S 0486APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDIN-ELECTRICAL
CITY OF CUPERTINO G.
BUILDIN(; DIVISION APPLICATION/PERMIT ILUSIBING.-MECHANICAL
BUILDING PROJECT IDEN'PIFICATION
PF I'r N°.
J 0486
BUILDINGADDRISS:
io3bo MA06:R v6
SANITARY NO.
API'LICADON SUBMI I'1'AI. OA'I li
(_\_tC; 11
O . '$NAM& ����J� PyH NE: _
CONT ACTOR' ME: LIC NO'.
N/C
CONI ROI.X
rRCII1IECT/[N EC:H: LIC NO:
S!
ADDRESS:
CONTACT. HONG:
a7
�� C� 7+C4,,77?
❑Consultant Fees Paid by Applicant (Initial)
BUILDING PFRMVI' INFO
BI� EWiCI' PLUMB MECH
/f IIyA
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 atm licensed under provisions of Chapter 9 (commencing
anhm Baslns and ProfeWr a, coda and my licence is
n Sexa 70x140 offimmon B as
with do
in fall force and effect.
QTY. ELECTRIC PERMIT FEE
DESCRIPTION
JOB DESCRIPTION
RESIDENTIAL :
'I'TCIIEN RBMOUEI.
PERMIT ISSUANCE❑SPDWh
APPLIANCES TI
Liccnsc Class Lic.N
Date Contractor
❑ADDITION PLUMBING RE -PIPE
❑ MUITI UNIT ❑ MODIDCA'DON
[I INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT []SWIMMING POOLS
BATH REMODEURIlPAIR El DEMOLITION
❑ OTHER
ARCHITECTS DECLARATION
I unJcarnnd my plans shall he used as public records
PANELS
UP TO 200 AMPS
Licensed Prolessinnal
OWNER -BUILDER DECLARATIONOVER
I botchy Often thin 1 um exempt from (ticCimtmclor's License Law for the
t following reason. (Section 703 IS. Business and Professions Cede: Any city or county
201-1000AMPS
land AMPS
SIGNS ELECTRICAL
which requires a ixrmit to conxtrvct, alter, improve, deneli'th nr repair any ehucture
prion t.'. u also req th pPlic If M1pcmtilk 11 6 cJ swat Heol
that he is licensed parsd to the provisions fm Contructor's Liclorw L (Chapter9
nommencing with Section 960) ofD"sri 3 ofth Business andMi am Code)or
Ihal he is excmpl therefrom and he basis for the alleged cxmmpuon. Any violation of
` Section 7031.5 by any applicant far a permit subjects lbs applicant a a civil Penalty of
on tic than film hundred collars (SSW).
L as owner of the tur,, y. Cor my employees with wages us their sole"alpcn", 1.
.1 dome work, and the dructure is not intended maffeted forsale ISec. 701P 11usiness
i and Professions Cade:'llte Control License Law docs nal ISlY In an owner of
progeny who builds or improves thermal, and who dries such work himself or through
his own employees, provided that such improvcme i% arc not intended or offered for
sale. If. however, the building ar improvement is sold within tine year ofcompletion.'hc
SPECIALCIRCUI'UMISC.
]ENIRMETBRORPOLEINS'1'.
COMMERCIAL
❑ NEW BLDG/AUDITION LJ DEMOLITION
❑TENANT ❑FOOD SERVICE,
IMPROVEMENT
❑OTHER
POWER DTIVIC17S
SWIMMINQPOOLELECTRIC
(IUTLITS-SWITCHES-Fl%TURfS
O
NfiW RLSIUIiNTIAL BLECI'R SQ PI'.
SG FT. Iq.00H AREA
gISQ. F1'.
owner -builder w 111 have the burden of proving that he did not build or improve for par-
Mm ofsalcy
1, Its owner of the property, am exclusively, contracting with licensed c mmeamrs ni
ondmel the project (See. ]614. Business and Professions Caddell) The Contractor's Li-
nc Law Ares not apply to an owner of prepeny who builds or imPrnves thereon, and
p A I D
SEP 15
TOTAL:
QTY PLUMBING PERMIT FF.E
who comructs for such pnga l ece, with a contrlicensed pursuantN the ContmetorM
RECTI
Liecnse Luw.
❑lamexe tundmr Sec. ,B&PCformixreason
PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATER(EA)
_.
ALUAT I
�w
V Own Date
' WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declarations:
])have and will muinmina Cerifcatc of Canxnuo¢If-inmrelnr Wnrkcr'e Camp.-
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. HOOF, AREA. CONE.
ORIES
'I'YI`E CONSI'RUCI'ION
sa ion, as provided for by Suction 3100 of the Labor Code, lar me pedeman ce of the
xnrk for which this person is issued.
C] 1 have and will maintain Worker's Conlpen.wtion Insurance, as required by Satins
T/00oftne [.No Cale. for the peTfirunce of the work for which this Pcrmar, icwed.
:10)CC.GROUP
MIN
I>IXIURES - t.'1ek TRAP`
GAS - EA. SYS TEM- I INC.4 OM LETS
GAS -EA. SYSTEM -OVER 4(EA)
My Workers Compensation Inmmnce currier and Policy number um:
Carie,. Policy No.:
CER I'IFICATE OI' EXEMPTION FROM WORKERS'
COMPENSATION INSURANCEBUILDING
GREASFANDUSTRI. WASTE INTERCEPTOR
DIVISION PEES
GREASETRAP
I'LANCIIECK PEE
(This section need net be cnnlplered ifine Permit is for one hundred dollars IS l(X11
or IcncJ
lcenify that in lM1e performance the work for olbb, this permit isis' Comleil
nm unlpinY anY Ixrsnn In any manner so ns m become subject m the Wnrker� Campion-
smion Laws of California. Date
SEWIiR- SANITARY -STORM IiA. 2(x1 FT.
ENERGY ITE
WAIIIR HEATER W/VI?NT/l LI4C`TR
GRADING FEE
j Applicant
p NONCE TO APPLICANT: If, after making this pontificals, of Exemption, you .should
Meome.subject ra me Wnrkcr's Cnmfo a tam provisions of the Labor Cala, you mall
forthwith Comply with such provisions or this prey itshall he deemed revoked.
WATER SYSTEMOMEA'TING
SOILS FEE
WA'I ER SE RVICE
NEW RESIDEN'I'[AL.)'LMB, SO FY
CONSTRUCTION LENDING AGENCY
I hereby affmvhat there is a crmsuuctiun lending agency for the performance of
the wank for which this permit is Isx.W (Sec. 30IG. Civ. C.)
PAID
Dom Be' 'Pt p
'I (YTAIc
Lendrr'x Some
lender's Address
L I sonify that I have read this application and state Ihal the above information is
n real l agree to comply with all city and county ordinances and stale laws rotating to
building cnnslmmion. and hereby aumuoiee represenwtives of Nis city to enter, upri the
TfTI'AL:
I
QTY. MECHANICAL PERMIT FEF.
;' to
.Nn'e-mentioned properly tin inspection purposes.
(We) agree in save, indemnify and keep hermlas the City of Cupnino against
lixhilitlma,judgn¢n6, costs and cxpensca whlcb stay in any w'aY accrue againw sail CllY
PERMIT ISSUANCE
FEE
PLUMPING FF:
jHOUINGMITIGNp
AI TIiR OH ADD'fO MECII.
consequencein of the granting of this permit.
APVLIC DERSTANDS AND WILT. COMPLY WITH ALL NON -POINT
AIR HANDLING UNIT Or 10.001 CFM)
C .FEC
S UR(' iGU Up ONS.
I,
AIH HANDLING UNI'I'(OVER 10.000CEM)
1'ION TAX
Ignawre of Applleanl/Cnntrenor Uatc
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant at future building occupant small or handle hazardous material
m defined by use Cupcnino Municipal Code. Chapter 9. 12. and the Ilcaah and Sulcty
Code, Section 25532(a)T
❑Yes El No
EXHAUST HOOD OXIDUC)
T NFEF,
HEATING UNIT (TO 100010 BTU)
HEATING UNIT (OVER Bx.cloo i'IC)
PAID
Urate ulsc6ptg
VP.NTILA'1'ION IAN (SINGLE RESID)
Will the applicant or future building occupant use ugatpnxnt Or devices which
,.nit hazardous air contaminants as, defined by the Bay Area Air Quality Management
BOILER (31 If
'TG'TAI,:
BOILER-COMP(OVE❑Yes
Ulntrict"
EI NoNIH
MU)
CONUITUIM!kISSUANCIi
DATE
1 nave mad the hourel maurial.e tegvireromm, under Chapter 6.95of Ne Cath.Ibmia
NEW RESIDENVAL Mbuilding
Health & Safety Code, Sections 25505.255)) and 255:U.1 understand Ina if me
dors nix currently navea waant. that it is my resp nubility to ratify theoccupant
of the rrquimments which must he mel Pdonn issuance ofa Cendieate, ofOeruPaocYOwner
SUED BY:
or omhorisJ agemDam
OFFICE