S 1338i
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY lDCUPERTINO BUILDING "ELEC'hTRICA1, ,811. No,
PLUMBING "lSMOAI
U11.}NGDIVISION APPWCATIONIPERMIT nrrr,ll" allo.trMArano% 1338
M �J
ADDRESS:
❑ Consultant Fecs Paid by Applicant (Initial)
LICENSED CON'IRACIUN l UI4C,,AKAIJUN1y
TY ELECTRIC PERA1IT
I berchy arfinn Thal 1 am Timone] under provisions of Chapter H (commencing
with Section 7000) of Division J of the Business and Profession% Cole, and my license is PER MIT ISSUANCE
in full force and effect.
LiAmse Class Lick APPLIANCES—RESIDENTIAL
Dam Commcar
ARCIII'I ECTS DECLARN'ION PANELS
I undergend my plum %hall he used us Public records
UP TO 21X1 AMPS
OWNER BUILDER DECLARATION
1 hereby affirm that I um eacmpl trun, doe Combo is License Law lin the
following masom (Section 7031.5. Business and Profce,ion5 Crile Any city.., county
which requires a permit ,, mm,roct, alter, in,p rce, demolish, or repair any structure
prior I,it issuance, also contacts -,heapplicant heanch .it In file.si,.cd smtemmrl
that he I% licensed puroaran to the provisions ofthe Commemrs License Law (Chapter 9
(commencing with Section 9f00) of Divi%ian l of,hc liu%ine%s and Profesions Coda or
that he is exempt thercrrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a Eamon subjects the applicant to a civil penalty of
an, nume than five hundred call. n (SYM).
D 1. as owner of the propcny.trtoy employees with wages n,% their sale camaculdon.
will du the work, and the sneaure is not intended ural tried lin%ale(Set. T". lits%
r ons
and Pmteseionn Cade The Contrmmr's IJ,cu c Law docs n apply ton A
pmpuny who hnilds or Inh,m m thereon, and who docs such wet k hltnscll' or(bmagh
his own entployccx, pno ecd ,ha( suck inq,ttwctneoll se nor intended or odeul fn'
sale. ll, linvoor,( he hdldingor rotensent is. sold within one yerrolo delion, the
owienbullder will have the M1udm, ofInning that he did nm hand or inq,mvc lbr put -
%a
le
unsole 7.
WE as owner of the pmpeny, am exclusively contracting with licenmd comment,In
c"Mmet the pr qmL (Sec 9044 Business and Pudessions Code:) The Con,mctors I.i.
cen.e hw dsxs nal apply re as owner of pmpeny who builds or impmves ,hemm. and QTY
who contracts forsuch projects with a contra s) licensed pursuant to the Comracmrs
License Law.
❑ tum exeh .B&PC 11 this reason
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC, A /L
TEMP. MITF"R OR POLE INST. /
POWER DEVICES
SWIMMING I, ELECTRIC
OUT —SWITCHES — FIX'I UIt LS
NEW BESIDES ']AL ELECT It SQ FT.
wKW'kER'S COMPENSATION DECLARATION
bene ruttirnhuoder,coolly.,f,,,i,,Yuncoflhernllowingdaluratinns'.
Ino vol Ills inmin a CemOeatem Cloven( to xcleallmc lhr Worker's Con,pn,.
,atinn, as rosided I by Section 17m) of the Lubar Codc, for the Pe fomnnn ofthe
work h r which (his perms is issued.
D 1 have and will maintain Worker's Compenta(ion Insurance, as required by Section
3700 of the IaM,r Cede, for the,erformanec of the wink for which this pcmhit is issued.
My Workers Compensation Insumnce carrier and Policy number arc:
'non" Policy No.:
CERTIITCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(']This section need not be COoldeted if the Extent is foronc hundred dollars (5110)
or co,.)I
I comfy that in the performance of the work for which this permit is issued. Lshall
it... employ any person in any none, so ns,, M,come x.bj,r, to the Worker,' Conopen-
smion Law, of Callli,mia. Date
Applicant
NO'I'ICI? TO APPLICANT IL outer, making (hie Cenilicam of ff ca,t nn, you shnald
becamesahjc,l m he Waite, , Campmsa(ionpanisi or of (he LabCedno
e, n mast
a
f mbwcomplyith nply with such provisions or This Krmil shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that hem is a comwnion lending agency for the performance of
,he work for which this mand ie issued (Sec. 309. Civ. C.)
Icnder's Name
Lender'%Addrow
I cervi fy that I hove read this r,dication and ,am (hut the HsAc information is
reel l agme to comply wi,h all city and .... nly orlinanees and slam laws mlating n' Q'I'y
.
buildings one,ion, and hereby umhmiacm,resemnti se of this city n) enter clots' (lie
ab ... e.utmaionud Pro,,y rte' inpcction larl,oscs.
We) agme (o.avc. Indunmll'y and keep haroles, the City of Cu,ertino ngai,ol
Iinhilitics, judgments, a ittmdexpenses which may in any way%cane ogaln, said City
no ....egaence of the pmnall, of this "nor
APPI ICANT UNDF. STANDS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will mapplieam or future building occupier store or haru0e haeadnm material
as deflumd by the Capetian Municipal Gale, Chapter 9.12, and the Health and Safety
Code. lection 25532(%)'!
DYe% Fl No
Will am nt up"Lli or Imar, bonding o etq,ttnt n npdpncut ar duvieex'Ind,
mit hnumdous air contaminants its defined by an, Itny Ara Air Quality Munugnnenl
C3 Yes No
I have read the hazudou. urned d, ect mar minst under Chapter 695 of the Cut, -
ford. Health k Stacy Code, Sections 25505, 25533 and 25534.1 unders0md Ihat if the
building does net currently have a tenant, that it is my msponsiblllty to notify the «mpam
of the requirements which mus, be met Prior mI I,,-- of to Ceri6cate of Useclotncy.
PLUMBING
PERMIT ISSUANCE ll/
ALTER—DRAIN bh VEST —6tATER "
I4ACK PLOW fR(YI'ECT. U' CP
niA1NS—IrLDOR ROOF.ARBA. 11
FIXI'URLS —ITER TRA('
GAS — EA. SYSTEM -1 INC. J OUTLETS
GAS — EA. SYSTEM OVER 4 (EA)
GREASMNDUSTRL WASTE INTERCEPTOR
CREASE TRAP
SEWER—SANITARY—STORM EA. 2q1 FT.
WATER HEATER W/MENTI/IiLFCTR
WATER SYS'TEM11/1'RIiAI'INC.
WATER SERVICE
NEW RESIDENTIAL ('LMR, SQ. II'.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MPC] L
AIR HANDLING UNIT (TO Iff,IX)ECPM)
AIR HANDLING UNIT(OVI:V 10.000 CFM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT GO 100 ,000 BTU)
HEATING ON] 1' (OVER 100.000 BTU)
VENT LATION PAN (SINGLE RESID)
BOILER —COMP(3HI'Olt Itl(I IHNI If I' U)
BOILER—COMP (OV lilt IEd (IS IfI"UI
AIR CONDITIONER
NEW RESIDENTIAL MECIL SQ. EL
COMMERCIAL:
D NEW BLDG/ADDITION
0 1IFNANT
IMPROVEMENT
❑ OTHER
D DEMOLITION
)N
❑ FOOD SERVICE
SQ St. AXP 107.A S/SQ-IT.
MAR 9 v ANS'D
FEE
V ur �urtnIIhu
I VALUATION
STORIES 'rYl'L'CONS"rRUC'1'ION
OCC. GROUP AI'N
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FIJI
PAID
Dam icipl x
TOTAL:
BUILDING RiE le
1'LI, SEISMIC FEE
VI.EC'1'RIC FEL
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
DOUSING MITIGATION PER
PAID
Dux Receipt#
I DIAL:
ISSUANCE DNEE
SIC
CONUOLM
BUILDING PI„RNHT INFO
_
^ PLUMB MEC
BhU ELECT II
.
l
FLT”
JOB DESCRIP'T'ION
RESIDENTIAL
D SFDWI, TCHEN REMODEL
ADDITION PLUMBING RE -PIPE
DMUI.TI-UNIT STRIJ fURAI.
MODIFICATION
INTERIOR CHIMNEY REPAIR
IMPROVEMENT DSWIMMINGPOOLS
D BATH RFMODIdJRFI'AIR DDEMOIJ TION
DOB HER
COMMERCIAL:
D NEW BLDG/ADDITION
0 1IFNANT
IMPROVEMENT
❑ OTHER
D DEMOLITION
)N
❑ FOOD SERVICE
SQ St. AXP 107.A S/SQ-IT.
MAR 9 v ANS'D
FEE
V ur �urtnIIhu
I VALUATION
STORIES 'rYl'L'CONS"rRUC'1'ION
OCC. GROUP AI'N
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FIJI
PAID
Dam icipl x
TOTAL:
BUILDING RiE le
1'LI, SEISMIC FEE
VI.EC'1'RIC FEL
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
DOUSING MITIGATION PER
PAID
Dux Receipt#
I DIAL:
ISSUANCE DNEE
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