31126APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO . BUILDING - ELECTRICAL
. 'j q n L+
PERMIT N031126
BUIIJ)ING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
J 1 c U
BUILDING PROJF,CT IDENTIFICATION
BUILDINGADDRFSS:
SANITARY NO,
APPLICATION SUBMITTAL DATE
166 51 AC-
0: 'S N ME: 1'110 E:
CONTRAQIUR:S NAME: LIC NO:
❑
CONCT'RROLX
��� /
WamldNIC
%RCH :/ENGINHER: LIC NO'.
QAC M teww
ADDRESS:
CONTACT: PHONE:
BUILDING PERMIT INFO
IL g �C(• 1159 p Amt
(••Ik �J
❑ Consultant Fccs Paid by Applicant (Initial)
B� ELECT PLUMB MECH
O Rop
m
5C U U
FF,ZW
Q a
LICENSNSEDDCCONN FRACI'OR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
onwith Section Division 3o1ahemanesanromy B,d Pm.ms itnCade,andlamew is
In Tull aClass effcea.
License Class Co.
Dae Contractor
QTY. ELECTRIC PERMIT IB8
JOB DESCRIPTION
RESIDENTIAL:
❑ Slapo ❑ KITCHEN REMODEL
❑ADDITION O PLUMBING RE-PIPE
❑MULTI-DNR ❑STRUCTURAL.
MODIFICATION
PERMIT ISSUANCE
APPLIANCES- RESIDENTIAL
N
Fpy
Z
ARCHITECTS DECLARATION
1 understand my plvns shall be used as public records
PANELS
OZ C
UP TO 21x1 AM PS
[D INTERIOR ❑CHIMNEiY REPAIR
IMPROVEMENT
El BATH REMODEUREPAIR ❑DEMOLIT[ON
❑ OTHER
LLI hlcvnneJ Professional
a cyT�`] OWNER-BUILDER DECLARATION
E C q YJ, 1 hereby affirm that I mm coward from the Contractor's License Law lin The
3 LLU following reason. (Secilon ]031.5. Business and Professions Cale: Any city orcounty
y which requires a
a permit , consumer, aper, improve, demolish, or mpair any structure,1"��g Prior to its isuarce. ala,require% the applicant for. such Permit o file a signedna¢mcnt
icy That he is licensed purstim, mthc provimm., close Counselors License Law (Chains,9
�y'Q� (eammencing wi@Scttinn]UMt)of Division3nl the Business and Rafessiona Gariel ter
6 C that he is exempt therefrom and the basis for the alleged exemption Any violation of
„�• Section 0031.5 by any applicant fora pe.it.wbrret,me.ppilenat ma civil pena,of
P'y mat mareahan Five hundred dollar, ($500),
do 0 Lasowncr otlnyo
he pmpar my employees with wage%as their solea opar,nion,
T, will do the work, and the structure isnot intended or offered forsele(Sec.]614, Business
W3 se and Professions Code: The Contractors License law docs not apply to an owner of
property who builds or improves Thereon, and who docs such work himself or through
his own employees, provided that such improvements am not intended or offered for
sale. If. however. We building or improvement is sold within one yearofeumpletion.Jho
2111-IIXX)AMPS
OVER I(XIUAMYS
SIGNS ELECTRICAL
SPECIAL Cl RCUIT/MISC.
TEMP. METER OR POLE INST.
-
COMMERCIAL: pp��
0 NEW BLDGIADDITHA r
�QENANT OEMOLIT'ION OD SERVICE
_ IIMPROVEN■M/g/N.T
❑OTHER tlM, ry ^•--
—�
�f r 7 (,/r
SQ. FT. FLOORA ESQ. Ff.
POWER DEVICES
SWIMMING POOL F'LEC
OUTLETS-SWITCHES-
NEW RI• IALELECTS/
ovener-buiLder will have The human of proving that he did not build or improve for pur-
,w of sale ).
1, os owner of the pmpuny, um exclusively mmmmling with licensed commcne%m
coot
3
O L.
Cale:) The Commor', Li.
4. Busimess and Pfessiam, Cam
conchae, the To (Sec. 961m
w
cars, l,awdoe. not apply it, an owner of property who land% ar improve% atercon, and
QTY. PLU BI RMIT PEE
who contracts Turman projectswith a commmor(s) licensed pursuant U, the Comil
PERMIT ISSUANCE
License Law,
❑ I am ex ttdenac . B & P C for this reason
ALTER -DRAIN & VENT- WATER (EA)
watt ' Dare
WOR KERS COMPENSATION DECLARATION
VALUATION
//J!
—I �G
BACK FLOW PROTECT. DEVICE
1 hereby at7um under penalty of pe jury ane of Floc following dmlamdons;
Y V
[have and will maintain a Certificate of Ccnwnuo selt-in.wre for Workers Compere
smion, as provided lis by Section 3900 of the Labor Calc, h r The performance of The
DRAINS- FLOOR. ROOF, AREA, COND.
ST(lRII TYPE. CONSTRUCTION
work for whichthi, parmil is issued.
FIXTURES -PER TRAP
❑ 1 base and will maintain Worker's Compensation Insurance. as required by Section
31110 f,ha labor, Cade, for the psrfomence of the work for which This permit is issued
GAS -PA. SYSTEM-I INC. 4 OUTLETS
U
AVN
Worker's Compensation Insurance and Policy number arc:
My Workercarrier
Carrier: Policy No.:
GAS - E. SYSTEM OVER 4 EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASUINDUSTRL WASTE INTERCEPTOR
ILDING DIVISION FEES
or lesc)Thrcsection need rad Mromplemdif Ne permit is Tirane hundred dollars (81(X)1
GREASE TRAP
L ECK 'E
ijethio permitisiss Col shall
Loy any Thoio in any nmmnceof the worknor
subject
nou�mLaw any peoon in try mnnnersu asmhecoine suAicct n, me Workers Cnmpen-
SEWER- SANITARY -STORM EA. 2W P1'.
IiNE F,
Z .firm of California. Oar.
C 2 Applicant
NOTICE TO APPLICANT. IL after making dais Certificate of Exemption, you should
a ; become subject m the Workers Compensation previsions of the labor Code, you must
forthwith comply said, such provisions m Nis pennit,hoill be dccmed revoked
a�
UO CONSTRUCTION LENDING AGENCY
I hereby a0imvhut There is a eunswction landing agency far The perfonnnnm of
the work far which This penal is issued (Sec. 3097. Clv. C.)
C) H Lender, Name
U Lcnduf, Parishes,
} y I certify that I have read this application and nam That the tl,ove mmnnmion is
FO) mnenT.I.,. mcomply with all city and county ordinances and sane laws slating to
UZ building construction. and hereby vu0todu representatives of Nis city To cnterupnn the
WATER HEATER W/VENT/ELECfR
GRADING � •E
WATER SYSTEMOREATING
SOILS To
WATER SERVICE
PAID Dae Recd #
p
NEW RfSIUIiN'FIAL FUME. SQ. FT
iT TOTAL:
TOTAL:
IIHILDING FE ��
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
above-mcmiancd propcny for inspection purpous.
(We) agree ve, indemnify and keep hamdes, the City of Captain. against
m sa
PLUMBING FEE
habit fics,judgments, costs and expenses which may in any way acme againa said City
in asequence terme Sam, gofthis permit
ALTER OR A UU TO MECH.
AIR HANDLING UNIT (TU 10,6x1 ChM)
M
LCIIANICAI. PUT:SOURCERF
APPLICANT UNfY�.iST'A S ANU LL COMPLY W TH 1. NON-POINT
,U ATI(i
AIR HANDLING UNIT (OVER TO." CILM)
CONSTRUCTION TAX
/Signamn
of ApplmanUCunaruam I Dae
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD EV/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100.000 BTU)
Will the applicant or future building occupant store or handle Trarardon,motorial
as defined by she Cmar ho Municipal Code. Chaffer 9.12, and the Health and Safely
Code, Scctirn 25532(a)9
HEATING UNIT (OVER 10O,OfI(1 BTU)
VENTILATION FAN (SINGLE REST]))
❑Yes ❑No
PAID
Dec Receipt p
BOILER -COMP (3HP OR 100,0001 BTU)
Will The applicant or future building occupant use equipment or devices which
:mice hicandous air contaminants as defined by me [lay Ana Air Quality Management
TOTAL.
BOILER - COMP (OVER 100,000 BTU)
DTsmn1
❑Yes ON.
AIR CONDITIONER
I have sad the hamNnis materials requirement, under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDEMI'IAL MECH. SQ. FT.
amain Health & Safely Code, Sections 25505, 25533 and 25534. I understand that If The
building eowsmarmandy loss, aenam,thaid is my responsibility terrify Thesccupm1
of the requirements which mast be met prior to issuance of a Certificate of Occupancy.
ISSUED BY:
TOTAL: I
Owner or sulborirW agent Dam
OFFICE