B 0424APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT P1,UMBING-MECHANICAL Cpppy
BUILDING PROJECT IDENI[FIC'A] ION �00T
rBU1;; ADDRESS: S e9� SANITAR
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❑ CoratIWBI re" Paid by Applicant (initial)
1 hereby a firm mal I mI licensed coder pmvisinna UI Chapler 9 to anionein,
CmZ .,in Seelio.700l)of Oivi.inn 9 afore Bmmor,rad Prnfesaions Ced,,andpmylieenseis
won
F 1= in full force and eBfI. G Si ISO
IV U Liccrosc Class—Lw #
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ARCHTOiC1-S DEGr�.AR���IpPjI��N
F N Z 1 understood my plant snail h used vx public ¢curds
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IF `=1J' w Limned I'mfevsioml
OWNER -BUILDER DECLARATION
ce tY Q 1 hereby anlnn that I am exempt from the Contractors License Law for the
'aL O a U following reason. (Section 7031.5. Business and pmressior, Code Any city or county
frf i LL N which requires a permit it, construct, altar, improve, demolish. or rep air any someone
prim to its isuuncn,also requires the applicant fcrsuen permit to file a signed xtatemenr
icy mal he is licensed pwsvdnuo the provisions III COmracmT's License I,.(Chapter ')
=a�CC (commencing with SeclionTXXB of Division 3 oflhe Business and Professions Cede) Or
a a e C that he is exrntpl Inercfmm end the hasis lin the alleged excmplam. Any violation of
HSerino 7o3l.5 by any mppllcam far n pemat adjens me up,iicvnt to a civil penally of
not more than five hundred dollars (5500).
C S Q p L as ownm Of me nopert, m my employees with wages as Meir tole comperraum.
F. will do the work.and theauchre in col intendednraffered hwoole(Sol. 9004. Bmimecv
Wm and Pro&xsicox Code: 'tire Contractor's License Law does not apply to an owner of
property who builds or improves thcrem, and who does such work himself or through
his own employers, provided that such improvements am not intended or offered for
sec. If, however, me building or improvement livid within one yea of completion, the
rrhoilder will have the burden of proving that he did not build or improve for par-
'Uu Ofsale.).
❑ L as owner of the pn,perly, am exclusively contracting with licensed contractors it.
OnslNfl the project (SM. 90i , Business cad Professions Codr:) The Contractors Li-
a Law does nil apply In an owner or property who builds or improves Iherenn, and QTY.
who controls for such pmjeao with a contmetor(v) licensed personal n the Contractor's
Lice me low.
I am rxempt under Sec. B & to C for Ibis reason
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP'10200 AMPS
SIGNS EL[CI'RICAL
$I•EC.At CIRCUIT/MINC.
000
TEMP. MEEfER OR POLE INS K
POWER DEVICES
SWIMMING POOL ELIiCfRIC
O V FLUS - SWITCHES - FIXTURES
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby Unirm under penally of perjury one al the I'ol4wing declarations:
�l I hove and will mninmin v Ceaifisute of Coroem m selGlnsure for Wnrker'x Compen-
onion, as pmvlded for by Seclion 3900of the [,Awr Code, for the pedbm ounce ell me
work Pur whi n Iris pcmil ix issued,
1 have and will mainmin Workers Compensation Insurance, as required by Section
39:0 nl'Ihe I.ubm Calm 4n the gednmmnce of the wok for which this pemit is issued.
My Workers Cumpcnwninn Imumncc Cartier and Policy number are:
Comers Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPIENSATION INSURANCE
Uptho secion duration becnmpletedifthe permit is Inr one hundmAdnllers (51 W)
le".)
1 certify that in the pafnmmnce of the work lin which this proml is issued, l shall
not ctuplay any person in any manner m ns to become suojem m the Workers' Compen-
z x.Iran Lowsof Califamis. Date
z Q AlTlicunt )
z' (A NOTICETO APPLICANT: If, a0er, making all, Ccnificatc of Exon,ptim. you should
(~ Moan, subject to the Worker's CUn)ponsalon provisinas of the LnMe Code, you must
Wfonhwim comply with such provisinm of this permit shallM deemed creaked.
a
CONSTRUCTIONLENDING AGENCY
UO Ihcrcny unirm mat them isummtmction Pennine agency for the per(omunttnf
(•' the work for which this pemit is issued (Sec. 3019. Civ. C.)
VLenders Name
Lender's Address
y 1 orify that I have road this application and scala Ira the douse information is
N correct. l agree to comply with all city and so my ordinances and state laws relating to QTY.
V Z mildingcnnmarclien.and thereby ..in mreprcaenlutives m dh, city .care, upon the
aMvemenliuned military fill Impearm purposes.
(Wee) agrcc to nava, aides nfy and keep harmless IheCity of Cupertino against
liabilities judgments, coos and expenses which may in any way arcane against said City
in nsegcen.r of fi a granting of this Folaril.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1- NON -POINT
SOURCE REGULATIONS.
1t lel_/
SI aturenf Apphear/Cotnmclrn Dale
IIAZAROOIIS MATIERIALS DISCI,OS(1RE
Will the upplicam or fare. building recupanl score no handle h:vallous mamriul
as delincd by the Cupcnino Mmticipal Code, Chapler 9.12, and the Health ant Safety
Calc, Section 25532(a)^
❑Yes No
Will Ibe upplicam or home build'mg occupant uac equipment or devices which
Am,iI holom sir c,ntemim UU, as defined by the Bay Arca Air Quality Mumlicmcm
utnd'r
❑Yes QNo
1 have read the haimdous materials rryuiremcnls under Chaprer 6.11 of the Call -
fomia []cull], & Solely Code, Sections 25505, 8599 and 25534. 1 Underhand that if the
building does nal currently have a muni, that it is my responsibility to notify me occupant
,S
el �rcyuiremeich toast he met priuno lx r Unfn Cenifctne algal�n�
Ownerm amnnnudngcm -� y/1/) e
BIAL ELECTR SQ Cr.
PLUMBING PERMIT
PERM IT ISSUANCE
ALTER - DRAIN & VENT- WATFR (EAI ti
BACK FLOW PROIECL DEVICE
DRAINS - FLOOR. ROOK AREA, COND.
VENTURES-PERTRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
GAS EA.SYS'1'IEM-OVER 4(EA)
GREASFIINDOS'I RL WAS IT IN'I ERClinOR
GREASETRAP
SEWER - SAN I'I'ARY - S'IURM EA. 2(X) FL
WATER HEADER W/VEN"I'mLECTR
WATER SYS'rEMITRF.A PING
WA'1'[III SERVICE
NEW BESIDES IIAL PLMIL SQ. IT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTIER OR ADD TO MECH.
AIR HANDLING UNIT' (90 10010 CFMD
AIR I IANDLING UNIT (OVER 10.000 CFM)
17XIIAUS'I' HOOD (W/DUCq
HEATING UNIT' (10 100.000 111 U)
HEAPING UNIT' (OVER 1I0,000 BTU)
VBNTILA'TION FAN (SINGLE RESID)
BOILER -COMP QHPOR 100,0(6 U)
BOILER -COMP (OVER 100.(X10 PTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. CT.
OFFICE
FEE
CONTROL«
BUILDING PERMIT INFO
'I.DGIELECI' PLUMB MECH
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
El PLUMBING RE -PIPE
❑MUTAI-UNIT
❑STRUCTURN-
FEE
MODIFICATION
❑INTIERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
0SWIMMING POOLS
❑ BATH RF.MODELIREPAIR ❑DEMOLITION
❑ DTIUER
[I NEW BLDG/ADDITION
❑ 1 ENANT
IMPROVEh1ENT
❑OTHER
SQ. IT. FI.00R AREA
FEE 11is6
❑ DEh10L1'r10N
❑ FOOD SERVICE
•-5 vns.ww,m U V
S1Y)RIIS 'rYPC CONST RUCI'10
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%L �5 7-i7_Cy)
BUILDING DIVISION FEELS
Irl-ANCHECK FETE gi
ENERGY FEE l s Y
GRADING PI/E"I
SOILS fEIE
PAR, 5 rs�-yy Opti
Dam Raccip) p
(yl'AL:
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BUILDINIrTION
FEE
iFELFEIEON
TAX
'IGATION FEE
PAID
I ' Al,"
ISSU�ANC� ATE
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