S 2743 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPIdCAPION/PERMlIT PLUMBING.MECHANICAL �7 1 S 2743
BUILDING PROJECT IDENTIFICATION
RUILDINGADDRISS: SANITARY NO. APPLICATION SUBMITTAL.DATE
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AHCIID.Cp NEER: LIC NO. AID/ }S:
F9 26ac
CON'T'ACT: PHONE: IBUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDO �I?LEPLUMB_ MF❑,CII
RN9
LICENSED Co RAGfOR'S >ECLARATION QTY. ELECTRIC PERMIT FEE �/ I�
I hereby anirm that 1 an reused under provisions of Chapter 9(commencing JOB DESCRIPTION
CTYZ ishseainn 9(NX))of Di 'ion3n(me Business nnJ Professions C:xle and licenseis REID
D W_ w PERMIT ISSUANCE
f-� rola]]force and cRUC ❑SFDWL [I KITCHEN REMODF.I. I
IY U -imnsa Cl Lim.p
6 U APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Date Commcmr
H 6 a
ARC ITECT DECLAHATI ❑MULTI.UNIT OSTRUCTURAL
Mz 1 rst puhlicre ds PANELS MODIFICATION
zOZ�� UPT02W AMPS El INTERIOR ❑CHIMNEY REPAIR
F an IFp" Lis n�(veT—cfou'd �il 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
Y E M OWNER-BUILDER DECLARATIO i OVER 1000AMPS ❑BATH RP.MODI:IIREPAIR (]DEMOLITION
K CC''�� i hereby infirm that 1 am exempt from the Contractor's License Law for the
ippi55,�O c.U hallowing reason.(Section 7031.5,Business and I'nd'nsinnx Coda:Any oily nr county SIGNS HI.HC'I'RICAL ❑OTHER
wh lch ce"ites a permit m conswet,vhcr,imp nrva,Amnnllsh,nr repair any mmmum
..¢...111 prior to itn issuunce,vbn rcyuircs the upplirnnl ler such perminniilcnsigned stmvnem SI•IiCIAL CIRCUIT/M INC.
4� that heNl em,rdporsuam mthepancroansofthe Conlrudnrs License Law(Chapmr9 OMM L'
(rommcncing with Sution]1XXp of Division3nl the Business and Professions Cude)or TIiMI'.MITIiR OR POLE INST.
d y o that he is cuinpt therefrom and the basis fur the nllegW exemption.Any violation of ❑NEW BLDG/ADDI PION ❑DEMOLITION
LLXS Y•
Section 7031.5 by any applicant for a permit subjects the applicant In a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
m of moro than five hundred dollar(S50B).
F.Z Y IMPROVEMENT
�=600Lo the%orofthe property.ormyet s not intended with wred fi th (Sec.ale compenou Businesson, SWIMMING POOL ELECTRIC ❑OTHER
F
will I' mework,and
(Ae: ne Conim[oes LinenlelMwdmsnrmle(SuJ044.Busincss
W3$
property erty whit)builds
The Contractors License Lew duos not apply s if owner of OUTLETS-SWITCHES-FlXTURFS
his o ny who builds or improves thereon,and who dtwx such work himself or through O O
his own employees,provided that such impruvemenu sat nm amended or offend for NEW HESIDF.NTIAL ELECfR SQ IT.
tote.IL however,the building or improvemem issold within one year of completion,the SQ.Ff.FLOOR AREA LSQ.Ff.
owner-had er will leve the burden of proving that he did not build or improve for put-
"m nLsulc.l.
I,as owner of me property,am exclusively contracting with licensed contractors m TOTAL: (Mso
construct the project(Sun.7144,Business and Pndcssions Came,The-...stunts..Lb
use Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT PEE
whit contracts fur such projects with a contracar(s)licensed pursuant tome Contractors
Licenm Le.. PIiNMIT ISSUANCE
I mit exempt under Sec. ,B&P C for mit reason
ALTER-DRAIN&VLNT-WATER WA) VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE.
I heathy aRum under pcnahy of perjury one of the following dedamtions:
have and will far
Section
37te of the Labor
Code,
Workersm, f,hc DNAINN-FhODR,ROOF.AREA,COND. STORIES TYPE CONSTRUCf1ON
roof oe provided for mi Section 3]W of me IrMu Cala fur the performance of the
work fur and mit maintain
is issued. Z FI%TITHES-PER TRAP /!g Com.
I hove and will maintain Workers aneoft ti w Insurance,h required by Section ` •J �fS
3]1X]of the LaborCode R.r the performance of the work for which this permit is issued. GAS-IiA.SYSTEM-t INC 40UTLLTS OCC GROUP APN
My Worker's Compensation Insurance carrier and Policy number ac:
Currier Polley No.; GAS-IiA.SYSIEM-OVER 4(EA)
CERTIFICATE OF EXIN ITION FROM WOR KERSG It HASIANDUSTRL WASTE.INTERCEPT OR ��+ ✓'_
COMPF.NSAI'ION INSURANCE BUILDING DIVISION FEES
('I'hissecum need not b martilded ti thclennit is fortme hundred dollars G IW) pHHASE TRAP
or leu.) PLANCHECK FEE
leerily that in theperfmormaccofinework fmwhlchlhispermit isi.sued,l shut] SEWER-SANITARY-STORM EA.201 FT.
not employ any person any inner so' to Nec n njcn t WmkerF G.mpcn- ENERGY FEE
z ,Z ration laws of Cal - WATER HEATER WNCNT/ELECTR
0 Applicant �g GRADING ITE
.N. NOTICE TO AP L ANT:If
after rtieking niHram of F:xcmption, ould WA'ILR SYS'IEMTIREATING SOILS FF.F.
a ' Msnme mhjea m the Wcalmex Compensation provisions of the Labor Cad,you must
0 fnnhwithcnmply wish such Provisions or this permitsma be deemed revoked. WATER SERVICE
L
� z. CONSTRUCTION LENDING AGENCY NEW XESIDENGIAL PLMB. SQ.FE PAID Dae pp
U O I hereby alBrn that them is a construction lending agency for the performance of
the work for which this permit is issued(See.3097,Civ.C.)
Lender's Name 'TOTAL:
U Lenders Address TOTAL; S,2t/J
BUILDING P5
k.� unify that 1 lava with
lusty and
unJ aloe Ann the starve inl'ormatio,Is'
Fr pal amreell ngreemcnmply wits Ali dtyand mmnty ordinances and sone lvwsrdathtgm QTY. :CHAN PERMI FEE
g hereby prescn y poo If SEISMIC FEE _
U 7a. naudnt.ronswcron.arae heren udmdrcre tmmesnnmseit to enterm The •UO
ohnve-mentioned property far important lamleves. FERMI TI NCE
tWd egrecrosave,indemnify and Aap hannleu the City of Cspenino against 5� ELECTRIC FEE ✓
liabtlitics,judgmenls.costs ata expenses which may many way aceractil,bst said City ALTERDD 1H H. jQ0Q 11
in consequence of the gmming of this Permit. IT PER
APPLICA DF.RSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HAILING UNIT(TO lo.nOB CFM) MECHANICAL IM-11
SOURC' U ATION
AIR IIA 1 1NG UNIT(OVER 1g0(X)CPM) CONSTRUCTION TAX
13
a
Sig are of AppliconVC actor ate E%HA ? HOUSING MITIGATION FEE
HAZARDOUS MKIERIA DI' .OSURE
Will theapplicant or future building as store ar handle hazardous material I IEAUNG UNIT(TO 100,001 RTIJ)
us Acfined by the Cupenina Municipal Cale,Chapter 212.and the Health and Salcey
Code,Section 25532(x)] 1117A'I'ING UNIT(DVER I00,004)BTU)
❑Yat VENT ILAGON PAN(SINGLE RESIT» PAID —Dale
Ru
eipt
Will the applicant ofuture building occupant use equipment lddeviceswhich
emit hwardom oirconmmmwfc as defined by the I1xy Area Air -
Quality Mansgvment BOILER-COMP(3HP OR 100,000 BTU) TOTAL:
District/
❑Yes q(No BOILER-COMP(OVER 100,000,PTU)
AIR CONDITIONER
Ilave teas me hazsNwstnateriols requirements under ChaMcr 6.95 ofmc coli- e--� ISSUANCE DATE.
fomis Health&Safety Cale,Sections 25585,25533 am1255344 ndersuml mat if dse NEW BES'IDIiMT AL MECH. SQ.FR e r- _Q
buiWi dsss mcurer haveat ]that it is my to no a lythe aaupant 3
of qui t Imus tprionoiss cif s Occupancy.
er 01 uushmizc eat Date TOTAL-: ISSUED BY:
OFFICE
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DE at"o MAR 2 21999
d uu.,NSPECTIONOtrr .
CITY OF CUPERMO
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