S 0665 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICNI'IONMERMIT PLUMBING-MECHANICAL
BUILDING PROjFCI'IDENT'IF'ICATION 0665
BUILDING ADDRESS: SANI'IA=11(
ImP,^V\OWNERS NAME PH NE: CONI RACfOR'S NAME: LIC NO:�� NIC
i
,CHIlTC OENGINEER: LI NO: 'DURESS: ❑
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTFLlJtvpl MECH
❑ ❑ 719/ ❑
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE JOB D85CRIPTION
1 hereby affirm Ilett I ant licensed under unti,itm,of Chapter 9(cormhaming
0 a'Z with Section 7000)of Division t of the Bunine.ss and Poofilcxsions Cote,and my liccno,'% RESIDENTIAL'
FSB mfnnlbrecendenecl. L- !� 4L PERMIT ISSUANCE ❑SFDWI. ❑KIT CHFN REMODEL
J6 Lia» b
QUU License Claes APPLIANCES-RFSIDF.M'IAL [I ADDITION ❑PhUNRING RE-I'II'li
HZW Dalc Contmcmr ❑MULTI-UNIT ❑STHUCI'UR'1.
'HCI{I"TIiCTS DEChAHATION J PANELS MODIFICATION
zonK I understand my plan"shall to uxcd as public records UP TO IlO AMPS
❑END[MPR VIL E]CHIMNEY RIiI'Allt
D IMPROVhMI>NT EISWIMMINGPOOIS
W N Licensed Pndessinnal 21VER 16AM1!S
OWNER-BUILDER DECLARATION OVF,R IIX%LAMPS ATH kGh10DEURIJ'AIk ❑DIiMOLITI0'
p, a hereby uffimt ibm I am exempt from the Coatmctoe,Liernse Law for the
)(�d following (Section 7031 5,Holmes,and it 1,4..ons Code:Any city or county SIGNS ELECTRICAL OTIIIiR
reason
IA 3 a y which rcyuires a permit m con%wcl,aper,improve,demolish,or repair any umcmrc
prior whits issuance,also requites fleappl,o for CoM1merci,Liiense Ur.
SYF,CIALCIRCUIT/MIST.
that he is licensed pursuant to the provisions of lM1c Cnmracmrs License LwlChupmr9 COMMERCIAL:
W�pO (commencing with Section 7000)of Division J of"the Business anti Prnfcssi, Calepx Tl!MP.METER OR POLE INST.
ao,etG that he is exempt Ihercfrnm and the basis for the alleged cxcnhplion.Any violation of El NEW HhUG/ADDITION ❑DIiM01,1"f10N
Section 703 LS by any applicant for a Permit subjects the applicant o a civil Penalty of POWER DEVICES ❑TENANT' ❑FOOIISERVICE
m more than five hundred dollar 1S500), IMPROVEMENT
SSG Las owner ofthe pmpeny,or my employees with wages as their sole compensation. MPLUMBING
POOL ELECTRIC ❑OTHER
E., will do the work,and the structure is not intended or offered for%do!Sec.961,1.Ball e%sSWITCHIiS-PI ES
Lam and Prole,inn,Calc:'I'he Counncmrx License Law does not apply to an owner of
proptoy wno builds nr imprw'es thereon.and who does such walk himself or throughEN'TIAL ELECT FT
his own employees,provided that such impowervetns are not intended or offered forygt 11'FLfOR AH&\ VSQ.PC
sola If.however,the Willing.,lmpmvemem is sold withinoreyearofsuradatiar,theY� A p
owner-builder will have the burden of proving that he did not!wild or imPmve for Pur-
Inmcofs:lr.) 'TOTAL OC
O I,as owner al''he propOry.am corlusively contracting with licensed elicitation,mT O 6
nmtnhn the project(Sec.70,VU holiness and Professions Cash:)The Contrecam's Li- I o x111
come Lw does not apply to an owncrofpmperty who builds or imProvcsthcrcon.and PLUMBING PERMIT FEEv{/who contracts for such projects with a mnroctor(0 licensed pursuant to the ContractorsLicense Law. ,liffi VC mnhis rwsonUANCEY Urp I ant exempt under Sec. RAIN&VIiNT-W'ATF,H IEAI VALUATION
Owner DateW'ORKER'S COMPENSATION DECLARATION W PROTECT.DEVICE
I hereby abinn under penalty A perjury ora of the following dcclareliom
I hove andwill nuninlain mCerliticamof
0ocal local(-insure for Workers Cotnpmt- DRAINS-[lOOR,RO(1F.AREA�COND. SI'01210.5 TYPH CONS']R,C'I'ION
cation,as provided fur by Section 3910 of the Labor Cade,for the peffirm anee of the
ve A for which Ibis permit is issued. FIXTURI!S-PER TRAP
300 sl and
L hurl us`
tine for permsrmaneof thcvonkfmotion ornct,as which ill!spertm 0.issucIf GAS-EA.SYSTEM-1 INC.!OUTLETS
��Section —
fICC.GROUI' APN
My Wa rs mlvCu� asurtR'o cam PoI iyN"Wtq "� GAS-EA.SYSTEM-OVIiHJ(EA)
Cartier: it l
CERfIFICAll. 'EXEMPTION FROM WORKERS' GREASFIINDU$TRL WA$'1'E INTEHCIiI'IT)R
COMPENSATION INSURANCE, BUILDING DIVISION FEES
fTbisaedmn need not IN,completed HW Permit is for one hundreddollars(EIW) GREASETRAP PLANCIHICK FEE
Ics")I
Icenifytbm..in perli..be,cof unwork lie,atij this the Wois rkers
Com,o11 SEWF.H-SAN]'TAHY-STORM EA.200 FL ENERGY FEE
Dol employ any Peraun in any munncno s m Ita"omc subjccuo the workers'Cnmpen-
Z salion laws of California.Dam WATER HEATER WNENT/ELECTR GRADING ItHE
zO Applicant
C
NOITCE'IG APPLICANT:11;after cooking his CcniGcate al lixemption,you huld soWATER$Yl'IEM/THF.A'I'ING
SOILS Plil?
I"s Mame subject to the Worker's Cmnpersation pruvkinas ol'the Lab Come,you nmst
forthwith comply with such previsions or this Permit shallM dcatread rcvoked. WATER SERVICE
W
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.FL PAID
c In Or
I hcreM1y nlEnn that them is u amelmdinn lending agency Iur the pednmmncea(
U F the work for which Olin Fennel ix Inured(SI:.7099,Civ.C.) 'I Ol AI.
O Landers Name TOTAL:
r Landers Address BUILDING ItiC
0. 1 certify that 1 have read this lWhcation and%rate that the above information is
F IA e acct.I agree to comply som all city and county ordinances and store laws relating tut QTY. MECHANICAL PERMIT FEE SEISMIC ITITT
U buildingcmmtmcliun,and hereby author;,reporroulttives oflhillul to cmcruponihe
.Nwcmenlioncd pmpcny for inspection purgtxs. PERMITISSUANCF. ELECTRIC IE
(We)agree m save,indemnify and keep harmless the City of Copeninn against
liabilities.judgments,costs and expenses which may in any way becme against said City ALTER OR ADD TO MECH. PLUM 'G FEE
y DM1e granting of this Permit.
'a AMP UNDERSTAN AND WILL C(IMPLY WITH ALL NON-POINT AIR IIANULING GNII(1'G If1.11IX1 CFM) MECIIA .AI.PEE
SOl eREGULATION _ ''/1 AIR HANDLING UNIT(OVER IO.gOCFM) CONSTRU ON TAX
�� /� pa1C EXHAUST HOOD(W/DUCfI
Signature of Applicu ort r HOUSING h11T1 'TION ITL
HAZARDOUS MATERIALS DISCLOSURE;
Will the appla,nl or future building occupant store,),handle hazoNoux material HEATING ON IT TO 100!000 BTU)
as defined by the CuPenino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER It0.000 BTU)
Cale.Section 255)21x)?
E]No VENTILATION PAN(SINGhE RESIDI LAID
Dale Hewiph p
Will hbc applicant or future building^a'upanl use equipment nr devices which pOIL1iH-COMP OHP OR H.)WE
I{'Up
emit hvardous air contaminants as defined by the Bay Arca Ail Quality Meaagement 'IOTA h:
District? BOILER-COMP(OVER IIO.HBO If rU)
❑Yes FNn
AIR CONDITIONER ISSUANCE DATE
1 have rend the hmdic.Se iona,15 requirements under Chuplcr h.95 of to CuIL
fnmia Health&Sulkty Cade Sttlinns 25505.25531 and 25511.1 understand Lha if tat: NEW HI!SIULNTIAL MISCII. SQ.FT.
helping docs not currently have a tenant.Nat it it my responsibility ho many thwecup rd
of the mquiremenw which must he met prior to issuance of a Certificate of Occupancy.
ownrr or anmorival asem
Dwc TUFAI.: ISSUED IIV'.
OFFICE