1ey
W d nt he is csentin Wercfront and the basis for me alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^sA Section](1315 by any applicant for a permit subject the applicant to a civil penalty of POWER DEVICES W^r/I ❑TENANT ❑FWD SERVICE
C=Ot mom than five hundred dollars($500).
isLothe work.thepmlwny, remyot intended withwogesastl,(So,.contpeusiness SWIMMING POOLBLIiCTRIC OTHER IMPROVEMENT
f will Pr thework.andtheoCommmns Livens Low and forotapply to an omit of ❑OTHER
W 3 m and Professions Gxie The Compactor's License law)nes not apply cat an owner of OIIIU!TS-SWI ICHES-FIXTURES
propcny who builds or improves thereon,and who does such work himself nr through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR Q FT.
safe.IL however,the building orimprovemem issold within one year ofcompletion.the SQ.FT.FLOOR AREA &;Q.14.
owner-huilder will have the burden of proving that he did not build or improve for pur-
lose of
0 h as owner of the property.am exclusively contracting with licensed contractors at TOTAL: P A I D
constrict the project(Sec 7044,Businca sad profession,CWc:)The Committees .h
cense Lawdoeamnapply torn owner of property who build,or intprmvealhcreon.tmd QTY. PLUMBING PERMIT FEE
who commas for such project with a contractors)Inciewd pursuant to the Contractors JUL 06
License law. PERMIT ISSUANCE ANSI
I vm exempt under Sas .B k P C for this...son
Owner Dam ALTER-DRAIN&VENT-WATIiR EA)) GII I urVALUATION
WORKER'S COMPEM1'SADBACK MOW i'ROTECf.DEVICE ON DECLARATION ka-Cl-IIf IIS,)
Per
ry
of
doul
have
and will client a penalty of ofConont oslSufnRow log Worker's Ca
IJlhuve andwie for
eCion 3700 of Cc Labor Code.for the Worker's Confirm-of the
DRAINS-PLOOR.RWRAREA,GOND. STORIES TYPE CONSTRUMI(
ration as provided for by Section 3]1X1 of the labor Code.for the pMonnanu of Ibc
ark fur wInch this pcmtil is issued, FIX'I ORES-PER'IRAP
e and will maintain Worker's Compensation Insurance,as required by Section
00ofthc labor CWe.for the performance of the work for which this permit is issued GAS-FA.SYSTEM-L INCA OUTLETS
MY a Co tri In r ar-nod Policy g��t�,����/+/yam} OCC GROUP AI'N
CI s they No.,/ n •� GAS-HA.SYS TEM-OVER4(EA)
llllll������ CERTIFICATE O E(EMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INTERCEPTOR
(Thissection need flare itplored if the permit is future hundred del lines;($1Bill RUILDI NO DI V IS ION FE ES
or Ica.) GREAS17 TRAP
1'LANCHIiCK PER
(certify that
porsnthe any
so as
manneork r whish this permit it ismeJ.I shall SEWER-SAN]'I'ARY-
S'I'ORM HA.20()FT.
not..ornployLaw any Carson in any manncrsu as nt M1ccmnm snhiccnntha Wurkcrs'Cnmpery a ENERGY THE
Z ration Laws of California Date
Q - WATER NEA'T'ER W/VLM/ELECI'R
Z Applicata I GRADING FEF.
h becomeNCHTCEsTOAPPLICANT. is Compensation
This viniRcam of Exasnptindyoushould WAITiR SYS TEM/fREAIING
abecome scoop m the Worker's Gions or this provisions of the med Code.you moa SOILS ILL?
�
forthwith comply with such previsions or permit shall Mdeerrted revoked. WATER SERVICE
Q
Uz CONhem isaTIGNLENDINGAGENCY NF.W kESNEN'1'IALPLMB. SQ.Cr. PAID
VQ I for whihthithathereisoad(See construction lending agency for the performance of Dam Rcceiptp
{lr (" the work Name which this pcnnit is issued(SIL.31Y9],Civ.Cd
Q V Leader's Nano 'I'OIAL:
Lender's AJJrca TOTAL:
pr 1 tt'nify that 1 have mad this apPlicaion and sato that We whose information is BUILDING FEE
fi (A correct.l agree to comply with all city and county ordinances and state laws mining to QTY. MECHANICAL PERMIT FI7E
C) Z building construction,and hereby outhorim representatives ofthis city toemeropon the SEISMIC PEE
ebevc-mornened propcny to....per,.on tgeves. PERMIT ISSUANCE
(We)a e,indemnify. k 'p harmless the City of superior agoing ELECTRIC ITE
liabilities.' gmnd,cestandespen swhi canny in any way aurae against said City ALTER OR ADD TO MSCI I.
' wce of egmming o' permit. PLUMBING FEE
APPI 'ANT U, )ERSTA H ALL NON-POINT ALR HANDLING UNIT(TO IO,000CFM)
SOU ItREG MECHANICAL LEE
9d AIR HANDLING UNIT(OVER 18.000 CFM) CONSTRUCTION TAX
pplicam/Contranor Dale EXHAUST FOOD VODUCq DOUSING MITIGATION FEE
MATER1A1 S DISCLOSURE.
Will the applicant or future Wilding occupant store or handle Weardoas material HEATING UNIT CIO 100.000 BTU(
as defined by the Capenino Municipal Code,Chapter 9.12,and the Health and Safety
Gyle,Saalon 25532(x)( HEA'T'ING UNIT LOVER 100.( 113'1'U)
❑yes ON.
VENTILATION FAN(SINGLE RF_SID) PAID
'Will Wu a t or Boom huildim f use e I or devices which Dme R....pl a
v" Ppintn gby then Area
n BOILER-COMP QHP OR l00.0n)BTU)
oat hevallous air contaminants as refined by the gay Atha Air Quality Management y
District! TOTAL,: L
0Ves nNo BOILER-COMP(OVER 11q,0X1 BTU)
I have read the hvnNois mamia{s requirements under Chapter 6,95 of to Cali. AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Gds Sections 25505,25533 and 2.5534.1 understand that if the NEW RIiSIUENI'IAL MSCI I. SQ.IT.
building does not currently have a tenon.Wal it is my msgmsihility m notify the mrupvm
ofthe requirements which mus be met prior to ixsuance of a Cenificare of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE