S 2051APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROAtC'r IDEN HFICNI In
BUILDING ADDRESS:
CONTACT: Ayt ds PHONE
sat i (� ass �a . sh, N
❑ Consultant Fees Paid by Applicant (Initial)
I hereby a1Rmh End I ren liven¢d under provininre of Chapter 9lmmmuendng
CC)Z w11h Section 701 Division 3 ofthc Business and /pr'ofession. Cade, and my limmeis
QUWMU LimneClxe nd eml-a-<r�- 4n �Ql./r
License Clan Lica
0<0.
nate comtac
ARCHIE ECTS DECLARATION
z OFolz I undenutWmy plmoshellbe used as public meoNs
OZ -e.
[-
Ll F W Licensed Professional
Q I OWNER -BUILDER DECLARATION
6 I hereby alarm that 1 am c%empl from the Contractor's License Law for the
XL 3 i U following reason. (Section 7131.5. Business and Profession% Came: Any city or county
W y which requires a Permit u) commuct, uhee improve, dernolish, or repair any structorc
prior to its issuance, also requires the applicant for such comit to file a signed%lammem
�4} that he is livened pursuant to the provisions ofthe Contractors Liceme Law (Chapter 9
lal�p0 (commencing with Sectiun 7000) of DlvlXlam3 oflhc Business and 11 ..lesion Came) nr
M. c. C thus he is exempt therefrom and the hams for the alleged exemption. Any violation of
X m Y. Section 70315 by any applicant lin a permit subjects the applumit m a civil peoahy of
not more than fve hundred dollars ($500).
SD 01. an owner of the pmpeny, or Loy cmpinyco with wages as their sNe corniest
q,HCl will do the work, and thevwcmmn not intended or offered for %alc(See. 70114. Bus e%
W i an and Poi Cuda Be Contractors Licemc Law docs on apply In an owner (If
property who builds or Improves themm, and who docs such work hinmdf or through
his own employecc, provided that such improvements are not Intended or offered lin
sale. IL however, the building or Impnrveman is sold as thin one year It cumpletin I, the
III builder will hove the burden of proving thus he did nut build or Inipm a for pus
own v ° .
I of sole..
1, m owner of (he pmps(y, nm exclusively cnnmhcting with licensed nunn(aors I,
msWcl the Prujeet (Sec 7WL busters, and Professions Codi ]lie Contralto, s ].I -
Lave JxsNut apply to an owner, of prnpeny who hullds or improves themon.ard QTY.
wpmeorracfs moudr prjug Is OF a comm y... licemal pursnnnt the Contmaor's
Lift se Law.
E] I nt exempt under Sec. . Il & 1' C ler this reason
Owner Date
. WORKER'S COMPENSATION DECI,ARA'ION
I herchyuffnr uulcrpantryul Perl"ry one of the 1011mwiel deulnrn(ioos:
I have and vid urame in u Cel ifcum of Comcnnu sdf-helem for Worker', C'ninpem
,union, as pmvidcd fine by Scciinn 9"100 of the Labor Caste. par me perGmnarm of me
work for which this pennil is issued.
I have and will maintain Worker's C01IIII colon Insurance, ns required by Section
3700 of the Lubar Ede. Ior the perfnrnumec al the work lar which this pennil o issued.
My Workch P` tion Insurnncr cnnier and Tolley one . aro:
22 tit
Cmricc �T"arsih �T - I'nliey
CERTIhICCOMPEN.ti A10N111N5URA CW�I1 Zpii / Y
Eyod' ///
('Phis wc(inn Iced urn McotnPlddif(he pennil is fnnmelrunJmJ Jollum( IIXB
or Ices.)
1 cenily that in the pe orprance it the work for which (]its perntil is issued.) shall
not employ any person in any manncrso as uh become subject ah the Workers' Courpm
Z Carlon Lawsnf Ceffnmm. Date
Z Applicant
NOTICE 10 APPLICANT : If, alter making Nis Ccnifcme of Excerption, you should
a ? hecmne object It, (he Workers Comrynmtion provisions nl the LMn Came, you tons(
Rai comply with such provisions or this permit shall lc dcemcd revoked.
0
a' CONSTRUCTION LENDINGAGENCY
0 1 hereby affimt that them is a comtructlon lending agency for the perfnmrana of
- he work for which this Fermis is issued (Sm. 3091. Civ" C.)
U. U. Name
U Lenders
}Lenders Address
D.1
W 1 certify that I have re:d this application and state that the above information is
F' TA
career. l agree In comply with all city and county ordinance% and shim laws miming to QTY.
building construction. and hereby amhorife opecemaivcs of this city In enter upam rhe
above"mentioned pmpeny for imptotion mmTwcs.
(We) agree to save, indemnify and keep hamelco, the City of Cupcnino against
liabilities. judgments, costs and expenses which may in any way accrue against said City
in n,equence of the granting of this permit.
A PPLICAN'1' UNDERSTANDS AND W ILh COMPL W TH ALL NON -POINT
SOUSOU ENS.
Signature of Ail pUCammcmr Date
HASdRDOUS MATERIALS DISCti
Will the applicant or more building xcupant store or handle hvallous petered
as defined by the Cupenien Municipal Code, Chapter 912, and the Health and Satety
Came, Section 25532(.)'
❑Yes No
Will the appecip, or! re building occupant use aq(ilp recto or devices which
Is e
mit haearJnu, air can(uminams as denied by the Buy Arca Air Quality Munagcmen(
District'
❑Yea �j No
I have eccdtL 'trial t. teedet Clialiec,-6 )54lie Cap.
infla Heiddh & Safety Cade. Scene) 25505 25531 and25514 1 I11111111and that it the
huld'ngdce: rItrtly ha,c 11 I'nt, tla(1_ iny - realthly no ovily (ba oislp(n
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUK.ELEcrRIC
TEMP. SIFTER O
POWER DEVIC
SWIMMING POOUTLETS-
NEW ..IDExITIALELECTR
PLUMBING PERMIT
PERMI"1ISSUANCE
ALTER -DRAIN & VENT'- WATER (EA)
BACK FLOW PROTECr. DEVICE
URA INS - FLOOR. ROOF. AREA. COND.
FIX'HUSES - PI;R TRAP
GAS - ILA SYSTITM-I INC. 4 OUTLETS
GAS -ILA. SYSTEM -OVER 4 (EA)
GREAS UI NDUSTRI, WASTE INTE EP
G RI7A SE TRAY
SEWER - SANITARY -- RM EA.2
WATER HFIER W :NTiEITTCTR t
WINE ER
MECHANICAL PERMIT
SQ FT
PERMIT ISSUANCE
ALTER OR ADD TO MITCH.
AIR HANDLING UNIT (TO 10.000 CENT)
AIR HANDLING UNIT (OVER 10.000 CFM)
EXHAUST HOOD (W/DUCT)
HEATING UNI "f (TO 100.000 BTU
HEAI'I NG ON I'r(OVER 100 BTU)
VENTILATION FAR . GLE RESID)
BOILER - CO 3HP OR IW,WO BTU)
IfO1LCR- MP(OVER 11X4gq BT U)
RI7S IDE UALMECH. SQ, IT,
OFR
2051
2 —�—q
7N
FEE
Si In' FLOOR AREA
k 1) 5(35 _ do
3 baga��
BUILDING DIVISION FEES
❑ ❑ ❑
FBL
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ ITT I CHIN REMODIH,
[]ADDITION ❑ PLUMBING BE PIPE
❑MULTI -UNIT ❑STRUCTURAL,
MODIFICATION
El INTERIOR WHIMN12Y REPAIR
IMPROVEMENT C)SWIMMING PCI
❑ BATH REMODB R'I tJlt
❑ OTHER /-NNe�ec`u" •._=.R
�IwLO U n
TOTAL:
BUILDING P
COMMF:RCIAIS
NET [I DEMOLITION
❑NF'W BL
❑'117NANI ❑FOODSERVICE
IMPROVEMENT'
❑ OTHER
FEE
S615Y11C Fli
FEE
Si In' FLOOR AREA
k 1) 5(35 _ do
3 baga��
BUILDING DIVISION FEES
PAID
' le Rettipl M
TOTAL:
BUILDING P
-
FEE
S615Y11C Fli
cl.rcrRlc FE
PLUMBING FTC
MECHANICAL. 'E
CONSTRUCTION I) X
HOUSING MI'I']GABON FITE
AID
Doe Nacip( If
IOIAL:
�SSLJAN`li DNI 17