S 1694 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL PER�pITl`J NO. 1694
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
2/ Gb Ley k� �� 74i�'/
OWNS NAM PHONE: CONTRACTT OR'S NAME: l LIC NO:
60 Cy Z1 /-//LL ✓: N/C CONTROL#
ARCHI FECT NGINEER: LCN ADDRESS: ❑
CON ACT: BUILDING PERMIT INFO
W6?1?-
❑ Consultant Fees Paid by Applicant(Initial) BLDi PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION -7QTY. ELECTRIC PERMIT , FEE
1 hereby affrm that I am licensed ander provisions of chapter 9(commencing
Wee39—
p arm Semien"lOW)uf Divisi(on311 Buainesxosi Professions Code,and my license;. JOB DESCRIPTION
RESIDENTIAL
F in full Foran and effect. PERMIT ISSUANCE
CSF
aUU License Class Gc.# WL ❑KITCHEN REMODEL,
yGd Date ConlmwN APPLIANCES-BESIDES'1'IAL ADDITION L1 PLUMBING RE-PIPE
ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT C1 STRUCTURAL
O$y (understand my plans shall be used as puhlicmcoM, MODIFICATION
UP'DO 20E AMPS
W L care"Pmfeastenr Ali El INTERIOR El CHIMNEY REPAIR
qL 201-I(XIOAMPS
OWNER-BUILDER DECLARATION VIMMING POOLS
1 hereby affirm that 1 am exempt front IM1e Contractors License Law for the OVER 1000AMPS ❑B MODE IR 1 IOLITI
3 d bi following amcma.(Section 7131.5.Business and Pnd'ession,Cede:Any city or county SIGNS ELECTRICAL
,sO r¢of which requires a Penni[In construct,altar,improve,demolish,or repair any.urethra Inj
�h.] priorn,ia ksunnca else require,theapplicant 0trsuch Permian file a signed statement SPECIAL HICIBUMISC. ia
¢s, mal he is licensed pursuant to the provisionsufine Comroamr's License Law(Chapler9
W�CaO (commwoing with Secion 7g11ry of Divixion3oflhe Business and Pmfesaions Cwife TEMP.MHTBR OR POLE INET E
d q m y
but he is axcmpl therefrom and the basis name alleged ascription.Any return.Of BLDG/ADDITION ❑pF.MOLI
Section 7031.5 by any applicant for apermit subjects me applicant loacivil pmmlry of POWER DEVICES �T ,kq�P ❑FOOII SE C
not more than five handreddollars($500). I P EMENT
d� 01,us owner of me property,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended Or(offered for sale(Sec.]Wt,Business 110
4 m and Professions Coude:The Commuters License Law does not apply at an Owner of OUTLETS-SWITCHES-FIXTURES
.. property who builds Or improves thereon,and whe doe.,,such work himself or through
his we omplOyec,,provided that each imptnvementa arc not lntunded or offemd for NEW RESIDENTIAL.ELECfR SQ PT.
sale.If,however,the building or improvement is sold within one year o �
f complenogme � - 1 SQ.FT.FLOOR AREA S/SQ.F1'.
o shar-builder will have the burden Of pmving that he door not build nrimpmvePor
pur-
poseofealeJ. -jn-vS
❑ 1,as ownerOf the property,am exclusively contracting with licensed contractors In
construct the project(Sec.9044,Business and Profcesiots Codd:)The Contractor's Li- -
c sc Law does Our apply to an ownerofproperty who builds or unproves therear,and QTY PLUMBING PERMIT FEE
who eemmets ferment projects with a commcmr(s)licenced pursuant m the Contractors �VD
License Law. PERMIT ISSUANCE
❑lamexemptunder Seo. ,B&PCforlhi,uw,mr
OwnerALTER-DRAIN& NT-WATER(EA)
Ualc VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO' v .DEVICE ��h
1 hereby affirm under penally Of perjury enc Of the following declamtinnsu
❑l have and will maintain a Certificate ofConsenl In self-insure for Workers C(ompen- DRAINS-FLOOR,RO AR' ND. STORI TYPE CONSTRUCTION
satin,as provided for by Section 37M of me Labor Code,for performance of the
work for which this Perini[is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's COmPemaiml harmance,as regoired by Section
37M oohs Lahm Chile,for IM1e performance nftha w(ork for which this permit is issued, GAS-EA.SYSTEM-]INCA OUTL OCG GROUP APN
My Workers Compematien Insurance named and Policy number are:
Cather: Pnllcy NO.', GAS-EA.SYSTEM-OVER
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUS'IRI,WASTE INTERCEPTOR RU LNG DIVISION PEES
(ThN,edion neudnmberomplmed ifthepermitle Rin rehundreddollen,O1W) GREASF.9'kAP e
or lescJ
I certify that in the performance of 1 work for which this permit is Issued,I shall PLANC
not employ any person in any manner Idea
m become subjecno[he Workers'Cnmpen- SEWER-SANITARY-STORM EA.2q1 F'1'. ENERGY FEE O�
O ry saran Laws of Caffornie.Dam WA'fF:RBEATER WNENTA LECI'k
Q Applicant GRADING r-
become
TOAPPLICANT:IF,afiu meking this Ccrilicom of Exemption,you should WATER SYS'1'HM/I'kHATING
abecome subject to the Worker's Compensation provisions Of the Labor Code,you trust SOILS FEE
L31 forthwith comply with such provisions or this P.nnil shall be deemed revoked. WATER SERVICE
Q
DCONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.IF PAID
V Q kf..by which
that them isacd(Sce.30 len ding agency forthe performance of m Recti
� r [hc work far which this pemrh is issued(Sec 3097,Civ.CJ
Lenders Name
TOTAL:
W Lenders Adef -
Fir - I certifyythat 1 have cad this n nand state mat the above infartnmion is BUILD( ,PEE
ti oomect.1 agree n,comply with ad rnom all dty and unry orelnuncea act ata[e Iowa miniog to QTY MECHANICAL PERMIT FEE
L) zi building concoction,and hereby uubmize rgnasentative,of this city to war upon the SEISMIC FEB no
o dive-mentioned properly for inspection purposes.
(We)agree m Iowa,indemnify and keep harmless the City of Captain.against PERMIT ISSUANCE ELECTRIC PEE
Ilabilities.judgments,costa and expenses which may in any way accrue against said City AITHRORADDTOMECIL D `
On come trance of me PLUMBING FEE
q gmnling or this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(Tet 10,0(10 CPM)
SOURCE REGULATIONS. MECHANICAL PEE
_
11416A,
� AIR HANDLING UNIT(OVER QOOO CFM) CONSTRUCTION TAX
SignmureuIAppb Co tar P EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
H RDOIIS M (ALS DISCLOSURE
Willtheuppliamtor aklatioceaped,lorem handlehazoNom material HEATINGUND"HO I81kWUBTU)
as defined by the Ctipenino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532mul HEATING UNIT(OVER 108,000 BTU) -
❑Yes ❑No
VENTILATION FAN(SINGLE RESIDI PAID
Will the applicant nr future building nm kcceipl p
pp g welie B BO
use equipment or devices which BOILER-COMP(THE OR 100,(X10 R'Ff
ami[Incursions air conformists as defined by me goy Area Air Quality Management )
DietrialP TOTAL
❑Yes NO BOILER-COME(OVER 100,(1)80TU7
I have cad[Ito bazurdnua mmeriols r p AIR CONDITIONER ISSUANCE DATE
e,2553 enO under .1 tar095of me the bOmia Health n Safety currently
have
Sections 25505,25533 end 25534.1 understand hatifthe NEW RESIDENTIAL MPRH.
building duosoat s whicy have Inlenat prior i[Ismyecofa responsibility to notify the necupam
of the requirement,which mLL l he mel priono issuance OF a CeuiOcotc of Occupancy.
Owner or authorized agentDam 0�.. ISSUED BY:
OFFICE